Best Insurance | Completed Leads

Edit Application

{!! Form::open(array('url' => 'account/edit-completed-lead/'.$information->id.'','id' => 'formValidation',)) !!}

{{ Form::hidden('id', $information->id,array('id' => 'informationId'))}} {{ Form::hidden('premiseName', $information->premiseName)}}

Date of issue:

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

Policy number:

{{ Form::text('policy_number', $information->policy_number_full, array( 'readOnly' => 'true', 'class'=>'form-')) }}

Title:

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

First Name:

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

Last Name:

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

Joint/2nd Applicant:

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

Email:

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

Contact Number:

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

Employer Name:

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

Bank Account Name :

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

Account Number:

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

Sort Code:

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

Direct Debit Date:

Reason for update: *

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