@extends('layouts.frontend')
@section('title', 'Best Insurance: Protection Insurance | Income Protection Plan | Payment Protection Policy')
@section('content')  
<section class="inner-content">
    <div class="clearfix"></div>
    <div class="container">
        <div class="get-quote">
            @if(Session::get('success'))
                <div class="alert alert-success">
                    {{Session::get('success')}}
                </div>
            @endif
            @if(Session::get('failure'))
                <div class="alert alert-danger">
                    {{Session::get('failure')}}
                </div>
            @endif
                        <form name="quotefrm" id="getQuoteFrm" method="post" action="{{ url('get-a-quote-continue') }}" class="form-horizontal" role="form">
                <input type="hidden" name="_token" value="{{ csrf_token() }}">
                <input type="hidden" name="qid" value="{{ $quote_data->id }}">
                <div class="bg">
                    <div class="form-group">
                        <label class="control-label col-sm-4" for="sex">Gender</label>
                        <div class="col-sm-8">
                            <div class="radio">
                                <div class="radio-inline padding-left-none">
                                    <input type="radio" name="sex" id="sex_1" value="Male" class="residence_status" {{ ($information_data->gender == 'Male' ? "checked":"") }}>
                                    <label for="sex_1"> Male </label>
                                </div>
                                <div class="radio-inline">
                                    <input type="radio" name="sex" id="sex_2" value="Female" class="residence_status" {{ ($information_data->gender == 'Female' ? "checked":"") }}>
                                    <label for="sex_2"> Female </label>
                                </div>
                                <br>
                            </div>
                        </div>
                    </div>

                    <div class="form-group {{ $errors->has('title') ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4" for="title">Title</label>
                        <div class="col-sm-4 padding-right-none">
                            <select name="title"  class="form-control"  id="title" title="Please Select Title">
                                <option value="">Please Select Title</option>
                                <option value="Mr." {{ ($information_data->title == 'Mr.' ? "selected":"") }}>Mr.</option>
                                <option value="Ms." {{ ($information_data->title == 'Ms.' ? "selected":"") }}>Ms.</option>
                                <option value="Mrs." {{ ($information_data->title == 'Mrs.' ? "selected":"") }}>Mrs.</option>
                                <option value="Miss." {{ ($information_data->title == 'Miss.' ? "selected":"") }}>Miss.</option>
                                <option value="Dr." {{ ($information_data->title == 'Dr.' ? "selected":"") }}>Dr.</option>
                            </select>
                        </div>
                    </div>

                    <div class="form-group{{ $errors->has('first_name') ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4">First Name</label>
                        <div class="col-sm-4 padding-right-none">
                            <input type="text" class="form-control" name="first_name" id="first_name" value="{{ $information_data->fname }}" />
                        </div>
                    </div>
                    <div class="form-group{{ $errors->has('last_name') ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4">Last Name</label>
                        <div class="col-sm-4 padding-right-none">
                            <input type="text" class="form-control" name="last_name" id="last_name" value="{{ $information_data->lname }}" />
                        </div>
                    </div>
                 
                    <div class="form-group {{ ($errors->has('day')  ||  $errors->has('month')  ||  $errors->has('year') ) ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4">Date of Birth</label>
                        <div class="col-sm-8 padding-left-none">
                            <div class="col-sm-2 padding-right-none">
                                <select name="day" id="day" class="form-control">
                                    <option value="">DD</option>
                                    @foreach ($days as $key => $value)
                                        <option value="{{$key}}" {{ ($dob[2] == $key ? "selected":"") }}> {{$value}} </option>
                                    @endforeach
                                </select>
                            </div>
                            <div class="col-sm-2 padding-right-none">
                                <select name="month" id="month" class="form-control" onChange="return checkdate();">
                                    <option value="">MMM</option>
                                        @foreach ($months as $key => $value)
                                            <option value="{{$key}}" {{ ($dob[1] == $key ? "selected":"") }}> {{ $value }}</option>
                                        @endforeach
                                </select>
                            
