Best Insurance | Completed Leads

{{ Form::hidden('id', $information->id,array('id' => 'informationId'))}} {{ Form::hidden('premiseName', $information->premiseName)}}

Application Date:

{{ Form::text('txtDateOfIssue', $date_added, array( 'readOnly' => 'true', 'class'=>'form-control')) }}

Policy number:

{{ Form::text('policy_number', $information->policy_number_full, array( 'readOnly' => 'true', 'class'=>'form-control')) }}

Title:

{{ Form::text('title', $information->title, array( 'class'=>'form-control','readOnly' => 'true')) }}

First Name:

{{ Form::text('fname', $information->fname, array( 'class'=>'form-control','readOnly' => 'true')) }}

Last Name:

{{ Form::text('lname', $information->lname, array( 'class'=>'form-control','readOnly' => 'true')) }}

Email:

{{ Form::text('email', $information->email, array( 'class'=>'form-control')) }}

Contact Number:

{{ Form::text('telephone', $information->telephone, array( 'class'=>'form-control')) }}

Employment Status:

Employed

emp_status == 'Self-Employed' ? "checked":"") }}/> Self Employed

emp_status == 'Contract Worker' ? "checked":"") }} {{ ($information->emp_status == 'Contractor' ? "checked":"") }} /> Contractor

emp_status == 'Unknown' ? "checked":"") }} /> Unknown

Employer Name:

{{ Form::text('employer_name', $information->employer_name, array( 'class'=>'form-control')) }}

Date started with current Employer :

{{ Form::text('employer_startdate', $information->employer_startdate, array('id' => 'employer_startdate', 'class'=>'form-control','data-date-format'=>'dd/mm/yyyy')) }}

Industry Type :

Occupation :

Gross Annual Income:

{{ Form::text('monthly_gross_income', $annual_income, array( 'class'=>'form-control')) }}

Other Contact Number:

{{ Form::text('alternate_phone', $information->alternate_phone, array( 'class'=>'form-control')) }}

Other Email Address:

{{ Form::text('alternate_email', $information->alternate_email, array( 'class'=>'form-control')) }}

Are you transferring cover from another provider?

transfer == 'Yes' ? "checked":"") }} /> Yes

transfer == 'No' || $information->transfer == '' ? "checked":"") }} /> No

Name of the current provider

Date on which the current policy was incepted

Smoker:

Yes

smoker == 'No' ? "checked":"") }}/> No

smoker == 'Unknown' ? "checked":"") }} /> Unknown

Joint/2nd Applicant:

{{ Form::text('extra_applicant', $information->extra_applicant, array( 'class'=>'form-control','readOnly' => 'true')) }}

2nd Applicant DoB:

{{ Form::text('extra_applicant_dob', $information->extra_applicant_dob, array( 'class'=>'form-control', 'readOnly' => 'true')) }}

2nd Applicant Occupation:

{{ Form::text('extra_applicant_occupation', $information->extra_applicant_occupation, array( 'class'=>'form-control','readOnly' => 'true')) }}

Bank Account Name :

{{ Form::text('accountname', $information->accountname, array( 'class'=>'form-control')) }}

Account Number:

{{ Form::text('accountnumber', $information->accountnumber, array( 'class'=>'form-control')) }}

Sort Code:

{{ Form::text('sortcode', $information->sortcode, array( 'class'=>'form-control')) }}

Direct Debit Date:

Reason for update: *

{{ Form::submit('Confirm',array('id' => 'formSubmit','class'=>'btn btn-success','rows' => '4')) }}

Edit Application

{{strtoupper( 'Download Pdf')}}