@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-edit') }}" class="form-horizontal" role="form">
                <input type="hidden" name="_token" value="{{ csrf_token() }}">
                <input type="hidden" name="qid" value="{{ $quote_data->id }}">
                <div class="bg">
                    <div class="form-group">
                        <label class="control-label col-sm-4" for="sex"><span class="asterisk">* </span>Gender</label>
                        <div class="col-sm-8">
                            <div class="radio">
                                <div class="radio-inline padding-left-none">&nbsp;&nbsp;&nbsp;&nbsp;
                                    <input type="radio" name="sex" id="sex_1" value="Male" class="residence_status" {{ ($information_data->gender == 'Male' ? "checked":"") }}>
                                    <label for="sex_1"> Male </label>
                                </div>
                                <div class="radio-inline">&nbsp;&nbsp;&nbsp;&nbsp;
                                    <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>

                                 <div class="radio-inline">&nbsp;&nbsp;&nbsp;&nbsp;
                                    <input type="radio" name="sex" id="sex_3" value="Prefer Not to say" class="residence_status" {{ ($information_data->gender == 'Prefer Not to say' ? "checked":"") }}>
                                    <label for="sex_3"> Prefer Not to say </label>
                                </div>
                                <br>
                            </div>
                        </div>
                    </div>

                    <div class="form-group {{ $errors->has('title') ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4" for="title"><span class="asterisk">* </span>Title</label>
                        <div class="col-sm-4 padding-right-none">
                            <select name="title"  class="form-control"  id="title" title="Please Select Title">
                                <option value="">Please Select Title</option>
                                <option value="Mr." {{ ($information_data->title == 'Mr.' ? "selected":"") }}>Mr.</option>
                                <option value="Ms." {{ ($information_data->title == 'Ms.' ? "selected":"") }}>Ms.</option>
                                <option value="Mx." {{ ($information_data->title == 'Mx.' ? "selected":"") }}>Mx.</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"><span class="asterisk">* </span>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"><span class="asterisk">* </span>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')  ||  $errors->has('year') ) ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4"><span class="asterisk">* </span>Date of Birth</label>
                        <div class="col-sm-8 padding-left-none">
                            <div class="col-sm-2 padding-right-none">
                                <select name="day" id="day" class="form-control">
                                    <option value="">DD</option>
                                    @foreach ($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 = 1958; $i <= 2006; $i++)
                                            <option value="{{$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"><span class="asterisk">* </span>Smoker</label>
                        <div class="col-sm-8">
                            <div class="radio">
                                <div class="radio-inline padding-left-none">&nbsp;&nbsp;&nbsp;&nbsp;
                                    <input type="radio" name="smoker" id="smoker_1" value="Yes" class="residence_status" {{ ($information_data->smoker == 'Yes' ? "checked":"") }}>
                                    <label for="smoker_1"> Yes </label>
                                </div>
                                <div class="radio-inline">&nbsp;&nbsp;&nbsp;&nbsp;
                                    <input type="radio" name="smoker" id="smoker_2" value="No" class="residence_status"  {{ ($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">
                    
                    
                    <input type="hidden" name="txtWaiverBasis" value="None">
                    <input type="hidden" name="txtCoverBasis" value="JointFirstEvent">

