248 lines
16 KiB
PHP
248 lines
16 KiB
PHP
<div class="row">
|
|
<div class="col-12">
|
|
<div class="<?= !isset($ticket_data) ? "card" : "" ?>" style="margin-right: 23px;">
|
|
<div class="card-body">
|
|
<?php if(!isset($ticket_data)){ ?>
|
|
<!-- Header Section -->
|
|
<div class="row mb-3">
|
|
<div class="col-6 d-flex align-items-center">
|
|
<h4 class="mb-0">Claim GMC</h4>
|
|
</div>
|
|
<div class="col-6 text-right">
|
|
<a href="<?= base_url('ticket/list'); ?>" aria-label="Back to ticket list">
|
|
<i class="fas fa-arrow-left" style="font-size: 17px;"></i>
|
|
</a>
|
|
</div>
|
|
</div>
|
|
<?php } ?>
|
|
<form role="form" class="parsley-examples" method="post" id="ticket_form_gmc" onsubmit="submitClaimForm(event, this)" enctype="multipart/form-data">
|
|
|
|
<input type="hidden" id="ticket_type_id" name="ticket_type_id" value="1">
|
|
<input type="hidden" id="ticket_master_id" name="ticket_master_id" value="<?= isset($ticket_data['id']) ? $ticket_data['id'] : '' ?>">
|
|
|
|
<div class="form-group">
|
|
<div class="form-row">
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="claim_status">Status<span class="text-danger"></span></label>
|
|
<select class="form-control" id="claim_status_id" name="claim_status_id">
|
|
<!-- <option value="0">Select status</option> -->
|
|
<?php
|
|
if (isset($claim_status) && count($claim_status)) {
|
|
foreach ($claim_status as $key => $value) {
|
|
$selected = (isset($ticket_data) && $ticket_data['claim_status_id'] == $value['id']) ? 'selected' : '';
|
|
echo "<option value=" . $value['id'] . " $selected>" . $value['claim_status'] . "</option>";
|
|
}
|
|
}
|
|
?>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="priority">Priority<span class="text-danger"></span></label>
|
|
<select class="form-control" id="priority" name="priority">
|
|
<!-- <option value="0">Select Priority</option> -->
|
|
<?php
|
|
if (isset($priorityType) && count($priorityType)) {
|
|
foreach ($priorityType as $key => $value) {
|
|
$selected = (isset($ticket_data) && $ticket_data['priority'] == $key) ? 'selected' : '';
|
|
echo "<option value=" . $key . " $selected>" . $value . "</option>";
|
|
}
|
|
}
|
|
?>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="acm_id">Account Manager<span class="text-danger"></span></label>
|
|
<select class="form-control" id="acm_id" name="acm_id">
|
|
<!-- <option value="0">Select Account Manager</option> -->
|
|
<?php
|
|
if (isset($acms) && count($acms)) {
|
|
foreach ($acms as $key => $value) {
|
|
$selected = (isset($ticket_data) && $ticket_data['acm_id'] == $value['id']) ? 'selected' : '';
|
|
echo "<option value=" . $value['id'] . " $selected >" . $value['first_name'] . "</option>";
|
|
}
|
|
}
|
|
?>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="policy_no">Policy No<span class="text-danger"></span></label>
|
|
<input type="text" class="form-control" id="policy_no"
|
|
value="<?= isset($ticket_data['policy_no']) ? $ticket_data['policy_no'] : '' ?>"
|
|
name="policy_no" placeholder="Policy Number" >
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="insurer_id">Insurer<span class="text-danger"></span></label>
|
|
<input type=hidden id="insurer_id" name="insurer_id" value="<?= isset($ticket_data['insurer_id']) ? $ticket_data['insurer_id'] : '' ?>">
|
|
<input type=text class="form-control" id="insurer_name" placeholder="Insurer" value="<?= isset($ticket_data['insurer_name']) ? $ticket_data['insurer_name'] : '' ?>" readonly>
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="tpa_id">TPA<span class="text-danger"></span></label>
|
|
<input type=hidden id="tpa_id" name="tpa_id" value="<?= isset($ticket_data['tpa_id']) ? $ticket_data['tpa_id'] : '' ?>">
|
|
<input type=text class="form-control" id="tpa_name" placeholder="TPA" value="<?= isset($ticket_data['tpa_name']) ? $ticket_data['tpa_name'] : '' ?>" readonly>
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="client_name">Corporate Name<span class="text-danger"></span></label>
|
|
<input type="hidden" id="client_id" name="client_id" value="<?= isset($ticket_data['client_id']) ? $ticket_data['client_id'] : '' ?>">
|
|
<input type="text" class="form-control" id="client_name" placeholder="Client" value="<?= isset($ticket_data['client_name']) ? $ticket_data['client_name'] : '' ?>" readonly>
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="emp_code">Employee ID <i class="fa fa-search text-danger"
|
|
aria-hidden="true" onclick="openFetchEmpDataodal(this)"></i> <span
|
|
class="text-danger"></span></label>
|
|
<input type="text" class="form-control" id="emp_code" placeholder="Enter Employee ID"
|
|
value="<?= isset($ticket_data['emp_code']) ? $ticket_data['emp_code'] : '' ?>"
|
|
name="emp_code">
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="tpa_id">TPA ID<span class="text-danger"></span></label>
|
|
<input type="text" class="form-control" id="tpa_no" placeholder="Enter TPA ID"
|
|
value="<?= isset($ticket_data['tpa_no']) ? $ticket_data['tpa_no'] : '' ?>"
|
|
name="tpa_no">
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="emp_name">Employee Name<span class="text-danger"></span></label>
|
|
