Best Insurance | Completed Leads

Edit Application

{!! Form::open(array('url' => 'account/edit-completed-lead-bestaccident/'.$information->information_id.'','id' => 'formValidation',)) !!}

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

Date of issue:

{{ Form::text('txtDateOfIssue', date('d/m/Y'), array( 'readOnly' => 'true', 'class'=>'form-control')) }}

Policy number:

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

Title:

{{ Form::select('title', [ '0' => 'Select', 'Mr.' => 'Mr.', 'Ms.' => 'Ms.', 'Mrs.' => 'Mrs.', 'Dr.' => 'Dr.', 'Rev.' => 'Rev.', 'Miss.' => 'Miss.'],$information->title, ['class' => 'form-control select2 select2-hidden-accessible'] ) }}

First Name:

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

Last Name:

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

Email:

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

Contact Number:

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

Reason for update: *

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

Edit Application

{{strtoupper( 'Download Pdf')}}