                    
                    <div class="form-group {{ $errors->has('residential_status') ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4" for="pwd"><span class="asterisk">* </span>Residential Status</label>
                        <div class="col-sm-8">
                            <div class="radio">
                                <div class="radio-inline padding-left-none">&nbsp;&nbsp;&nbsp;&nbsp;
                                    <input type="radio" name="residential_status" id="res_status_1" value="owner" class="residence_status" {{ ($quote_data->residential_status == 'owner' ? "checked":"") }}>
                                    <label for="res_status_1"> Home Owner </label>
                                </div>
                                <div class="radio-inline">&nbsp;&nbsp;&nbsp;&nbsp;
                                    <input type="radio" name="residential_status" id="res_status_2" value="tenant" class="residence_status" {{ ($quote_data->residential_status == 'tenant' ? "checked":"") }}>
                                    <label for="res_status_2"> Tenant </label>
                                </div>
                                <div class="radio-inline">&nbsp;&nbsp;&nbsp;&nbsp;
                                    <input type="radio" name="residential_status" id="res_status_3" value="other" class="residence_status" {{ ($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"><span class="asterisk">* </span>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 {{ $errors->has('mortgage_type') ? ' has-error' : '' }}">
                                        <label class="control-label col-sm-4" for=""><span class="asterisk">* </span>Mortgage Type</label>
                                        <div class="col-sm-8">
                                            <div class="radio">
                                                <div class="radio-inline padding-left-none">&nbsp;&nbsp;&nbsp;&nbsp;
                                                    <input type="radio" name="mortgage_type" id="new_mortgage" value="1" class="home_mortgage_type" onclick="new_mortgage_load()" {{ ($quote_data->mortgage_type == '1' ? "checked":"") }}> 
                                                    <label for="new_mortgage">New Mortgage</label>
                                                </div>
                                                <div class="radio-inline">&nbsp;&nbsp;&nbsp;&nbsp;
                                                    <input type="radio" name="mortgage_type" id="existing_mortgage" value="2" class="home_mortgage_type" onclick="existing_mortgage_load()" {{ ($quote_data->mortgage_type == '2' ? "checked":"") }}> 
                                                    <label for="existing_mortgage">Existing Mortgage</label>
                                                </div>
                                                <div class="radio-inline">&nbsp;&nbsp;&nbsp;&nbsp;
                                                    <input type="radio" name="mortgage_type" id="without_mortgage" value="3" class="home_mortgage_type" onclick="existing_ownandlive_load()" {{ ($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"><span class="asterisk">* </span>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')  ||  $errors->has('mortgage_duration_month') ) ? ' has-error' : '' }}">
                                        <label class="control-label col-sm-4"><span class="asterisk">* </span>Duration of your financial agreement : </label>
                                        <div class="col-sm-2 padding-right-none">
                                            <select id="no_of_years" name="mortgage_duration_year" class="form-control">
                                                <option value="">YY</option>
                                                <option value="0">00</option>
                                                                                                    <option value="01" {{ ($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"><span class="asterisk">* </span>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">
           
                        <label class="control-label col-sm-4"><span style="color:red">*</span> Home Postcode</label>
                        <div class="col-sm-4 padding-right-none">                   
                        <input name="postcode" class="form-control required " id="postcode" title="Please enter postcode" value="{{ $information_data->postcode }}" maxLength="8" />
                        <label for="postcode" generated="true" class="error"style="display:none"></label>
                        <div class="clearfix"></div>
                        <div class="small-btn2 margin-top-5"><a href="javascript:void(0)" id="btnPO">Find Address</a>
                        
                        <div class="ajxLoader"></div></div>
                    </div>
                    <div class="clearfix"></div>
                    <div class="form-group" id="POAddress" style="display:none;">
            <label class="control-label col-sm-4">Highlight the address that matches your selection and click &quot;Select&quot;</label>
                  
            <div class="col-sm-4 padding-right-none">
              <div class="address-results"></div>
              <div class="small-btn2 margin-top-5"><a href="javascript:void(0)" id="btnPOFetch">Select</a>
              </div>
            </div>
          </div> 
          @if($information_data->postcode != '')
          <div class="form-group"  id="tblFullAddress" style="display:block; ">
          @else
          <div class="form-group"  id="tblFullAddress" style="display:none; ">
          @endif
          
            <label class="control-label col-sm-4">Address Information</label>
            <div class="col-sm-4 padding-right-none">
              <p id="CompleteAddress">
                @if($complete_address != '')
                    {!!$complete_address!!}
                @endif
              </p>
            </div>

            <input type="hidden" name="formattedPO" class="" id="fullPO" value="{{$information_data->formattedPO}}" title="Address Information Required: Please Select Your Address"/>
            <input type="hidden" name="premise" class="" id="popremise" value="{{ $information_data->premiseName }}" />
            <input type="hidden" name="line1" class="" id="poline1" value="{{ $information_data->address1 }}" />
            <input type="hidden" name="line2" class="" id="poline2" value="{{ $information_data->address2 }}" />
            <input type="hidden" name="line3" class="" id="poline3" value="{{ $information_data->address3 }}" />
            <input type="hidden" name="line4" class="" id="poline4" value="{{ $information_data->address4 }}" />
            <input type="hidden" name="town" class="" id="potown" value="{{ $information_data->postaltown }}" />
            <input type="hidden" name="county" class="" id="pocounty" value="{{ $information_data->county }}" />
          </div> 
                    