                            </div>
                            <div class="col-sm-2 padding-right-none">
                                <select name="year" id="year" class="form-control" onchange="return checkLeapYear();">
                                    <option value="">YYYY</option>
                                        @for ($i = 1954; $i <= 1999; $i++)
                                            <option value="{{$i}}" {{ ($dob[0] == $i ? "selected":"") }}> {{$i}} </option>
                                        @endfor
                                </select>
                            </div>
                        </div>
                    </div>

                    <div class="form-group">
                        <label class="control-label col-sm-4" for="sex">Smoker</label>
                        <div class="col-sm-8">
                            <div class="radio">
                                <div class="radio-inline padding-left-none">
                                    <input type="radio" name="smoker" id="smoker_1" value="Yes" class="residence_status" {{ ($information_data->smoker == 'Yes' ? "checked":"") }}>
                                    <label for="smoker_1"> Yes </label>
                                </div>
                                <div class="radio-inline">
                                    <input type="radio" name="smoker" id="smoker_2" value="No" class="residence_status"  {{ ($information_data->smoker == 'No' ? "checked":"") }}>
                                    <label for="smoker_2"> No </label>
                                </div>
                                <br>
                            </div>
                        </div>
                    </div>
                    
                    
                    <input type="hidden" name="txtProtectionSubtype" value="TERM">
                    <input type="hidden" name="txtBenefitType" value="DEATH_BENEFIT">
                    <input type="hidden" name="txtCICTPDMask" value="19">
                    
                    
                    <div class="form-group">
                        <label class="control-label col-sm-4" for="title">Increasing Benefit</label>
                        <div class="col-sm-8">
                            <div class="radio">
                                <div class="radio-inline padding-left-none">
                                    <input type="radio" name="txtIncreasingBenefit" id="txtIncreasingBenefit_1" value="Yes" class="residence_status">
                                    <label for="txtIncreasingBenefit_1"> Yes </label>
                                </div>
                                <div class="radio-inline">
                                    <input type="radio" name="txtIncreasingBenefit" id="txtIncreasingBenefit_2" value="No" class="residence_status" checked>
                                    <label for="txtIncreasingBenefit_2"> No </label>
                                </div>
                                <br>
                            </div>
                        </div>
                    </div>

                    <input type="hidden" name="txtWaiverBasis" value="None">
                    <input type="hidden" name="txtCoverBasis" value="JointFirstEvent">

                    
                    <div class="form-group {{ $errors->has('residential_status') ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4" for="pwd">Residential Status</label>
                        <div class="col-sm-8">
                            <div class="radio">
                                <div class="radio-inline padding-left-none">
                                    <input type="radio" name="residential_status" id="res_status_1" value="owner" class="residence_status" {{ ($quote_data->residential_status == 'owner' ? "checked":"") }}>
                                    <label for="res_status_1"> Home Owner </label>
                                </div>
                                <div class="radio-inline">
                                    <input type="radio" name="residential_status" id="res_status_2" value="tenant" class="residence_status" {{ ($quote_data->residential_status == 'tenant' ? "checked":"") }}>
                                    <label for="res_status_2"> Tenant </label>
                                </div>
                                <div class="radio-inline">
                                    <input type="radio" name="residential_status" id="res_status_3" value="other" class="residence_status" {{ ($quote_data->residential_status == 'other' ? "checked":"") }}>
                                    <label for="res_status_3"> Other </label>
                                </div>
                                <br>
                            </div>
                            <label name="residential_status-error" class="error" for="residential_status" style="display:none;"></label>
                        </div>
                    </div>
                    
                    <div id="block_1">
                        @if ($quote_data->residential_status == 'tenant')
                            <div id="div_tenant_opts">
                                <div class="form-group {{ $errors->has('monthly_rent') ? ' has-error' : '' }}">
                                    <label class="control-label col-sm-4">Monthly Rent Amount</label>
                                    <div class="col-sm-4 padding-right-none">
                                        <input type="text" class="form-control" name="monthly_rent" id="monthly_rent" value="{{ $quote_data->monthly_rent }}" /> 
                                        <span id="monthly_rent_err" class="error"></span>
                                    </div>
                                </div>
                            </div>
                        @endif

