@extends('layouts.admin')
@section('pageTitle')
<title>Best Insurance | Completed Leads</title>
@stop
@section('pageCss')
<link rel="stylesheet" href="{{ URL::asset('assets/plugins/datepicker/datepicker3.css') }}">
@stop
@section('content')
<section class="content mtablock">
  <div class="box">
    <div class="box-warning ">
      <div class="box-header text-center">
        <h2 class="box-title " > <b>Renew Application </b></h2>
      </div>
    </div>

  <div class="box">
    <div class="box box-warning ">
      <div class="box-header with-border text-center">
         <ul class="errors_list_">
          @if($errors->has())
          @foreach ($errors->all() as $error)
          <li class="error">{{ $error }}</li>
          @endforeach
          @endif
        </ul>
      </div>
    </div>
  </div>


    <div class="box-body no-padding ">
      {!! Form::open(array('url' => 'account/renew-completed-lead/'.$information->id.'','id' => 'formValidation')) !!}
      <!-- text input -->
      <div class="form-group col-md-12">
        <!-- Quote Id -->
        {{ Form::hidden('id', $information->id)}}
        {{ Form::hidden('premiseName', $information->premiseName)}}
        <div class="col-md-3">&nbsp;&nbsp;&nbsp;{!! Form::label('Date of issue:') !!}</div>
        <div class="col-md-4">
          {{ Form::text('txtDateOfIssue', date('d/m/Y'),
          array( 'readOnly' => 'true',
          'class'=>'form-control'))
        }}
      </div>
    </div>

    <div class="form-group col-md-12 required">
      <div class="col-md-3"><b>
        <span class=" control-label "></span>&nbsp;
      Policy number:</b> </div>
      <div class="col-md-4">
        <span>{{$information->policy_number_full}}  </span>
                        <!-- {{ Form::text('policy_number', $information->policy_number,
                           array(
                          'class'=>'form-'))
                        }} -->
                      </div>
                    </div>
                    <div class="form-group col-md-12 required ">
                      <div class="col-md-3"><b>
                        <span class=" control-label "></span>&nbsp;
                      Title:</b> </div>
                   

                      <div class="col-md-4">
                        {{ Form::text('title', $information->title,
                        array(
                        'class'=>'form-control','readOnly'=>true))
                      }}
                    </div>

                    </div>

                    <div class="form-group col-md-12 required">
                      <div class="col-md-3"><b>
                        <span class=" control-label "></span>&nbsp;
                      First Name:</b> </div>
                      <div class="col-md-4">
                        {{ Form::text('fname', $information->fname,
                        array(
                        'class'=>'form-control','readOnly'=>true))
                      }}
                    </div>
                  </div>

                  <div class="form-group col-md-12 required">
                    <div class="col-md-3"><b>
                      <span class=" control-label "></span>&nbsp;
                    Last Name:</b> </div>
                    <div class="col-md-4">
                      {{ Form::text('lname', $information->lname,
                      array(
                      'class'=>'form-control','readOnly'=>true))
                    }}
                  </div>
                </div>
                                <div class="form-group col-md-12">
                  <div class="col-md-3">&nbsp;&nbsp;&nbsp;{!! Form::label('Policy holder Address:') !!} </div>
                  <div class="col-md-6">
                    <span>{{$address}} </span><br><br>
                    <!-- <div class="col-xs-4">

                      <input name="postcode2" class="search_postcode form-control col-md-3" id="postcode2-" placeholder="Please enter postcode" title="Please enter postcode" value="" maxLength="8" readOnly='true'>&nbsp;&nbsp;
                      <span class="text text-red error-msg"> </span>
                      
                      <div class="col-xs-1 refresh-btn">

                      </div>
                     
                    </div>

                   <a href="#address" class="find_address_cls2 find_add_btn btn btn-info btn-sm" id="btnPO2-" style="font-size:14px;"><span>Find Address</span></a>
                    <a href="#" class="btn btn-warning btn-sm" id="manual_address" style="font-size:14px;">
                      <span>Add Address Manually</span>
                    </a>-->

