247 lines
15 KiB
PHP
247 lines
15 KiB
PHP
<div class="row">
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<div class="col-12">
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<div class="<?= isset($ticket_form) ? "card" : "" ?>">
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<div class="card-body">
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<?php if(isset($ticket_form)){ ?>
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<div class="row" style="margin-bottom:1rem;">
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<div class="col-6" style="align-self: center;">
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<h4 id="page_title" style="position: relative;">Claim GMC </h4>
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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"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_id" name="claim_status_id">
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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'] . ">" . $value['status'] . "</option>";
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}
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}
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?>
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</select>
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</div>
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<div class="form-group col-md-3">
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<label for="priority">Priority<span class="text-danger"></span></label>
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<select class="form-control" id="priority" name="priority">
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<option value="0">Select Priority</option>
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<?php
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if (isset($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'] . ">" . $value['status'] . "</option>";
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}
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}
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?>
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</select>
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</div>
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<div class="form-group col-md-3">
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<label for="policy_no">Policy No<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="policy_no"
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value="<?= isset($client['client_name']) ? $client['client_name'] : '' ?>"
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name="policy_no">
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</div>
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<div class="form-group col-md-3">
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<label for="acm_id">Insurer<span class="text-danger"></span></label>
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<select class="form-control" id="insurer_id" name="insurer_id">
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<option value="0">Select insurer</option>
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<?php
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if (isset($claim_status) && count($claim_status)) {
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foreach ($claim_status as $key => $value) {
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echo "<option value=" . $value['id'] . ">" . $value['status'] . "</option>";
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}
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}
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?>
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</select>
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</div>
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<div class="form-group col-md-3">
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<label for="acm_id">TPA<span class="text-danger"></span></label>
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<select class="form-control" id="tpa_id" name="tpa_id">
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<option value="0">Select TPA</option>
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<?php
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if (isset($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'] . ">" . $value['client_name'] . "</option>";
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}
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}
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?>
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</select>
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</div>
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<div class="form-group col-md-3">
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<label for="emp_code">Employee ID<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="emp_code" placeholder="Enter Employee ID"
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value="<?= isset($client['client_name']) ? $client['client_name'] : '' ?>"
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name="emp_code">
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</div>
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<div class="form-group col-md-3">
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<label for="tpa_id">TPA ID<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="tpa_no" placeholder="Enter TPA ID"
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value="<?= isset($client['short_name']) ? $client['short_name'] : '' ?>"
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name="tpa_no">
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</div>
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<div class="form-group col-md-3">
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<label for="emp_name">Employee Name<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="emp_name" placeholder="Enter Employee Name"
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value="<?= isset($client['short_name']) ? $client['short_name'] : '' ?>"
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name="emp_name">
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</div>
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<div class="form-group col-md-3">
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<label for="insured_name"> Insured Name <span class="text-danger"></span></label>
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<select class="form-control" id="insured_name" name="insured_name">
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<option value="0">Select Insured Name</option>
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<?php
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if (isset($ticket_type) && count($ticket_type)) {
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foreach ($ticket_type as $key => $value) {
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echo "<option value='" . $key . "'>" . $value . "</option>";
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}
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}
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?>
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</select>
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</div>
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<div class="form-group col-md-3">
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<label for="relationship"> Relationship <span class="text-danger"></span></label>
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<select class="form-control" id="relationship" name="relationship">
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<option value="0">Select Relationship</option>
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<?php
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if (isset($ticket_type) && count($ticket_type)) {
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foreach ($ticket_type as $key => $value) {
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echo "<option value='" . $key . "'>" . $value . "</option>";
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}
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}
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?>
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</select>
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</div>
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<div class="form-group col-md-3">
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<label for="client_name">Employee Mobile No<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="emp_mobile" placeholder="Enter EMP Mobile"
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value="<?= isset($client['client_name']) ? $client['client_name'] : '' ?>"
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name="emp_mobile">
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</div>
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<div class="form-group col-md-3">
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<label for="emp_mail">Employee Mail ID<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="emp_mail" placeholder="Enter EMP Mail"
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value="<?= isset($client['short_name']) ? $client['short_name'] : '' ?>"
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name="emp_mail">
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</div>
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<div class="form-group col-md-3">
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<label for="mode_of_intimation"> Mode of Intimation <span
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class="text-danger"></span></label>
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<select class="form-control" id="mode_of_intimation" name="mode_of_intimation">
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<option value="0">Select Mode</option>
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<?php
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if (isset($ticket_type) && count($ticket_type)) {
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foreach ($ticket_type as $key => $value) {
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echo "<option value='" . $key . "'>" . $value . "</option>";
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}
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}
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?>
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</select>
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</div>
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<div class="form-group col-md-3">
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<label for="claim_type"> Claim Type <span class="text-danger"></span></label>
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<select class="form-control" id="claim_type" name="claim_type">
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<option value="0">Select claim Type</option>
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<?php
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if (isset($ticket_type) && count($ticket_type)) {
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foreach ($ticket_type as $key => $value) {
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echo "<option value='" . $key . "'>" . $value . "</option>";
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}
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}
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?>
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</select>
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</div>
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<div class="form-group col-md-3">
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<label for="hospital_name">Hospital Name<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="hospital_name"
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placeholder="Enter Hospital Name"
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value="<?= isset($client['short_name']) ? $client['short_name'] : '' ?>"
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name="hospital_name">
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</div>
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<div class="form-group col-md-3">
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<label for="doa">DOA<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="doa" placeholder="Enter DOA"
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value="<?= isset($client['client_name']) ? $client['client_name'] : '' ?>"
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name="doa">
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</div>
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<div class="form-group col-md-3">
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<label for="dod">DOD<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="dod" placeholder="Enter DOD"
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value="<?= isset($client['short_name']) ? $client['short_name'] : '' ?>" name="dod">
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</div>
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<div class="form-group col-md-3">
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<label for="claim_amount">Claim Amount<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="claim_amount"
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placeholder="Enter Claim Amount"
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value="<?= isset($client['short_name']) ? $client['short_name'] : '' ?>"
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name="claim_amount">
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</div>
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<div class="form-group col-md-3">
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<label for="pod_no">POD No<span class="text-danger"></span></label>
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<input type="text" class="form-control" id="pod_no" placeholder="Enter POD NO"
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value="<?= isset($client['short_name']) ? $client['short_name'] : '' ?>"
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name="pod_no">
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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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