                        @if ($quote_data->residential_status == 'owner')
                            <div id="res_status_1">
                                <div id="div_mortgage_opts">
                                    <div class="form-group {{ $errors->has('mortgage_type') ? ' has-error' : '' }}">
                                        <label class="control-label col-sm-4" for="">Mortgage Type</label>
                                        <div class="col-sm-8">
                                            <div class="radio">
                                                <div class="radio-inline padding-left-none">
                                                    <input type="radio" name="mortgage_type" id="new_mortgage" value="1" class="home_mortgage_type" onclick="new_mortgage_load()" {{ ($quote_data->mortgage_type == '1' ? "checked":"") }}> 
                                                    <label for="new_mortgage">New Mortgage</label>
                                                </div>
                                                <div class="radio-inline">
                                                    <input type="radio" name="mortgage_type" id="existing_mortgage" value="2" class="home_mortgage_type" onclick="existing_mortgage_load()" {{ ($quote_data->mortgage_type == '2' ? "checked":"") }}> 
                                                    <label for="existing_mortgage">Existing Mortgage</label>
                                                </div>
                                                <div class="radio-inline">
                                                    <input type="radio" name="mortgage_type" id="without_mortgage" value="3" class="home_mortgage_type" onclick="existing_ownandlive_load()" {{ ($quote_data->mortgage_type == '3' ? "checked":"") }}> 
                                                    <label for="without_mortgage">Own and live in my primary residence without Mortgage</label>
                                                </div>
                                            </div>
                                         </div>
                                    </div>
                                </div>
                            </div>

                        @endif
                    </div> <!-- End block_1-->
                    <div id="block_2">
                        @if ($quote_data->mortgage_type == '1')
                            <div id="div_new_mortgage">
                                <div class="form-group {{ $errors->has('mm_repay_1') ? ' has-error' : '' }}">
                                    <label class="control-label col-sm-4">Monthly Mortgage Repayment</label>
                                    <div class="col-sm-4 padding-right-none">
                                        <input type="text" class="form-control" name="mm_repay_1" id="mm_repay_1" value="{{ $quote_data->monthly_mortgage_repay }}" />
                                    </div>
                                </div> 
                                <!-- Start -- mm_duration_div -->
                                <div id="mm_duration_div">
                                    <div class="form-group {{ ($errors->has('mortgage_duration_year')  ||  $errors->has('mortgage_duration_month') ) ? ' has-error' : '' }}">
                                        <label class="control-label col-sm-4">Duration of your financial agreement : </label>
                                        <div class="col-sm-2 padding-right-none">
                                            <select id="no_of_years" name="mortgage_duration_year" class="form-control">
                                                <option value="">YY</option>
                                                <option value="0">00</option>
                                                                                                    <option value="01" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    01                                                </option>
                                                                                                    <option value="02" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    02                                                </option>
                                                                                                    <option value="03" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    03                                                </option>
                                                                                                    <option value="04" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    04                                                </option>
                                                                                                    <option value="05" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    05                                                </option>
                                                                                                    <option value="06" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    06                                                </option>
                                                                                                    <option value="07" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    07                                                </option>
                                                                                                    <option value="08" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    08                                                </option>
                                                                                                    <option value="09" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    09                                                </option>
                                                                                                    <option value="10" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    10                                                </option>
                                                                                                    <option value="11" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    11                                                </option>
                                                                                                    <option value="12" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    12                                                </option>
                                                                                                    <option value="13" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    13                                                </option>
                                                                                                    <option value="14" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    14                                                </option>
                                                                                                    <option value="15" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    15                                                </option>
                                                                                                    <option value="16" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    16                                                </option>
                                                                                                    <option value="17" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    17                                                </option>
                                                                                                    <option value="18" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    18                                                </option>
                                                                                                    <option value="19" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    19                                                </option>
                                                                                                    <option value="20" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    20                                                </option>
                                                                                                    <option value="21" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    21                                                </option>
                                                                                                    <option value="22" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    22                                                </option>
                                                                                                    <option value="23" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    23                                                </option>
                                                                                                    <option value="24" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    24                                                </option>
                                                                                                    <option value="25" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    25                                                </option>
                                                                                                    <option value="26" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    26                                                </option>
                                                                                                    <option value="27" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    27                                                </option>
                                                                                                    <option value="28" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    28                                                </option>
                                                                                                    <option value="29" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    29                                                </option>
                                                                                                    <option value="30" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    30                                                </option>
                                                                                                    <option value="31" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    31                                                </option>
                                                                                                    <option value="32" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    32                                                </option>
                                                                                                    <option value="33" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    33                                                </option>
                                                                                                    <option value="34" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    34                                                </option>
                                                                                                    <option value="35" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    35                                                </option>
                                                                                                    <option value="36" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    36                                                </option>
                                                                                                    <option value="37" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    37                                                </option>
                                                                                                    <option value="38" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    38                                                </option>
                                                                                                    <option value="39" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    39                                                </option>
                                                                                                    <option value="40" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    40                                                </option>
                                                                                                    <option value="41" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    41                                                </option>
                                                                                                    <option value="42" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    42                                                </option>
                                                                                                    <option value="43" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    43                                                </option>
                                                                                                    <option value="44" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    44                                                </option>
                                                                                                    <option value="45" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    45                                                </option>
                                                                                                    <option value="46" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    46                                                </option>
                                                                                                    <option value="47" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    47                                                </option>
                                                                                                    <option value="48" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    48                                                </option>
                                                                                                    <option value="49" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    49                                                </option>
                                                                                                    <option value="50" {{ ($quote_data->mortgage_duration_year == $i ? "selected":"") }}>
                                                    50                                                </option>
                                                                                                </select> 
                                            <span id="new_mm_year_err" class="error"></span>
                                        </div>

