48 lines
2.6 KiB
PHP
48 lines
2.6 KiB
PHP
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<div class="form-row custom_fields">
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<!-- Risk Location -->
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<div class="form-group col-md-6">
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<label>Risk Location</label>
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<div>
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<?php $risk_location = isset($lead_edit_data['risk_location']) ? $lead_edit_data['risk_location'] : ''; ?>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" id="single" name="risk_location" value="Single" <?= ($risk_location == 'Single') ? 'checked' : ''; ?>>
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<label class="form-check-label" for="single">Single</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" id="multi_floater" name="risk_location" value="multi_with_floter" <?= ($risk_location == 'multi_with_floter') ? 'checked' : ''; ?>>
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<label class="form-check-label" for="multi_floater">Multi with Floater</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" id="multi_no_floater" name="risk_location" value="multi_without_floter" <?= ($risk_location == 'multi_without_floter') ? 'checked' : ''; ?>>
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<label class="form-check-label" for="multi_no_floater">Multi without Floater</label>
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</div>
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</div>
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</div>
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<!-- Product -->
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<div class="form-group col-md-3">
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<label for="product">Product</label>
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<input type="text" class="form-control" id="product" name="product" value="<?= isset($lead_edit_data['product']) ? htmlspecialchars($lead_edit_data['product']) : ''; ?>">
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</div>
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<!-- Nature of Business -->
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<div class="form-group col-md-3">
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<label for="nature_of_business">Nature of Business</label>
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<input type="text" class="form-control" id="nature_of_business" name="nature_of_business" value="<?= isset($lead_edit_data['nature_of_business']) ? htmlspecialchars($lead_edit_data['nature_of_business']) : ''; ?>">
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</div>
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<!-- Communication Address -->
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<div class="form-group col-md-3">
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<label for="pinCode">Pin Code</label>
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<input type="text" class="form-control" id="pinCode" name="pincode" value="<?= isset($lead_edit_data['pincode']) ? htmlspecialchars($lead_edit_data['pincode']) : ''; ?>">
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</div>
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<div class="form-group col-md-3">
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<label for="address">Communication Address</label>
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<textarea class="form-control" id="address" name="address" rows="1"><?= isset($lead_edit_data['address']) ? htmlspecialchars($lead_edit_data['address']) : ''; ?></textarea>
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</div>
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</div>
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