<input type=hidden id="emp_id" name="emp_id" value="<?= isset($ticket_data['emp_id']) ? $ticket_data['emp_id'] : '' ?>">
|
|
<input type="text" class="form-control" id="emp_name" placeholder="Enter Employee Name"
|
|
value="<?= isset($ticket_data['emp_name']) ? $ticket_data['emp_name'] : '' ?>"
|
|
name="emp_name">
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="insured_name"> Insured Name <span class="text-danger"></span></label>
|
|
<input type=hidden id="insured_emp_id" name="insured_emp_id" value="<?= isset($ticket_data['insured_emp_id']) ? $ticket_data['insured_emp_id'] : '' ?>">
|
|
<input class="form-control" id="insured_name" name="insured_name" value="<?= isset($ticket_data['insured_name']) ? $ticket_data['insured_name'] : '' ?>">
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="relationship"> Relationship <span class="text-danger"></span></label>
|
|
<select class="form-control" id="relationship" name="relationship">
|
|
<option value="0">Select Relationship</option>
|
|
<?php
|
|
if (isset($relationshipType) && count($relationshipType)) {
|
|
foreach ($relationshipType as $key => $value) {
|
|
$selected = (isset($ticket_data) && $ticket_data['relationship'] == $key) ? 'selected' : '';
|
|
echo "<option value='$key' $selected>$value</option>";
|
|
}
|
|
}
|
|
?>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="emp_mobile">Employee Mobile No<span class="text-danger"></span></label>
|
|
<input type="text" class="form-control" id="emp_mobile" placeholder="Enter EMP Mobile"
|
|
value="<?= isset($ticket_data['emp_mobile']) ? $ticket_data['emp_mobile'] : '' ?>"
|
|
name="emp_mobile">
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="emp_mail">Employee Mail ID<span class="text-danger"></span></label>
|
|
<input type="text" class="form-control" id="emp_mail" placeholder="Enter EMP Mail"
|
|
value="<?= isset($ticket_data['emp_mail']) ? $ticket_data['emp_mail'] : '' ?>"
|
|
name="emp_mail">
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="mode_of_intimation"> Mode of Intimation <span
|
|
class="text-danger"></span></label>
|
|
<select class="form-control" id="mode_of_intimation" name="mode_of_intimation">
|
|
<!-- <option value="0">Select Mode</option> -->
|
|
<?php
|
|
if (isset($modeOFIntimate) && count($modeOFIntimate)) {
|
|
foreach ($modeOFIntimate as $key => $value) {
|
|
$selected = (isset($ticket_data) && $ticket_data['mode_of_intimation'] == $key) ? 'selected' : '';
|
|
echo "<option value='" . $key . "' $selected>" . $value . "</option>";
|
|
}
|
|
}
|
|
?>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="claim_type"> Claim Type <span class="text-danger"></span></label>
|
|
<select class="form-control" id="claim_type" name="claim_type">
|
|
<!-- <option value="0">Select claim Type</option> -->
|
|
<?php
|
|
if (isset($claim_type) && count($claim_type)) {
|
|
foreach ($claim_type as $key => $value) {
|
|
$selected = (isset($ticket_data) && $ticket_data['claim_type'] == $key) ? 'selected' : '';
|
|
echo "<option value='" . $key . "' $selected>" . $value . "</option>";
|
|
}
|
|
}
|
|
?>
|
|
</select>
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="hospital_name">Hospital Name<span class="text-danger"></span></label>
|
|
<input type="text" class="form-control" id="hospital_name"
|
|
placeholder="Enter Hospital Name"
|
|
value="<?= isset($ticket_data['hospital_name']) ? $ticket_data['hospital_name'] : '' ?>"
|
|
name="hospital_name">
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="doa">DOA<span class="text-danger"></span></label>
|
|
<input type="text" class="form-control" id="doa" placeholder="Enter DOA"
|
|
value="<?= isset($ticket_data['doa']) ? $ticket_data['doa'] : '' ?>"
|
|
name="doa">
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="dod">DOD<span class="text-danger"></span></label>
|
|
<input type="text" class="form-control" id="dod" placeholder="Enter DOD"
|
|
value="<?= isset($ticket_data['dod']) ? $ticket_data['dod'] : '' ?>" name="dod">
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="claim_amount">Claim Amount<span class="text-danger"></span></label>
|
|
<input type="text" class="form-control" id="claim_amount"
|
|
placeholder="Enter Claim Amount"
|
|
value="<?= isset($ticket_data['claim_amount']) ? $ticket_data['claim_amount'] : '' ?>"
|
|
name="claim_amount">
|
|
</div>
|
|
|
|
<div class="form-group col-md-3">
|
|
<label for="pod_no">POD No<span class="text-danger"></span></label>
|
|
<input type="text" class="form-control" id="pod_no" placeholder="Enter POD NO"
|
|
value="<?= isset($ticket_data['pod_no']) ? $ticket_data['pod_no'] : '' ?>"
|
|
name="pod_no">
|
|
</div>
|
|
|
|
</div>
|
|
</div>
|
|
<div class="form-group col-md-12 text-right m-b-0" style="margin-top: 29px;">
|
|
<button type="submit" class="btn btn-primary waves-effect waves-light mr-1" id="btnSubmit" >Submit</button>
|
|
</div>
|
|
|
|
</div>
|
|
</form>
|
|
</div>
|
|
</div>
|
|
</div>
|
|
|
|
<script>
|
|
$(document).ready(function() {
|
|
|
|
var doa = flatpickr("#doa", {
|
|
dateFormat: "d/m/Y",
|
|
allowInput: false
|
|
});
|
|
|
|
var dod = flatpickr("#dod", {
|
|
dateFormat: "d/m/Y",
|
|
allowInput: false
|
|
});
|
|
|
|
})
|
|
</script>
|