                                        <div class="col-sm-2 padding-right-none">
                                            <select name="mortgage_duration_month" id="no_of_months" class="form-control">
                                                <option value="">MM</option>
                                                <option value="0">00</option>
                                                                                                    <option value="01" {{ ($quote_data->mortgage_duration_month == $i ? "selected":"") }}>
                                                    01                                                </option>
                                                                                                    <option value="02" {{ ($quote_data->mortgage_duration_month == $i ? "selected":"") }}>
                                                    02                                                </option>
                                                                                                    <option value="03" {{ ($quote_data->mortgage_duration_month == $i ? "selected":"") }}>
                                                    03                                                </option>
                                                                                                    <option value="04" {{ ($quote_data->mortgage_duration_month == $i ? "selected":"") }}>
                                                    04                                                </option>
                                                                                                    <option value="05" {{ ($quote_data->mortgage_duration_month == $i ? "selected":"") }}>
                                                    05                                                </option>
                                                                                                    <option value="06" {{ ($quote_data->mortgage_duration_month == $i ? "selected":"") }}>
                                                    06                                                </option>
                                                                                                    <option value="07" {{ ($quote_data->mortgage_duration_month == $i ? "selected":"") }}>
                                                    07                                                </option>
                                                                                                    <option value="08" {{ ($quote_data->mortgage_duration_month == $i ? "selected":"") }}>
                                                    08                                                </option>
                                                                                                    <option value="09" {{ ($quote_data->mortgage_duration_month == $i ? "selected":"") }}>
                                                    09                                                </option>
                                                                                                    <option value="10" {{ ($quote_data->mortgage_duration_month == $i ? "selected":"") }}>
                                                    10                                                </option>
                                                                                                    <option value="11" {{ ($quote_data->mortgage_duration_month == $i ? "selected":"") }}>
                                                    11                                                </option>
                                                                                                </select>
                                            <span id="new_mm_month_err" class="error"></span>
                                        </div>
                                    </div>
                                </div>
                                <!-- end -- mm_duration_div--> 
                            </div>
                        @endif

                        @if ($quote_data->mortgage_type == '2')
                            <div id="div_existing_mortgage">
                                <div class="form-group {{ $errors->has('mm_repay_2') ? ' has-error' : '' }}">
                                    <label class="control-label col-sm-4">Monthly Mortgage Repayment</label>
                                    <div class="col-sm-4 padding-right-none">
                                        <input type="text" class="form-control" name="mm_repay_2" id="mm_repay_2" value="{{ $quote_data->monthly_mortgage_repay }}" />
                                        <span id="ex_mm_repay_err" class="error"></span>
                                    </div>
                                </div>
                            </div>