                    <div class="fornRow search_new_address" id="POAddress2-" style="display:none;">
                      <table width="100%" border="0" cellspacing="0" cellpadding="0">
                       <tr>
                        <td width="10%" align="left" valign="middle"><p class="blue">Highlight the address that matches your selection and Select</p>
                          <table width="100%" border="0" cellspacing="0" cellpadding="0">
                            <tr>
                              <td align="left" valign="middle">
                                <table width="100%" border="0" cellspacing="0" cellpadding="0">
                                  <tr id="address_tr">
                                    <div class="address-results2" id="address-results2-">
                                    </div>
                                    <td align="" valign="middle">
                                    </td>

                                  </tr>
                                </table>
                              </td>
                            </tr>
                          </table>
                        </td>
                      </tr>
                    </table>
                  </div>
                  <div class="form-group col-xs-12 selected_add">
                    <b>Selected Address</b>
                    <p id="new_line1"> </p>
                    <p id="new_line2"> </p>
                    <p id="new_line3"> </p>
                    <p id="new_line4"> </p>
                    <p id="new_town"> </p>
                    <p id="new_country"> </p>
                    <p id="new_postcode"> </p>

                    {{ Form::hidden('form_new_line1', null, array( 'id' => 'form_new_line1' ,'class'=>'form-control'))}}
                    {{ Form::hidden('form_new_line2', null, array('id' => 'form_new_line2', 'class'=>'form-control'))}}
                    {{ Form::hidden('form_new_line3', null, array('id' => 'form_new_line3', 'class'=>'form-control'))}}
                    {{ Form::hidden('form_new_line4', null, array('id' => 'form_new_line4', 'class'=>'form-control'))}}
                    {{ Form::hidden('form_new_town', null, array('id' => 'form_new_town' ,'class'=>'form-control'))}}
                    {{ Form::hidden('form_new_country', null, array('id' => 'form_new_country', 'class'=>'form-control'))}}
                    {{ Form::hidden('form_new_postcode', null, array('id' => 'form_new_postcode', 'class'=>'form-control'))}}
                    <br>
                  </div>
                  <br>
                  <div class="form_manual_address">
                    <h4><b>If you are unable to find the address please enter the manual Address here</b></h4>
                    <div class="form-group col-md-12 required">

                      <div class="col-md-4"><b>
                        <span class=" control-label "></span>&nbsp;
                      Line1</b> </div>
                      <div class="col-md-8">
                        {{ Form::text('line1', null,
                        array( 'class'=>'form-control'))
                      }}

                    </div>
                  </div>
                  <div class="form-group col-md-12 required">
                    <div class="col-md-4"><b>
                      <span class=" control-label "></span>&nbsp;
                    Line2</b> </div>
                    <div class="col-md-8">
                      {{ Form::text('line2',null,
                      array( 'class'=>'form-control'))
                    }}

                  </div>
                </div>
                <div class="form-group col-md-12 required">
                  <div class="col-md-4"><b>
                    <span class=" control-label "></span>&nbsp;
                  Line3</b> </div>
                  <div class="col-md-8">
                    {{ Form::text('line3', null,
                    array( 'class'=>'form-control'))
                  }}

                </div>
              </div>
              <div class="form-group col-md-12 required">
                <div class="col-md-4"><b>
                  <span class=" control-label "></span>&nbsp;
                Line4</b> </div>
                <div class="col-md-8">
                  {{ Form::text('line4', null,
                  array( 'class'=>'form-control'))
                }}
              </div>
            </div>
            <div class="form-group col-md-12 required">
             <div class="col-md-4"><b>
              <span class=" control-label "></span>&nbsp;
            Town</b> </div>
            <div class="col-md-8">
              {{ Form::text('town', null,
              array( 'class'=>'form-control'))
            }}
          </div>
        </div>
        <div class="form-group col-md-12 required">
          <div class="col-md-4"><b>
            <span class=" control-label "></span>&nbsp;
          Country</b> </div>
          <div class="col-md-8">
            {{ Form::text('country', null,
            array( 'class'=>'form-control'))
          }}
        </div>
      </div>
      <div class="form-group col-md-12 required">
       <div class="col-md-4"><b>
        <span class=" control-label "></span>&nbsp;
      Postal Code</b> </div>
      <div class="col-md-8">
        {{ Form::text('postal_code', null,
        array( 'class'=>'form-control'))
      }}
    </div>
  </div>
</div>
<div class="fornRow">
  <table width="100%" cellspacing="0" cellpadding="0" border="0">
    <tbody>
      <tr>
        <td valign="middle" align="left" style="display:none; " id="tblFullAddress2-" colspan="2">
          <p><strong>Address Information</strong>:</p>
          <p id="CompleteAddress2-"></p>
        </td>
      </tr>
    </tbody>
  </table>
</div>
</div>
</div>
<hr>
<div class="form-group col-md-12">
  <div class="text-center">
    <h3 style="color:#009aa9">SCHEDULE OF INSURANCE </h3>
    <span>{{$policy_prefix->pdf_underwritten_txt}} </span>
  </div>
</div>
<div class="form-group col-md-6 required">

