@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') }}" class="form-horizontal" role="form">
                <input type="hidden" name="_token" value="{{ csrf_token() }}">

               


                <div class="bg">

                    <div class="form-group">
                        <label class="control-label col-sm-4" for="sex"><span style="color:red">*</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" 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">
                                    <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">
                                    <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 style="color:red">*</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." {{ (old("title") == 'Mr.' ? "selected":"") }}>Mr.</option>
                                <option value="Ms." {{ (old("title") == 'Ms.' ? "selected":"") }}>Ms.</option>
                                 <option value="Mx." {{ (old("title") == 'Mx.' ? "selected":"") }}>Mx.</option>
                                <option value="Mrs." {{ (old("title") == 'Mrs.' ? "selected":"") }}>Mrs.</option>
                                <option value="Miss." {{ (old("title") == 'Miss.' ? "selected":"") }}>Miss.</option>
                                <option value="Dr." {{ (old("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 style="color:red">*</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="{{ old('first_name') }}" />
                        </div>
                    </div>
                    <div class="form-group{{ $errors->has('last_name') ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4"><span style="color:red">*</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="{{ old('last_name') }}" />
                        </div>
                    </div>
                 
                    <div class="form-group {{ ($errors->has('day')  ||  $errors->has('month')  ||  $errors->has('year') ) ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4"><span style="color:red">*</span> Date of Birth</label>
                        <div class="col-sm-8 padding-left-none">
                            <div class="col-sm-2 padding-right-none">
                                <select name="day" id="day" class="form-control">
                                    <option value="">DD</option>
                                    @foreach ($days as $key => $value)
                                        <option value="{{$key}}" {{ (old("day") == $key ? "selected":"") }}> {{$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}}" {{ (old("month") == $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}}" {{ (old("year") == $i ? "selected":"") }}> {{$i}} </option>
                                        @endfor
                                </select>
                            </div>
                        </div>
                    </div>

                    <div class="form-group">
                        <label class="control-label col-sm-4" for="sex"> <span style="color:red">*</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">
                                    <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" 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"><span style="color:red">*</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> -->

                    <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 style="color:red">*</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" {{ (old("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" {{ (old("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" {{ (old("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 (old("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="{{ old('monthly_rent') }}" /> 
                                        <span id="monthly_rent_err" class="error"></span>
                                    </div>
                                </div>
                            </div>
                        @endif