                        @endif
                    </div> <!-- End block_2-->

                    <div class="form-group {{ $errors->has('loan_repayment') ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4">Do you have any loan repayments</label>
                        <div class="col-sm-8">
                            <div class="radio">
                                <div class="radio-inline padding-left-none">
                                    <input type="radio" name="loan_repayment" id="loan_repayment_1" class="have_loan_check" value="1" {{ ($quote_data->loan_repayment == '1' ? "checked":"") }} /> 
                                    <label for="loan_repayment_1">Yes </label>
                                </div>
                                <div class="radio-inline">
                                    <input type="radio" name="loan_repayment" id="loan_repayment_2" class="have_loan_check" value="0" {{ ($quote_data->loan_repayment == '0' ? "checked":"") }} /> 
                                    <label for="loan_repayment_2"> No</label>
                                </div>

                            </div>
                            <label name="loan_repayment-error" class="error" for="loan_repayment" style="display:none;"></label>
                        </div>
                    </div>

                    <div id="block_3">
                        @if ($quote_data->loan_repayment == '1')
                            <div class="clear" id="div_takenloan_opts">
                                <div class="form-group {{ $errors->has('taken_loan') ? ' has-error' : '' }}">
                                    <label class="control-label col-sm-4">Have you taken loan in the last 60 days</label>
                                    <div class="col-sm-8">
                                        <div class="radio">
                                            <div class="radio-inline padding-left-none">
                                                <input type="radio" name="taken_loan" id="taken_loan_1" class="taken_loan" value="1" onclick="taken_loan_60(1)" {{ ($quote_data->taken_loan == '1' ? "checked":"") }} /> 
                                                <label for="taken_loan_1">Yes </label>
                                            </div>
                                            <div class="radio-inline">
                                                <input type="radio" name="taken_loan" id="taken_loan_2" class="taken_loan" value="0" onclick="taken_loan_60(0)" {{ ($quote_data->taken_loan == '0' ? "checked":"") }} /> 
                                                <label for="taken_loan_2"> No</label>
                                            </div>
                                        </div>
                                        <label name="taken_loan-error" class="error" for="taken_loan" style="display:none;"></label>
                                    </div>
                                </div>
                            </div>

                        @endif
                    </div> <!-- End block 3-->
                    <div id="block_4">
                        @if ($quote_data->taken_loan == '1' && $quote_data->loan_repayment == '1')
                            <div class="clear" id="div_monthlyloanrepay_opts">
                                <div class="form-group {{ $errors->has('monthly_loan_repay') ? ' has-error' : '' }}">
                                    <label class="control-label col-sm-4">Monthly Loan Repayment</label>
                                    <div class="col-sm-4 padding-right-none">
                                        <input type="text" class="form-control" name="monthly_loan_repay" id="monthly_loan_repay" value="{{ $quote_data->monthly_loan_repay }}" />
                                        <span id="monthly_loan_repay_err" class="error"></span>
                                    </div>
                                </div>

