Best Insurance | Completed Leads

Policy Transfer form Best income to Simple income

{!! Form::open(array('url' => '/account/completed-leads/polacy-transfer-bestincome-to-simple/'.$information->id.'','id' => 'formValidation')) !!}

{!! Form::label('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( '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( 'class'=>'form-control')) }}

Last Name:

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

Gross Income:

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

Date of Birth:

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

Employement Status:

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

Employer Name:

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

Employer Industry:

{!! Form::label('Policy holder Address:') !!}

Find Address Add Address Manually

Selected Address

{{ 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'))}}

If you are unable to find the address please enter the manual Address here

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Town

Country

{{ Form::text('country', null, array( 'class'=>'form-control')) }}

Postal Code

{{ Form::text('postal_code', null, array( 'class'=>'form-control')) }}

SCHEDULE OF INSURANCE

Policy Start Date:

{{ Form::text('editapppolicystartdate',$renwalday, array( 'id' => 'policyStartdate', 'class'=>'form-control')) }}

{!! Form::label('Policy End Date:') !!}

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

Cover type:

{{ Form::select('typeofcover', [ '0' => 'select', 'ASU' => 'Unemployment, Accident & Sickness', 'U' => 'Unemployment only', 'AS' => 'Accident & Sickness only' ],$information->typeofcover, array('class'=>'form-control','id' => 'typeofcover')) }}

Excess Period:

Monthly Benefit:

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

Maximum Benefit Period:

{{ Form::select('renew_benefit_period', [ '0' => 'select', '12' => '12 months', ],$information->benefit_period, array('class'=>'form-control')) }}

Monthly premium:

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

{!! Form::label('Payment option:') !!}

Monthly direct debit

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

Policy Transfer form Best income to Simple income

If you are unable to find the address please enter the manual Address here

SCHEDULE OF INSURANCE

{{strtoupper( 'Download Pdf')}}