                    <div class="form-group">
                        <label class="control-label col-sm-4"><span style="color:red">*</span> Email</label>
                        <div class="col-sm-4 padding-right-none">
                        <input name="email" type="text" class="form-control required" id="email" title="Please enter email" value="{{ old('email',  isset($information_data->email) ? $information_data->email : '') }}" maxLength=100 /> 
                        <label for="email" generated="true" class="error"></label>
                        </div>
                    </div>
                    <div class="form-group">
                        <label class="control-label col-sm-4"><span style="color:red">*</span> Contact Number</label>
                        <div class="col-sm-4 padding-right-none">
                        <input name="telephone" class="form-control required" id="telephone" title="Please enter phone" value="{{ old('telephone',  isset($information_data->telephone) ? $information_data->telephone : '') }}"  /> 
                        <label for="telephone" generated="true" class="error" style="display:none;width:190px;"></label>

                        </div>
                    </div>

                    <div class="form-group {{ $errors->has('monthly_gross_income') ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4"><span class="asterisk">* </span>Gross Annual Income</label>
                        <div class="col-sm-4 padding-right-none">
                            <input type="text" class="form-control" name="monthly_gross_income" id="monthly_gross_income" value="{{ round($quote_data->monthly_gross_income*12) }}" />
                            <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"><span class="asterisk">* </span>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">
                    <label class="control-label col-sm-4"><span style="color:red">*</span> Employment Status</label>
                    <div class="col-sm-8">
                    <div class="radio">
                        <div class="radio-inline padding-left-none">
                        <input name="emp_status" type="radio" id="emp1"  onclick="showEmployer()" value="Employed" checked="checked" />
                        
                        <label for="emp1">Employed</label>
                        </div>
                        <div class="radio-inline">
                        <input type="radio" name="emp_status" id="emp2" value="Self-Employed"  onclick="showEmployer()"  {{ ($information_data->emp_status == 'Self-Employed' ? "checked":"") }}/>
                        <label for="emp2">Self Employed</label>
                        </div>
                        <div class="radio-inline">
                        <input type="radio" name="emp_status" id="emp3" value="Contract Worker"  onclick="showEmployer()" {{ ($information_data->emp_status == 'Contract Worker' ? "checked":"") }} />
                        <label for="emp3">Contractor</label> 
                        </div>
                    </div>
                    <label for="emp_status" generated="true" class="error" style="display:none;"></label>
                    </div>
                </div>

                <div class="form-group" id="showEmployer">
                    <label class="control-label col-sm-4"><span style="color:red">*</span> Name of your employer</label>
                    <div class="col-sm-4 padding-right-none">
                    <input name="employer_name" class="form-control required" id="employer_name" title="Please Enter Employer" value="{{ old('employer_name',  isset($information_data->employer_name) ? $information_data->employer_name : '') }}" maxLength="50"/>
                    <label for="employer_name" generated="true" class="error" style="display:none;"></label>
                    </div>
                </div>

                    <div class="form-group {{ $errors->has('industry_type') ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4"><span class="asterisk">* </span>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"><span class="asterisk">* </span>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" style="display:none;">
                  <label class="control-label col-sm-4"><span style="color:red">*</span>  <i class="fa fa-question-circle" aria-hidden="true"> </i> Are you transferring cover from another provider? </label>
                        
                  <div class="col-sm-4 padding-right-none">           
                    <div class="radio">
                      <div class="radio-inline padding-left-none">
                        <input name="transfer" id="transfer1" type='radio' value='Yes' onclick="javascript:currentprovider()" {{ ($information_data->transfer == 'Yes' ? "checked":"") }} />
                        <label for="transfer1">Yes</label>
                      </div>
                      <div class="radio-inline">
                        <input type='radio' value='No' name="transfer"  id="transfer2" onclick="javascript:currentprovider()" {{ ($information_data->transfer == 'No' || $information_data->transfer == '' ? "checked":"") }} />
                        <label for="transfer2">No</label>
                      </div>
                    </div>
                  </div>  
                </div>