                                <div class="form-group {{ ($errors->has('loan_duration_year')  ||  $errors->has('loan_duration_month') ) ? ' has-error' : '' }}" id="taken_loan_yes">
                                    <label class="control-label col-sm-4">Duration of your financial agreement</label>
                                    <div class="col-sm-2 padding-right-none">
                                        <select id="loan_no_of_years" name="loan_duration_year" class="form-control">
                                            <option value="">YY</option>
                                            <option value="0">00</option>
                                                                                                    <option value="01" {{ ($loan_duration_year == $i ? "selected":"")}}>01</option>
                                                                                                    <option value="02" {{ ($loan_duration_year == $i ? "selected":"")}}>02</option>
                                                                                                    <option value="03" {{ ($loan_duration_year == $i ? "selected":"")}}>03</option>
                                                                                                    <option value="04" {{ ($loan_duration_year == $i ? "selected":"")}}>04</option>
                                                                                                    <option value="05" {{ ($loan_duration_year == $i ? "selected":"")}}>05</option>
                                                                                                    <option value="06" {{ ($loan_duration_year == $i ? "selected":"")}}>06</option>
                                                                                                    <option value="07" {{ ($loan_duration_year == $i ? "selected":"")}}>07</option>
                                                                                                    <option value="08" {{ ($loan_duration_year == $i ? "selected":"")}}>08</option>
                                                                                                    <option value="09" {{ ($loan_duration_year == $i ? "selected":"")}}>09</option>
                                                                                                    <option value="10" {{ ($loan_duration_year == $i ? "selected":"")}}>10</option>
                                                                                                    <option value="11" {{ ($loan_duration_year == $i ? "selected":"")}}>11</option>
                                                                                                    <option value="12" {{ ($loan_duration_year == $i ? "selected":"")}}>12</option>
                                                                                                    <option value="13" {{ ($loan_duration_year == $i ? "selected":"")}}>13</option>
                                                                                                    <option value="14" {{ ($loan_duration_year == $i ? "selected":"")}}>14</option>
                                                                                                    <option value="15" {{ ($loan_duration_year == $i ? "selected":"")}}>15</option>
                                                                                                    <option value="16" {{ ($loan_duration_year == $i ? "selected":"")}}>16</option>
                                                                                                    <option value="17" {{ ($loan_duration_year == $i ? "selected":"")}}>17</option>
                                                                                                    <option value="18" {{ ($loan_duration_year == $i ? "selected":"")}}>18</option>
                                                                                                    <option value="19" {{ ($loan_duration_year == $i ? "selected":"")}}>19</option>
                                                                                                    <option value="20" {{ ($loan_duration_year == $i ? "selected":"")}}>20</option>
                                                                                                    <option value="21" {{ ($loan_duration_year == $i ? "selected":"")}}>21</option>
                                                                                                    <option value="22" {{ ($loan_duration_year == $i ? "selected":"")}}>22</option>
                                                                                                    <option value="23" {{ ($loan_duration_year == $i ? "selected":"")}}>23</option>
                                                                                                    <option value="24" {{ ($loan_duration_year == $i ? "selected":"")}}>24</option>
                                                                                                    <option value="25" {{ ($loan_duration_year == $i ? "selected":"")}}>25</option>
                                                                                                    <option value="26" {{ ($loan_duration_year == $i ? "selected":"")}}>26</option>
                                                                                                    <option value="27" {{ ($loan_duration_year == $i ? "selected":"")}}>27</option>
                                                                                                    <option value="28" {{ ($loan_duration_year == $i ? "selected":"")}}>28</option>
                                                                                                    <option value="29" {{ ($loan_duration_year == $i ? "selected":"")}}>29</option>
                                                                                                    <option value="30" {{ ($loan_duration_year == $i ? "selected":"")}}>30</option>
                                                                                                    <option value="31" {{ ($loan_duration_year == $i ? "selected":"")}}>31</option>
                                                                                                    <option value="32" {{ ($loan_duration_year == $i ? "selected":"")}}>32</option>
                                                                                                    <option value="33" {{ ($loan_duration_year == $i ? "selected":"")}}>33</option>
                                                                                                    <option value="34" {{ ($loan_duration_year == $i ? "selected":"")}}>34</option>
                                                                                                    <option value="35" {{ ($loan_duration_year == $i ? "selected":"")}}>35</option>
                                                                                                    <option value="36" {{ ($loan_duration_year == $i ? "selected":"")}}>36</option>
                                                                                                    <option value="37" {{ ($loan_duration_year == $i ? "selected":"")}}>37</option>
                                                                                                    <option value="38" {{ ($loan_duration_year == $i ? "selected":"")}}>38</option>
                                                                                                    <option value="39" {{ ($loan_duration_year == $i ? "selected":"")}}>39</option>
                                                                                                    <option value="40" {{ ($loan_duration_year == $i ? "selected":"")}}>40</option>
                                                                                                    <option value="41" {{ ($loan_duration_year == $i ? "selected":"")}}>41</option>
                                                                                                    <option value="42" {{ ($loan_duration_year == $i ? "selected":"")}}>42</option>
                                                                                                    <option value="43" {{ ($loan_duration_year == $i ? "selected":"")}}>43</option>
                                                                                                    <option value="44" {{ ($loan_duration_year == $i ? "selected":"")}}>44</option>
                                                                                                    <option value="45" {{ ($loan_duration_year == $i ? "selected":"")}}>45</option>
                                                                                                    <option value="46" {{ ($loan_duration_year == $i ? "selected":"")}}>46</option>
                                                                                                    <option value="47" {{ ($loan_duration_year == $i ? "selected":"")}}>47</option>
                                                                                                    <option value="48" {{ ($loan_duration_year == $i ? "selected":"")}}>48</option>
                                                                                                    <option value="49" {{ ($loan_duration_year == $i ? "selected":"")}}>49</option>
                                                                                                    <option value="50" {{ ($loan_duration_year == $i ? "selected":"")}}>50</option>
                                                                                        </select>
                                        <span id="loan_year_err" class="error"></span>
                                    </div>
                                    <div class="col-sm-2 padding-right-none">
                                        <select name="loan_duration_month" id="loan_no_of_months" class="form-control" class="form-control">
                                            <option value="">MM</option>
                                            <option value="0">00</option>
                                                                                        <option value="01" {{ ($loan_duration_month == $i ? "selected":"")}}>01</option>
                                                                                        <option value="02" {{ ($loan_duration_month == $i ? "selected":"")}}>02</option>
                                                                                        <option value="03" {{ ($loan_duration_month == $i ? "selected":"")}}>03</option>
                                                                                        <option value="04" {{ ($loan_duration_month == $i ? "selected":"")}}>04</option>
                                                                                        <option value="05" {{ ($loan_duration_month == $i ? "selected":"")}}>05</option>
                                                                                        <option value="06" {{ ($loan_duration_month == $i ? "selected":"")}}>06</option>
                                                                                        <option value="07" {{ ($loan_duration_month == $i ? "selected":"")}}>07</option>
                                                                                        <option value="08" {{ ($loan_duration_month == $i ? "selected":"")}}>08</option>
                                                                                        <option value="09" {{ ($loan_duration_month == $i ? "selected":"")}}>09</option>
                                                                                        <option value="10" {{ ($loan_duration_month == $i ? "selected":"")}}>10</option>
                                                                                        <option value="11" {{ ($loan_duration_month == $i ? "selected":"")}}>11</option>
                                                                                    </select> 
                                        <span id="loan_month_err" class="error"></span>
                                    </div>
                                </div>
                            </div>
                        @endif

