202 lines
12 KiB
PHP
202 lines
12 KiB
PHP
<style>
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.readonly-select {
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pointer-events: none;
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background-color: #e0e0e0;
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color: #666;
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}
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</style>
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<div class="row">
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<div class="col-12">
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<div class="<?= isset($ticket_form) ? "card" : "" ?>" style="margin-right: 23px;">
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<div class="card-body">
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<?php if(isset($ticket_form)){ ?>
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<!-- Header Section -->
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<div class="row mb-3">
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<div class="col-6 d-flex align-items-center">
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<h4 class="mb-0">Claim <?= $ticket_form ?></h4>
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</div>
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<div class="col-6 text-right">
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<a href="<?= base_url('ticket/list'); ?>" aria-label="Back to ticket list">
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<i class="fas fa-arrow-left" style="font-size: 17px;"></i>
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</a>
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</div>
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</div>
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<?php } ?>
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<form role="form" class="parsley-examples" method="post" id="ticket_form_gmc"
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enctype="multipart/form-data">
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<div class="form-group">
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<div class="form-row">
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<div class="form-group col-md-3">
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<label for="claim_status">Status<span class="text-danger"></span></label>
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<select class="form-control" id="claim_status" name="claim_status">
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<option value="0">Select status</option>
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<?php
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if (isset($claim_status) && count($claim_status)) {
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foreach ($claim_status as $key => $value) {
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echo "<option value=" . $value['id'] . ">" . $value['status'] . "</option>";
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}
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}
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?>
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</select>
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</div>
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<div class="form-group col-md-3">
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<label for="acm_id">Account Manager<span class="text-danger"></span></label>
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<select class="form-control" id="acm_id" name="acm_id">
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<option value="0">Select Account Manager</option>
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<?php
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if (isset($claim_status) && count($claim_status)) {
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foreach ($claim_status as $key => $value) {
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echo "<option value=" . $value['id'] . ">" . $value['status'] . "</option>";
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}
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}
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?>
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</select>
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</div>
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<div class="form-group col-md-3">
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<label for="client_name">Corporate Name<span class="text-danger"></span></label>
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<select class="form-control" id="client_id" name="client_id">
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<option value="0">Select Corporate</option>
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<?php
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if (isset($claim_status) && count($claim_status)) {
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foreach ($claim_status as $key => $value) {
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echo "<option value=" . $value['id'] . ">" . $value['client_name'] . "</option>";
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}
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}
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?>
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</select>
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</div>
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<div class="form-group col-md-3">
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<label for="acm_id">Insurer<span class="text-danger"></span></label>
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<select class="form-control" id="insurer_id" name="insurer_id">
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<option value="0">Select insurer</option>
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<?php
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if (isset($claim_status) && count($claim_status)) {
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foreach ($claim_status as $key => $value) {
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echo "<option value=" . $value['id'] . ">" . $value['status'] . "</option>";
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}
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}
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?>
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</select>
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</div>
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<div class="form-group col-md-3">
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<label for="policy_no">Policy No<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="policy_no"
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value="<?= isset($client['client_name']) ? $client['client_name'] : '' ?>"
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name="policy_no">
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</div>
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<div class="form-group col-md-3">
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<label for="ticket_type_id"> Policy Type <span class="text-danger"></span></label>
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<select class="form-control readonly-select" id="ticket_type_id" name="ticket_type_id" readonly>
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<?php
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if (isset($ticket_type) && count($ticket_type)) {
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foreach ($ticket_type as $key => $value) {
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if($key != 1){
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echo "<option value='" . $key . "'>" . $value . "</option>";
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}
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}
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}
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?>
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</select>
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</div>
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<div class="form-group col-md-3">
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<label for="ticket_type"> Claim Type <span class="text-danger"></span></label>
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<select class="form-control" id="ticket_type" name="ticket_type">
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<option value="0">Select claim Type</option>
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<?php
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if (isset($ticket_type) && count($ticket_type)) {
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foreach ($ticket_type as $key => $value) {
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echo "<option value='" . $key . "'>" . $value . "</option>";
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}
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}
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?>
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</select>
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</div>
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<div class="form-group col-md-3">
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<label for="emp_code">Employee ID<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="emp_code" placeholder="Enter Employee ID"
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value="<?= isset($client['client_name']) ? $client['client_name'] : '' ?>"
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name="emp_code">
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</div>
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<div class="form-group col-md-3">
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<label for="emp_name">Employee Name<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="emp_name" placeholder="Enter Employee Name"
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value="<?= isset($client['short_name']) ? $client['short_name'] : '' ?>"
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name="emp_name">
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</div>
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<div class="form-group col-md-3">
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<label for="date_of_join">Date of joining<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="date_of_join"
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placeholder="Enter Joining Date"
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value="<?= isset($client['client_name']) ? $client['client_name'] : '' ?>"
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name="date_of_join">
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</div>
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<div class="form-group col-md-3">
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<label for="date_of_incep">Date of Inception<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="date_of_incep"
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placeholder="Enter Inception Date"
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value="<?= isset($client['short_name']) ? $client['short_name'] : '' ?>"
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name="date_of_incep">
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</div>
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<div class="form-group col-md-3">
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<label for="dob">Date of Birth<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="dob" placeholder="Enter Birth Date"
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value="<?= isset($client['short_name']) ? $client['short_name'] : '' ?>" name="dob">
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</div>
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<div class="form-group col-md-3">
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<label for="date_of_accident">Date of Accident<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="date_of_accident"
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placeholder="Enter Accident Date"
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value="<?= isset($client['client_name']) ? $client['client_name'] : '' ?>"
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name="date_of_accident">
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</div>
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<div class="form-group col-md-3">
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<label for="date_of_death">Date of Death<span class="text-danger"></span></label>
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<input type="date_of_death" class="form-control" id="date_of_death"
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placeholder="Enter Death Date"
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value="<?= isset($client['short_name']) ? $client['short_name'] : '' ?>"
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name="date_of_death">
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</div>
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<div class="form-group col-md-3">
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<label for="date_of_intimat">Date of Intimation<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="date_of_intimat"
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placeholder="Enter Intimation Date"
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value="<?= isset($client['short_name']) ? $client['short_name'] : '' ?>"
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name="date_of_intimat">
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</div>
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<div class="form-group col-md-3">
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<label for="si_amt">Sum insured<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="si_amt" placeholder="Enter SI"
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value="<?= isset($client['short_name']) ? $client['short_name'] : '' ?>"
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name="si_amt">
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</div>
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</div>
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</div>
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<div class="form-group col-md-12 text-right m-b-0" style="margin-top: 29px;">
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<button type="submit" class="btn btn-primary waves-effect waves-light mr-1"
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id="btnSubmit">Submit</button>
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</div>
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</div>
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</form>
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</div>
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</div>
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</div>
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