                <div id="transfercover" class="form-group">
                    <label class="control-label col-sm-4"><span style="color:red">*</span> Name of the current provider</label>
                    <div class="col-sm-4 padding-right-none">   
                      <input name="current_provider" class="form-control required" id="current_provider"  title="Please Enter Current Provider"  value="{{ $information_data->current_provider }}" maxlength="35">
                    </div>
                    <div class="clearfix"></div>
                    <br>
                    <label class="control-label col-sm-4"><span style="color:red">*</span> Date on which the current policy was incepted </label>
                    <div class="col-sm-4 padding-right-none">   
                      <input name="current_policy_date" class="form-control required" id="current_policy_date" value="{{ $information_data->current_policy_date }}"  title="Please Enter Policy Date">
                    </div>

                </div>

                    <div class="form-group {{ $errors->has('cover_type') ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4"><span class="asterisk">* </span>Cover Type</label>
                        <div class="col-sm-4 padding-right-none">
                            <select name="cover_type" id="cover_type" class="form-control">
                                <option value="">Select Cover</option>
                                <!--<option value="U" {{ ($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 inc-bnft" id="inc-bnft">
                        <label class="control-label col-sm-4" for="title"><span class="asterisk">* </span>Increasing Benefit</label>
                        <div class="col-sm-8">
                            <div class="radio">
                                <div class="radio-inline padding-left-none">&nbsp;&nbsp;&nbsp;&nbsp;
                                    <input type="radio" name="txtIncreasingBenefit" id="txtIncreasingBenefit_1" value="Yes" class="residence_status">
                                    <label for="txtIncreasingBenefit_1"> Yes </label>
                                </div>
                                <div class="radio-inline">&nbsp;&nbsp;&nbsp;&nbsp;
                                    <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>

                    <div class="form-group " id="age_or_term_div">
                        <label class="control-label col-sm-4" for="sex"> <span style="color:red">*</span> Age or Term Driven</label>
                        <div class="col-sm-8">
                            <div class="radio">
                                <div class="radio-inline padding-left-none">&nbsp;&nbsp;&nbsp;&nbsp;
                                    <input type="radio" name="age_or_term" id="age_or_term_1" value="Cease Age" class="residence_status" {{ ($quote_data->age_or_term == 'Cease Age' ? "checked":"") }}>
                                    <label for="age_or_term_1"> Cease Age Driven </label>
                                </div>
                                <div class="radio-inline">&nbsp;&nbsp;&nbsp;&nbsp;
                                    <input type="radio" name="age_or_term" id="age_or_term_2" value="Term Driven" class="residence_status" {{ ($quote_data->age_or_term == 'Term Driven' ? "checked":"") }}>
                                    <label for="age_or_term_2"> Term Driven </label>
                                </div>
                                <br>
                            </div>
                        </div>
                    </div>
                    <div class="form-group {{ $errors->has('cease_cover') ? ' has-error' : '' }}" id="cease_cover_div">
                        <label class="control-label col-sm-4"><span style="color:red">*</span> Cease Cover at age : </label>
                        <div class="col-sm-4 padding-right-none">
                            <div class="ui-widget">
                                <input placeholder="" name="cease_cover" id="cease_cover" class="form-control" type="text" value="{{ $quote_data->cease_cover }}" /> 
                            </div>
                            <span id="cease_cover_err" class="error"></span>
                        </div>
                    </div>
                    <div class="form-group {{ $errors->has('term_in_year') ? ' has-error' : '' }}" id="term_in_year_div">
                        <label class="control-label col-sm-4"><span style="color:red">*</span> Term In Years:     </label>
                        <div class="col-sm-4 padding-right-none">
                            <div class="ui-widget">
                                <input placeholder="" name="term_in_year" id="term_in_year" class="form-control" type="text" value="{{ $quote_data->term_in_year }}" /> 
                            </div>
                            <span id="term_in_year_err" class="error"></span>
                        </div>
                    </div>
                    <div class="form-group {{ $errors->has('excessperiod') ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4"><span class="asterisk">* </span>Excess Period</label>
                        <div class="col-sm-4 padding-right-none">
                            <select name="excessperiod" id="excessperiod"
                                class="form-control">
                                <option value="">Select Excess</option>
                                <option value="1" {{ ($quote_data->excess_period == '1' ? "selected":"") }}>Back to day 1</option>
                                <option value="14" {{ ($quote_data->excess_period == '30' ? "selected":"") }}>14 days</option>
                                <option value="30" {{ ($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 class="form-group">
                <label class="control-label col-sm-4"><span class="asterisk">*</span> When would you like this Insurance to start? </label>  
                <div class="col-sm-8 padding-left-none"> 
                  <div class="col-sm-2 padding-right-none">
              