                        @if ($quote_data->taken_loan == '0' && $quote_data->loan_repayment == '1')
                            <div class="clear" id="div_monthlyloanrepay_opts">
                                <div class="form-group {{ $errors->has('monthly_loan_repay') ? ' has-error' : '' }}">
                                    <label class="control-label col-sm-4">Monthly Loan Repayment</label>
                                    <div class="col-sm-4 padding-right-none">
                                        <input type="text" class="form-control" name="monthly_loan_repay" id="monthly_loan_repay" value="{{ $quote_data->monthly_loan_repay }}" />
                                        <span id="monthly_loan_repay_err" class="error"></span>
                                    </div>
                                </div>
                            </div>
                        @endif
                    </div> <!-- End block 4-->

                    <div class="form-group {{ $errors->has('monthly_gross_income') ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4">Gross Annual Income</label>
                        <div class="col-sm-4 padding-right-none">
                            <input type="text" class="form-control" name="monthly_gross_income" id="monthly_gross_income" value="{{ $quote_data->monthly_gross_income }}" />
                            <span id="monthly_gross_income_err" class="error"></span>
                        </div>
                    </div>

                    <div class="form-group {{ $errors->has('monthly_benifit_amount') ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4">Monthly Benefit Amount</label>
                        <div class="col-sm-4 padding-right-none">
                            <input type="text" class="form-control" name="monthly_benifit_amount" id="monthly_benifit_amount" value="{{ $quote_data->monthly_benifit_amount }}" />
                            <span id="monthly_benifit_amount_err" class="error"></span>
                        </div>
                    </div>