                        @if (old("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()" {{ (old("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()" {{ (old("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()" {{ (old("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 (old("mortgage_type") == '1')
                            <div id="div_new_mortgage">
                                <div class="form-group {{ $errors->has('mm_repay_1') ? ' has-error' : '' }}">
                                    <label class="control-label col-sm-4">Monthly Mortgage Repayment</label>
                                    <div class="col-sm-4 padding-right-none">
                                        <input type="text" class="form-control" name="mm_repay_1" id="mm_repay_1" value="{{ old('mm_repay_1') }}" />
                                    </div>
                                </div> 
                                <!-- Start -- mm_duration_div -->
                                <div id="mm_duration_div">
                                    <div class="form-group {{ ($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" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    01                                                </option>
                                                                                                    <option value="02" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    02                                                </option>
                                                                                                    <option value="03" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    03                                                </option>
                                                                                                    <option value="04" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    04                                                </option>
                                                                                                    <option value="05" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    05                                                </option>
                                                                                                    <option value="06" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    06                                                </option>
                                                                                                    <option value="07" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    07                                                </option>
                                                                                                    <option value="08" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    08                                                </option>
                                                                                                    <option value="09" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    09                                                </option>
                                                                                                    <option value="10" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    10                                                </option>
                                                                                                    <option value="11" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    11                                                </option>
                                                                                                    <option value="12" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    12                                                </option>
                                                                                                    <option value="13" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    13                                                </option>
                                                                                                    <option value="14" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    14                                                </option>
                                                                                                    <option value="15" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    15                                                </option>
                                                                                                    <option value="16" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    16                                                </option>
                                                                                                    <option value="17" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    17                                                </option>
                                                                                                    <option value="18" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    18                                                </option>
                                                                                                    <option value="19" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    19                                                </option>
                                                                                                    <option value="20" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    20                                                </option>
                                                                                                    <option value="21" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    21                                                </option>
                                                                                                    <option value="22" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    22                                                </option>
                                                                                                    <option value="23" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    23                                                </option>
                                                                                                    <option value="24" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    24                                                </option>
                                                                                                    <option value="25" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    25                                                </option>
                                                                                                    <option value="26" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    26                                                </option>
                                                                                                    <option value="27" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    27                                                </option>
                                                                                                    <option value="28" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    28                                                </option>
                                                                                                    <option value="29" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    29                                                </option>
                                                                                                    <option value="30" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    30                                                </option>
                                                                                                    <option value="31" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    31                                                </option>
                                                                                                    <option value="32" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    32                                                </option>
                                                                                                    <option value="33" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    33                                                </option>
                                                                                                    <option value="34" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    34                                                </option>
                                                                                                    <option value="35" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    35                                                </option>
                                                                                                    <option value="36" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    36                                                </option>
                                                                                                    <option value="37" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    37                                                </option>
                                                                                                    <option value="38" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    38                                                </option>
                                                                                                    <option value="39" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    39                                                </option>
                                                                                                    <option value="40" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    40                                                </option>
                                                                                                    <option value="41" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    41                                                </option>
                                                                                                    <option value="42" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    42                                                </option>
                                                                                                    <option value="43" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    43                                                </option>
                                                                                                    <option value="44" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    44                                                </option>
                                                                                                    <option value="45" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    45                                                </option>
                                                                                                    <option value="46" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    46                                                </option>
                                                                                                    <option value="47" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    47                                                </option>
                                                                                                    <option value="48" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    48                                                </option>
                                                                                                    <option value="49" {{ (old("mortgage_duration_year") == $i ? "selected":"") }}>
                                                    49                                                </option>
                                                                                                    <option value="50" {{ (old("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" {{ (old("mortgage_duration_month") == $i ? "selected":"") }}>
                                                    01                                                </option>
                                                                                                    <option value="02" {{ (old("mortgage_duration_month") == $i ? "selected":"") }}>
                                                    02                                                </option>
                                                                                                    <option value="03" {{ (old("mortgage_duration_month") == $i ? "selected":"") }}>
                                                    03                                                </option>
                                                                                                    <option value="04" {{ (old("mortgage_duration_month") == $i ? "selected":"") }}>
                                                    04                                                </option>