                    <input type="hidden" id="insurance_start_day" value="{{ date('d') }}">
                                                        
                        <input type="hidden" id="insurance_start_month" value="{{ date('m') }}">
                                        
                   
                        <input type="hidden" id="insurance_start_year" value="{{ date('Y') }}">
                    <select class="form-control required" id="insurance_dd" name="insurance_dd"  title="Select Insurance Day">
                              <option value="">DD</option>
                                                            <option value="01">01 </option>
                                                            <option value="02">02 </option>
                                                            <option value="03">03 </option>
                                                            <option value="04">04 </option>
                                                            <option value="05">05 </option>
                                                            <option value="06">06 </option>
                                                            <option value="07">07 </option>
                                                            <option value="08">08 </option>
                                                            <option value="09">09 </option>
                                                            <option value="10">10 </option>
                                                            <option value="11">11 </option>
                                                            <option value="12">12 </option>
                                                            <option value="13">13 </option>
                                                            <option value="14">14 </option>
                                                            <option value="15">15 </option>
                                                            <option value="16">16 </option>
                                                            <option value="17">17 </option>
                                                            <option value="18">18 </option>
                                                            <option value="19">19 </option>
                                                            <option value="20">20 </option>
                                                            <option value="21">21 </option>
                                                            <option value="22">22 </option>
                                                            <option value="23">23 </option>
                                                            <option value="24">24 </option>
                                                            <option value="25">25 </option>
                                                            <option value="26">26 </option>
                                                            <option value="27">27 </option>
                                                            <option value="28">28 </option>
                                                            <option value="29">29 </option>
                                                            <option value="30">30 </option>
                                                            <option value="31">31 </option>
                                                        </select>
                  </div>

                  <div class="col-sm-2 padding-right-none">
                    <select class="form-control required" id="insurance_mm"  name="insurance_mm"  title="Select Insurance Month">
                      <option value="">MM</option>
                      <option value="01">Jan</option>
                      <option value="02">Feb</option>
                      <option value="03">Mar</option>
                      <option value="04">Apr</option>
                      <option value="05">May</option>
                      <option value="06">Jun</option>
                      <option value="07">Jul</option>
                      <option value="08">Aug</option>
                      <option value="09">Sept</option>
                      <option value="10">Oct</option>
                      <option value="11">Nov</option>
                      <option value="12">Dec</option>
                    </select>
                  </div>

                  <div class="col-sm-2 padding-right-none">
                    <select name="insurance_yy" id="insurance_yy" class="form-control required" title="Select Insurance Year">
                      <option value="">YYYY</option>
                       <option value="2026">2026</option>
                      <option value="2025">2025</option>
                      <option value="2020">2020</option>
                    </select>
                  </div>

                  <div class="col-sm-12">
                    <label for="insurance_dd" generated="true" class="error1 col-sm-8"></label> 
                    <label for="insurance_mm" generated="true" class="error1 col-sm-8"></label>
                    <label for="insurance_yy" generated="true" class="error1 col-sm-8"></label>
                  </div> 

                </div>
              </div>

                </div>
                <input type="hidden" name="excess_period_value" id="excess_period_value" value="{{$quote_data->excess_period}}">

                <input type="hidden" id="current_year" value="{{ $current_year }}">
                <input type="hidden" id="current_month" value="{{ $current_month }}">
                <input type="hidden" id="current_date" value="{{ $current_date }}">

                <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_v5.js') }}"></script>
<script type="text/javascript" src="{{ URL::asset('assets/js/get-a-quote/get_a_quote_edit.js') }}"></script>
<script src="{{ URL::asset('assets/js/personal_details_add_v1.js?v=6') }}"></script>
<style type="text/css">
    .asterisk{
        color: red;
    }
</style>
<script type="text/javascript">
    
</script>
@stop