                    <div class="form-group {{ $errors->has('industry_type') ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4">Industry Type</label>
                        <div class="col-sm-4 padding-right-none">
                            <div class="ui-widget">
                                <input placeholder="Start typing your industry type" name="industry_type" id="industry_type" type="text" class="form-control" value="{{ $quote_data->industry_name }}"/> 
                                <input name="industry_type_id" id="industry_type_id" type="hidden"
                                    value="{{ $quote_data->industry_type_id }}" />
                            </div>
                            <span id="industry_type_err" class="error"></span>
                            <div class="clearfix"></div>
                            <div id="industry_clear" class="small-btn2">
                                <a href="javascript: void(0);">Change</a>
                            </div>
                        </div>
                    </div>

                    <div class="form-group {{ $errors->has('occupation_type') ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4">Occupation </label>
                        <div class="col-sm-4 padding-right-none">
                            <div class="ui-widget">
                                <input placeholder="Start typing your occupation type" name="occupation_type" id="occupation_type" class="form-control" type="text" value="{{ $information_data->occupation }}" /> 
                                <input name="occupation_type_id" id="occupation_type_id" type="hidden" value="{{ $quote_data->occupation_id }}" />
                            </div>
                            <span id="occupation_type_err" class="error"></span>
                            <div class="clearfix"></div>
                            <div id="occupation_clear" class="small-btn2">
                                <a href="javascript: void(0);">Change</a>
                            </div>
                        </div>
                    </div>

                    <div class="form-group {{ $errors->has('cover_type') ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4">Cover Type</label>
                        <div class="col-sm-4 padding-right-none">
                            <select name="cover_type" id="cover_type" class="form-control">
                                <option value="">Select Cover</option>
                                <option value="U" {{ ($quote_data->cover_type == 'U' ? "selected":"") }}>Unemployment only</option>
                                <option value="AS" {{ ($quote_data->cover_type == 'AS' ? "selected":"") }}>Accident & Sickness only</option>
                                <option value="ASU" {{ ($quote_data->cover_type == 'AUS' ? "selected":"") }}>Unemployment, Accident & Sickness</option>
                            </select> 
                            <span id="cover_type_err" class="error"></span>
                        </div>
                    </div>
                    <div class="form-group {{ $errors->has('excessperiod') ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4">Excess Period</label>
                        <div class="col-sm-4 padding-right-none">
                            <select name="excessperiod" id="excessperiod"
                                class="form-control">
                                <option value="">Select Excess</option>
                                <option value="1" {{ ($quote_data->excess_period == '1' ? "selected":"") }}>Back to day 1</option>
                                <option value="14" {{ ($quote_data->excess_period == '1' ? "selected":"") }}>14 days</option>
                                <option value="30" {{ ($quote_data->excess_period == '30' ? "selected":"") }}>30 days</option>
                                <option value="60" {{ ($quote_data->excess_period == '60' ? "selected":"") }}>60 days</option>
                            </select> 
                            <span id="excessperiod_err" class="error"></span>
                        </div>
                    </div>

                </div>
                <div style="padding-top:20px;padding-left:20px;">By pressing 'Get A Quote’ you give consent for Best Insurance to use your personal sensitive data for the purposes of obtaining quotations in accordance with the Best Insurance <a target="_blank" href="{{ URL::to('terms-of-use')}}" >terms and conditions</a> and <a target="_blank" href="{{ URL::to('privacy')}}" >privacy policy.</a></div>
                
                <div class="form-btns">
                    <button type="submit" class="medium-btn btn-default"
                        name="get_quote" id="get_quote">Get A Quote</button>
                </div>
            </form>
        </div>
    </div>
</section>
<div class="clearfix"></div>
@endsection
@section('page-script')
<script type="text/javascript" src="{{ URL::asset('assets/js/get-a-quote/jquery.min.js') }}"></script>
<script type="text/javascript" src="{{ URL::asset('assets/js/get-a-quote/jquery.validate.min.js') }}"></script>
<script type="text/javascript" src="{{ URL::asset('assets/js/get-a-quote/additional-methods.js') }}"></script>
<script type="text/javascript" src="{{ URL::asset('assets/js/get-a-quote/get_a_quote_validation_edit.js') }}"></script>
<script type="text/javascript" src="{{ URL::asset('assets/js/get-a-quote/get_a_quote_edit.js') }}"></script>
@stop