@extends('layouts.app')

@section('content')
<div class="page-breadcrumb">
    <div class="row">
        <div class="col-5 align-self-center">
            <h4 class="page-title">COC Issuance</h4>
            <div class="d-flex align-items-center">
                <nav aria-label="breadcrumb">
                    <ol class="breadcrumb">
                        <li class="breadcrumb-item"><a href="#">Home</a></li>
                        <li class="breadcrumb-item active" aria-current="page">COC Issuance</li>
                    </ol>
                </nav>
            </div>
        </div>
    </div>
</div>


  <!-- Page Content -->
  <div id="page-wrapper">
    <div class="container-fluid">
       
        
         <!--.row-->
         <div class="row">
            <div class="col-md-12">
                <div class="panel panel-info">
                    <div class="panel-wrapper collapse in" aria-expanded="true">
                        <div class="panel-body">
                            @if ($error = Session::get('error'))
                                <div class="alert alert-danger">
                                <strong> {{$error}}</strong>
                                </div>
                            @endif
                        <form action="{{route('endorsement.update', ['auth' => $auth,'transaction_id' => $data->policy_transaction_id, 'application_type' => $data->application_type, 'policy_code' => $data->policy_code])}}" method="Post" class="form-horizontal">
                            @csrf
                                <div class="form-body">
                                    <h3 class="box-title">Assured Details</h3>
                                    <hr class="m-t-0 m-b-40">
                                    <div class="row">
                                        <div class="col-md-4">
                                            <div class="form-group @if($errors->first('insurer_name')) has-error @endif">
                                                <label class="control-label col-md-4">Insurer / Borrower Name</label>
                                                <div class="col-md-8">
                                                    <input type="text" class="form-control" placeholder="" name="insurer_name" value="{{ $data->insurer_name }}">
                                                     <span class="help-block">{{ $errors->first('insurer_name') }} </span> 
                                                </div>
                                            </div>
                                        </div>
                                        <div class="col-md-8">
                                            <div class="form-group @if($errors->first('insurer_address')) has-error @endif">
                                                <label class="control-label col-md-2">Address</label>
                                                <div class="col-md-10">
                                                    <input type="text" class="form-control" placeholder="" name="insurer_address" value="{{ $data->    insurer_address }}">
                                                     <span class="help-block"> {{$errors->first('insurer_address')}} </span>  
                                                </div>
                                            </div>
                                        </div>
                                    </div>

                                    <!--/row-->
                                    <div class="row">
                                        <div class="col-md-4">
                                            <div class="form-group @if($errors->first('assured_tin')) has-error @endif">
                                                <label class="control-label col-md-4">Assured TIN</label>
                                                <div class="col-md-8">
                                                    <input type="text" class="form-control" placeholder="" name="assured_tin" value="{{ $data->assured_tin }}">
                                                    <span class="help-block"> {{$errors->first('assured_tin')}}</span> 
                                                 </div>
                                            </div>
                                        </div>
                                        <!--/span-->
                                        <div class="col-md-4">
                                            <div class="form-group @if($errors->first('assured_contact')) has-error @endif">
                                                <label class="control-label col-md-4">Contact Number</label>
                                                <div class="col-md-8">
                                                    <input type="text" class="form-control" placeholder="" name="assured_contact" value="{{ $data->assured_contact }}">
                                                    <span class="help-block"> {{$errors->first('assured_contact')}} </span> 
                                                 </div>
                                            </div>
                                        </div>
                                        <!--/span-->
                                        <div class="col-md-4">
                                            <div class="form-group @if($errors->first('assured_email')) has-error @endif">
                                                <label class="control-label col-md-4">Email</label>
                                                <div class="col-md-8">
                                                    <input type="text" class="form-control" placeholder="" name="assured_email" value="{{ $data->assured_email }}">
                                                     <span class="help-block"> {{$errors->first('assured_email')}} </span> 
                                                 </div>
                                            </div>
                                        </div>
                                        <!--/span-->
                                    </div>
                                    <!--/row-->
                                   
                                    
                                </div>
                                <div class="form-actions">
                                    <div class="row">
                                        <div class="col-md-12">
                                            <div class="row">
                                                <div class="col-md-offset-10 col-md-12">
                                                    <button type="button" class="btn btn-success" data-toggle="modal" data-target=".bs-example-modal-sm">Save Changes</button>
                                                    @if($auth==null)
                                                    <a href="{{ url('premium-verification/'.$data->policy_code.'/'.$data->policy_transaction_id) }}" type="button" class="btn btn-success" >Next</a>
                                                    @endif
                                                </div>
                                            </div>
                                        </div>
                                            <!-- sample modal content -->
                                            <div class="modal fade bs-example-modal-sm" tabindex="-1" role="dialog" aria-labelledby="mySmallModalLabel" aria-hidden="true" style="display: none;">
                                                <div class="modal-dialog modal-sm">
                                                    <div class="modal-content">
                                                        <div class="modal-header">
                                                            
                                                            <h4 class="modal-title" id="mySmallModalLabel"></h4> </div>
                                                        <div class="modal-body"> 
                                                            Please confirm all inputs before saving.<br><br>
                                                            <input type="Submit" value="Save" class="btn btn-primary">
                                                      <button type="button" class="btn btn-default" data-dismiss="modal" aria-hidden="true">Close</button>
                                                        </div> </div>
                                                    </div>
                                                    <!-- /.modal-content -->
                                                </div>
                                                <!-- /.modal-dialog -->
                                            </div>
                                            <!-- /.modal -->

                                        <div class="col-md-6"> </div>
                                    </div>
                                </div>
                            </form>
                        </div>
                    </div>
                </div>
            </div>
        </div>
        <!--./row-->

@endsection