                                                                                                    <option value="05" {{ (old("mortgage_duration_month") == $i ? "selected":"") }}>
                                                    05                                                </option>
                                                                                                    <option value="06" {{ (old("mortgage_duration_month") == $i ? "selected":"") }}>
                                                    06                                                </option>
                                                                                                    <option value="07" {{ (old("mortgage_duration_month") == $i ? "selected":"") }}>
                                                    07                                                </option>
                                                                                                    <option value="08" {{ (old("mortgage_duration_month") == $i ? "selected":"") }}>
                                                    08                                                </option>
                                                                                                    <option value="09" {{ (old("mortgage_duration_month") == $i ? "selected":"") }}>
                                                    09                                                </option>
                                                                                                    <option value="10" {{ (old("mortgage_duration_month") == $i ? "selected":"") }}>
                                                    10                                                </option>
                                                                                                    <option value="11" {{ (old("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 (old("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="{{ old('mm_repay_2') }}" />
                                        <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" {{ (old("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" {{ (old("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 (old("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)" {{ (old("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)" {{ (old("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 (old("taken_loan") == '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="" />
                                        <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" {{ (old("loan_duration_year") == $i ? "selected":"") }}>01</option>
                                                                                                    <option value="02" {{ (old("loan_duration_year") == $i ? "selected":"") }}>02</option>
                                                                                                    <option value="03" {{ (old("loan_duration_year") == $i ? "selected":"") }}>03</option>
                                                                                                    <option value="04" {{ (old("loan_duration_year") == $i ? "selected":"") }}>04</option>
                                                                                                    <option value="05" {{ (old("loan_duration_year") == $i ? "selected":"") }}>05</option>
                                                                                                    <option value="06" {{ (old("loan_duration_year") == $i ? "selected":"") }}>06</option>
                                                                                                    <option value="07" {{ (old("loan_duration_year") == $i ? "selected":"") }}>07</option>
                                                                                                    <option value="08" {{ (old("loan_duration_year") == $i ? "selected":"") }}>08</option>
                                                                                                    <option value="09" {{ (old("loan_duration_year") == $i ? "selected":"") }}>09</option>
                                                                                                    <option value="10" {{ (old("loan_duration_year") == $i ? "selected":"") }}>10</option>
                                                                                                    <option value="11" {{ (old("loan_duration_year") == $i ? "selected":"") }}>11</option>
                                                                                                    <option value="12" {{ (old("loan_duration_year") == $i ? "selected":"") }}>12</option>
                                                                                                    <option value="13" {{ (old("loan_duration_year") == $i ? "selected":"") }}>13</option>
                                                                                                    <option value="14" {{ (old("loan_duration_year") == $i ? "selected":"") }}>14</option>
                                                                                                    <option value="15" {{ (old("loan_duration_year") == $i ? "selected":"") }}>15</option>
                                                                                                    <option value="16" {{ (old("loan_duration_year") == $i ? "selected":"") }}>16</option>
                                                                                                    <option value="17" {{ (old("loan_duration_year") == $i ? "selected":"") }}>17</option>
                                                                                                    <option value="18" {{ (old("loan_duration_year") == $i ? "selected":"") }}>18</option>
                                                                                                    <option value="19" {{ (old("loan_duration_year") == $i ? "selected":"") }}>19</option>
                                                                                                    <option value="20" {{ (old("loan_duration_year") == $i ? "selected":"") }}>20</option>
                                                                                                    <option value="21" {{ (old("loan_duration_year") == $i ? "selected":"") }}>21</option>
                                                                                                    <option value="22" {{ (old("loan_duration_year") == $i ? "selected":"") }}>22</option>
                                                                                                    <option value="23" {{ (old("loan_duration_year") == $i ? "selected":"") }}>23</option>
                                                                                                    <option value="24" {{ (old("loan_duration_year") == $i ? "selected":"") }}>24</option>
                                                                                                    <option value="25" {{ (old("loan_duration_year") == $i ? "selected":"") }}>25</option>
                                                                                                    <option value="26" {{ (old("loan_duration_year") == $i ? "selected":"") }}>26</option>
                                                                                                    <option value="27" {{ (old("loan_duration_year") == $i ? "selected":"") }}>27</option>
                                                                                                    <option value="28" {{ (old("loan_duration_year") == $i ? "selected":"") }}>28</option>
                                                                                                    <option value="29" {{ (old("loan_duration_year") == $i ? "selected":"") }}>29</option>
                                                                                                    <option value="30" {{ (old("loan_duration_year") == $i ? "selected":"") }}>30</option>
                                                                                                    <option value="31" {{ (old("loan_duration_year") == $i ? "selected":"") }}>31</option>
                                                                                                    <option value="32" {{ (old("loan_duration_year") == $i ? "selected":"") }}>32</option>
                                                                                                    <option value="33" {{ (old("loan_duration_year") == $i ? "selected":"") }}>33</option>
                                                                                                    <option value="34" {{ (old("loan_duration_year") == $i ? "selected":"") }}>34</option>
                                                                                                    <option value="35" {{ (old("loan_duration_year") == $i ? "selected":"") }}>35</option>
                                                                                                    <option value="36" {{ (old("loan_duration_year") == $i ? "selected":"") }}>36</option>
                                                                                                    <option value="37" {{ (old("loan_duration_year") == $i ? "selected":"") }}>37</option>
                                                                                                    <option value="38" {{ (old("loan_duration_year") == $i ? "selected":"") }}>38</option>
                                                                                                    <option value="39" {{ (old("loan_duration_year") == $i ? "selected":"") }}>39</option>
                                                                                                    <option value="40" {{ (old("loan_duration_year") == $i ? "selected":"") }}>40</option>
                                                                                                    <option value="41" {{ (old("loan_duration_year") == $i ? "selected":"") }}>41</option>
                                                                                                    <option value="42" {{ (old("loan_duration_year") == $i ? "selected":"") }}>42</option>
                                                                                                    <option value="43" {{ (old("loan_duration_year") == $i ? "selected":"") }}>43</option>
                                                                                                    <option value="44" {{ (old("loan_duration_year") == $i ? "selected":"") }}>44</option>
                                                                                                    <option value="45" {{ (old("loan_duration_year") == $i ? "selected":"") }}>45</option>
                                                                                                    <option value="46" {{ (old("loan_duration_year") == $i ? "selected":"") }}>46</option>
                                                                                                    <option value="47" {{ (old("loan_duration_year") == $i ? "selected":"") }}>47</option>
                                                                                                    <option value="48" {{ (old("loan_duration_year") == $i ? "selected":"") }}>48</option>
                                                                                                    <option value="49" {{ (old("loan_duration_year") == $i ? "selected":"") }}>49</option>
                                                                                                    <option value="50" {{ (old("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" {{ (old("loan_duration_month") == $i ? "selected":"") }}>01</option>
                                                                                        <option value="02" {{ (old("loan_duration_month") == $i ? "selected":"") }}>02</option>
                                                                                        <option value="03" {{ (old("loan_duration_month") == $i ? "selected":"") }}>03</option>
                                                                                        <option value="04" {{ (old("loan_duration_month") == $i ? "selected":"") }}>04</option>
                                                                                        <option value="05" {{ (old("loan_duration_month") == $i ? "selected":"") }}>05</option>
                                                                                        <option value="06" {{ (old("loan_duration_month") == $i ? "selected":"") }}>06</option>
                                                                                        <option value="07" {{ (old("loan_duration_month") == $i ? "selected":"") }}>07</option>
                                                                                        <option value="08" {{ (old("loan_duration_month") == $i ? "selected":"") }}>08</option>
                                                                                        <option value="09" {{ (old("loan_duration_month") == $i ? "selected":"") }}>09</option>
                                                                                        <option value="10" {{ (old("loan_duration_month") == $i ? "selected":"") }}>10</option>
                                                                                        <option value="11" {{ (old("loan_duration_month") == $i ? "selected":"") }}>11</option>
                                                                                    </select> 
                                        <span id="loan_month_err" class="error"></span>
                                    </div>
                                </div>
                            </div>
                        @endif

