47 lines
2.3 KiB
PHP
47 lines
2.3 KiB
PHP
<hr>
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<div class="form-row custom_fields">
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<!-- Proposal Type -->
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<div class="form-group col-md-3">
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<label for="proposal_type">Proposal Type</label>
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<input type="text" class="form-control" id="proposal_type" name="proposal_type" value="<?= isset($lead_edit_data['proposal_type']) ? htmlspecialchars($lead_edit_data['proposal_type']) : ''; ?>">
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</div>
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<!-- GST -->
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<div class="form-group col-md-3">
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<label for="gst">GST</label>
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<input type="text" class="form-control" id="gst" name="gst" value="<?= isset($lead_edit_data['gst']) ? htmlspecialchars($lead_edit_data['gst']) : ''; ?>">
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</div>
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<!-- Trade Description -->
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<div class="form-group col-md-3">
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<label for="trade_description">Trade Description</label>
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<input type="text" class="form-control" id="trade_description" name="trade_description" value="<?= isset($lead_edit_data['trade_description']) ? htmlspecialchars($lead_edit_data['trade_description']) : ''; ?>">
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</div>
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<!-- Jurisdiction -->
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<div class="form-group col-md-3">
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<label for="jurisdiction">Jurisdiction</label>
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<input type="text" class="form-control" id="jurisdiction" name="jurisdiction" value="<?= isset($lead_edit_data['jurisdiction']) ? htmlspecialchars($lead_edit_data['jurisdiction']) : ''; ?>">
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</div>
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<!-- Address of the Premises to be Insured -->
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<div class="form-group col-md-6">
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<label for="premises_address">Address of the Premises to be Insured</label>
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<textarea class="form-control" id="premises_address" name="premises_address" rows="1"><?= isset($lead_edit_data['premises_address']) ? htmlspecialchars($lead_edit_data['premises_address']) : ''; ?></textarea>
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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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