  <div class="col-md-4"><b>
    <span class=" control-label "></span>&nbsp;
  Policy Renewal Date:</b> </div>
  <div class="col-md-8">
    {{ Form::text('editapppolicystartdate',$renwalday,
    array( 'id' => 'policyStartdate',
    'class'=>'form-control'))
  }}
</div>
</div>

<div class="form-group col-md-6">
  <div class="col-md-4">{!! Form::label('Policy End Date:') !!} </div>
  <div class="col-md-8">
   {{ Form::text('txtPolicyEndDate',$renewalEndDay,
   array( 'readOnly' => true,
   'class'=>'form-control'))
 }}
</div>
</div>
                   <div class="form-group col-md-6 required">
                    <div class="col-md-4"><b>
                      <span class=" control-label "></span>&nbsp;
                    Cover type:</b> </div>
                    <div class="col-md-8">

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

                  </div>
                </div>

                <input type="hidden" id="cover_type" value="{{$information->typeofcover}}">
                <input type="hidden" id="excess_period_value" value="{{$information->excessperiod}}">
                <input type="hidden" id="old_monthly_premium" value="{{$information->monthlycost}}">
                <input type="hidden" id="information_id" value="{{$information->id}}">
                <div class="form-group col-md-6 required">

                  <div class="col-md-4"><b>
                    <span class=" control-label "></span>&nbsp;
                  Excess Period:</b> </div>
                  <div class="col-md-8">

                  {{ Form::text('excessperiod', $information->excessperiod,
                  array(
                  'class'=>'form-control','id' => 'excessperiod','readOnly' => true))
                }}
                   
                </div>
              </div>

              <div class="form-group col-md-6 required">
                <div class="col-md-4"><b>
                  <span class=" control-label "></span>&nbsp;
                Monthly Benefit:</b> </div>
                <div class="col-md-8">

                
                  {{ Form::text('monthlybenefit', $information->monthlybenefit,
                  array(
                  'class'=>'form-control','id' => 'monthlybenefit','readOnly' => true))
                }}
              </div>
            </div>

            <div class="form-group col-md-6 required">

              <div class="col-md-4"><b>
                <span class=" control-label "></span>&nbsp;
              Maximum Benefit Period:</b> </div>
              <div class="col-md-8">

              {{ Form::text('renew_benefit_period', $information->benefit_period." Months",
                  array(
                  'class'=>'form-control','id' => 'renew_benefit_period','readOnly' => true))
                }}

               
           </div>
         </div>

         <div class="form-group col-md-6 required">

          <div class="col-md-4"><b>
            <span class=" control-label "></span>&nbsp;
          Monthly premium:</b> </div>
          <div class="col-md-8">
            {{ Form::text('monthlycost', $monthly_premium,
            array(
            'class'=>'form-control','id' => 'monthlycost','readOnly' => true))
          }}
        </div>
      </div>


      <div class="form-group col-md-6 required">

        <div class="col-md-4"><b>
          <span class=" control-label "></span>&nbsp;
        Previous Monthly premium:</b> </div>
        <div class="col-md-8">
          {{ Form::text('previous_monthly_premium', $information->monthlycost,
          array(
          'class'=>'form-control','id' => 'previous_monthly_premium'))
        }}
      </div>
    </div>

    <div class="form-group col-md-6 required">

      <div class="col-md-4"><b>
        <span class=" control-label "></span>&nbsp;
      Previous Annual premium:</b> </div>
      <div class="col-md-8">
        {{ Form::text('previous_annual_premium', $information->monthlycost*12,
        array(
        'class'=>'form-control','id' => 'previous_annual_premium'))
      }}
    </div>
  </div>