                        @if (old("taken_loan") == '0')
                            <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="" />
                                        <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="{{ old('postcode',  isset($personal_data->postcode) ? $personal_data->postcode : null) }}" 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> 
          
          <div class="form-group"  id="tblFullAddress" style="display:none; ">
         
            <label class="control-label col-sm-4">Address Information</label>
            <div class="col-sm-4 padding-right-none">
              <p id="CompleteAddress">
               
              </p>
            </div>

            <input type="hidden" name="formattedPO" class="" id="fullPO" value="" title="Address Information Required: Please Select Your Address"/>
            <input type="hidden" name="premise" class="" id="popremise" value="" />
            <input type="hidden" name="line1" class="" id="poline1" value="" />
            <input type="hidden" name="line2" class="" id="poline2" value="" />
            <input type="hidden" name="line3" class="" id="poline3" value="" />
            <input type="hidden" name="line4" class="" id="poline4" value="" />
            <input type="hidden" name="town" class="" id="potown" value="" />
            <input type="hidden" name="county" class="" id="pocounty" value="" />
          </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($personal_data->email) ? $personal_data->email : '') }}" maxLength=100 /> 
              <label for="email" generated="true" class="error"></label>
            </div>
          </div>
          <div class="form-group">
            <label class="control-label col-sm-4"><span style="color:red">*</span> Contact Number</label>
            <div class="col-sm-4 padding-right-none">
              <input name="telephone" class="form-control required" id="telephone" title="Please enter phone" value="{{ old('telephone',  isset($personal_data->telephone) ? $personal_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 style="color:red">*</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="" />
                            <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 style="color:red">*</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="" />
                            <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"  />
                  
                  <label for="emp1">Employed</label>
                </div>
                <div class="radio-inline">
                  <input type="radio" name="emp_status" id="emp2" value="Self-Employed"  onclick="showEmployer()"  />
                  <label for="emp2">Self Employed</label>
                </div>
                <div class="radio-inline">
                  <input type="radio" name="emp_status" id="emp3" value="Contract Worker"  onclick="showEmployer()"  />
                  <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($personal_data->employer_name) ? $personal_data->employer_name : '') }}" maxLength="50"/>
              <label for="employer_name" generated="true" class="error" style="display:none;"></label>
            </div>
          </div>

          <div class="clearfix"></div>

                    <div class="form-group {{ $errors->has('industry_type') ? ' has-error' : '' }}">
                        <label class="control-label col-sm-4"><span style="color:red">*</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=""/> 
                                <input name="industry_type_id" id="industry_type_id" type="hidden"
                                    value="" />
                            </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 style="color:red">*</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="" /> 
                                <input name="occupation_type_id" id="occupation_type_id" type="hidden" value="" />
                            </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()" />
                        <label for="transfer1">Yes</label>
                      </div>
                      <div class="radio-inline">
                        <input type='radio' value='No' name="transfer"  id="transfer2" onclick="javascript:currentprovider()" 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="" 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=""   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 style="color:red">*</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" {{ (old("cover_type") == 'U' ? "selected":"") }}>Unemployment only</option>-->
                                <option value="AS" {{ (old("cover_type") == 'AS' ? "selected":"") }}>Accident & Sickness only</option>
                                <option value="ASU" {{ (old("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 style="color:red">*</span> Increasing Benefit&nbsp; 
                        <a href="javascript:void(0)" style="color: #000">
                        <span title="Choosing an increasing option will allow the monthly benefit from the policy to increase on an annual basis to help offset the changes in inflation.
 
To cover this the monthly premiums may also increase annually"><i class="fa fa-info-circle" aria-hidden="true"></i>
                        </span>
                        </a></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">
                                    <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">
                                    <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="" /> 
                            </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="" /> 
                            </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 style="color:red">*</span> Excess Period</label>
                        <div class="col-sm-4 padding-right-none">
                            <select name="excessperiod" id="excessperiod"
                                class="form-control">
                                
                            </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>
                <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">

                <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 }}">

    
                    <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')


<style type="text/css">
/*Radio button label padding */
    .checkbox label, .radio label {
        padding-left: 5px;
    }
</style>

<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_v4.js') }}"></script>
<script type="text/javascript" src="{{ URL::asset('assets/js/get-a-quote/get_a_quote.js') }}"></script>
<script src="{{ URL::asset('assets/js/personal_details_add_v1.js?v=6') }}"></script>
<script type="text/javascript">
$(document).ready(function(){
    $('[data-toggle="tooltip"]').tooltip();   
});
</script>
@stop