  <div class="form-group col-md-6">
    <div class="col-md-4">{!! Form::label('Payment option:') !!}</div>
    <div class="col-md-8">
      Monthly direct debit
    </div>
  </div>

  <div class="form-group col-md-12 required">
    <div class="col-md-2"><b>
      <span class=" control-label "></span>&nbsp;
    Reason for update: * </b> </div>
    <div class="col-md-8">
     <textarea name="reason" required cols=52></textarea>
   </div>
 </div>

 <div class="form-group col-md-12 required">
  <div class="col-md-2"><b>
    <span class=" control-label "></span>&nbsp;
  Select Payment option: * </b>
  </div>
  <div class="col-md-8">
    <div id="payment_option_section">
      <label class="chec__lbl">
        <input type="radio" value='raf' name="payment_option"   class="_payment_option">
       Pay with Red Apple Finance</label>
      <label class="chec__lbl">
        <input type="radio" value='cc' name="payment_option"  class="_payment_option">
       Pay with CC</label>
       <label class="chec__lbl">
            <input type="radio" value='eazycollect' name="payment_option"   class="_payment_option">
               EazyCollect </label>
      <label class="chec__lbl">
            <input type="radio" value='others' name="payment_option"   class="_payment_option">
             Others </label>
       <br/>
    </div>
</div>
</div>

<div class="form-group col-md-12 text-center">
  &nbsp;&nbsp;&nbsp;
  {{ Form::submit('Confirm',array('class'=>'btn btn-success submit___btn','rows' => '4'))
}}
</div>
</form>
</div>
</div>
<!-- </div> -->
</section>



<!-- // Download Pdf section  -->
@stop
@section('pageBottomJs')
<style type="text/css">
  .error{
    color: red
  }

  .address-results1, .address-results2 {
    border: 1px solid #d5d6d7;
    height: 150px;
    overflow: auto;
    width: 300px;
  }
  .fancybox-skin {
    color: #444;
    text-shadow: none;
  }

  /*required field asterisk symbol */
  .form-group.required .control-label:after {
    content:"*";
    color:red;
  }

  .error{
    color: red
  }
  #renew_email_send .modal-dialog{
    width: 300px;
  }
  #renew_email_send .modal-content{
    border-radius: 8px;
  }
  .popform label{
   width: 35px;
 }
 .popform input{
   outline: none;
   border: 1px solid #cecece;
   height: 30px;
   width: 210px;
   padding: 5px 15px;
   font-size: 14px;
   box-shadow: none;
 }
 .popform .btn{
  width: auto !important;
  height: auto;
  line-height: normal;
}
.address-results1, .address-results2 {
  border: 1px solid #d5d6d7;
  height: 150px;
  overflow: auto;
  width: 300px;
}
.fancybox-skin {
  color: #444;
  text-shadow: none;
}

/*required field asterisk symbol */
.form-group.required .control-label:after {
  content:"*";
  color:red;
}.errors_list_{background-color: #ffe5e5;
    padding: 10px 10px 10px 30px; text-align: left;
    margin: 0;
    list-style-type: circle;}
.chec__lbl{    font-size: 15px;margin: 0 20px 0 0;}

</style>
<link rel="stylesheet" href="{{ URL::asset('assets/plugins/iCheck/all.css') }}">
<!-- pretty scroll bar(AdminLite Documentation page css) -->
<link rel="stylesheet" href="{{ URL::asset('assets/plugins/PrettyScroll/style.css') }}">
<!-- iCheck 1.0.1 -->
<script src="{{ URL::asset('assets/plugins/iCheck/icheck.min.js') }}"></script>
<script src="{{ URL::asset('assets/plugins/datepicker/bootstrap-datepicker.js') }}"></script>
<script type="text/javascript" src="{{ URL::asset('assets/js/views/leads/renew-comleted-view.js') }}" ></script>
<script type="text/javascript">
  $(document).ready(function(){
    ajax_call_monthly_premium();
    $( ".submit___btn" ).click(function(ev) {
      if($("#formValidation").valid()){
          $( ".submit___btn").attr('disabled', true);
          $( ".submit___btn").attr('value', "Please wait");
          $("#formValidation").submit();
      }
    });
  });
</script>

@stop