@extends('layouts.admin') @section('pageTitle') Best Insurance | Old Leads @stop @section('pageCss') @stop @section('content')

Renew Application

{!! Form::open(array('url' => 'account/renew-old-lead/'.$information->id.'','id' => 'formValidation')) !!}
{{ Form::hidden('id', $information->id)}} {{ Form::hidden('premiseName', $information->premiseName)}}
   {!! Form::label('Date of issue:') !!}
{{ Form::text('txtDateOfIssue', date('d/m/Y'), array( 'readOnly' => 'true', 'class'=>'form-control')) }}
  Policy number:
IPBST/05333A   {{ Form::text('policy_number', $information->policy_number, array( 'class'=>'form-')) }}
  Title:
{{ Form::select('title', [ '0' => 'Select', 'Mr.' => 'Mr.', 'Ms.' => 'Ms.', 'Mrs.' => 'Mrs.', 'Dr.' => 'Dr.', 'Rev.' => 'Rev.', 'Miss.' => 'Miss.'],$information->title, ['class' => 'form-control select2 select2-hidden-accessible'] ) }}
  First Name:
{{ Form::text('fname', $information->fname, array( 'class'=>'form-control')) }}
  Last Name:
{{ Form::text('lname', $information->lname, array( 'class'=>'form-control')) }}
   {!! Form::label('Policy holder Address:') !!}
{{$address}}

  
Find Address Add Address Manually
Selected Address

{{ Form::hidden('form_new_line1', null, array( 'id' => 'form_new_line1' ,'class'=>'form-control'))}} {{ Form::hidden('form_new_line2', null, array('id' => 'form_new_line2', 'class'=>'form-control'))}} {{ Form::hidden('form_new_line3', null, array('id' => 'form_new_line3', 'class'=>'form-control'))}} {{ Form::hidden('form_new_line4', null, array('id' => 'form_new_line4', 'class'=>'form-control'))}} {{ Form::hidden('form_new_town', null, array('id' => 'form_new_town' ,'class'=>'form-control'))}} {{ Form::hidden('form_new_country', null, array('id' => 'form_new_country', 'class'=>'form-control'))}} {{ Form::hidden('form_new_postcode', null, array('id' => 'form_new_postcode', 'class'=>'form-control'))}}

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

  Line1
{{ Form::text('line1', null, array( 'class'=>'form-control')) }}
  Line2
{{ Form::text('line2',null, array( 'class'=>'form-control')) }}
  Line3
{{ Form::text('line3', null, array( 'class'=>'form-control')) }}
  Line4
{{ Form::text('line4', null, array( 'class'=>'form-control')) }}
  Town
{{ Form::text('town', null, array( 'class'=>'form-control')) }}
  Country
{{ Form::text('country', null, array( 'class'=>'form-control')) }}
  Postal Code
{{ Form::text('postal_code', null, array( 'class'=>'form-control')) }}

SCHEDULE OF INSURANCE

Underwritten by UK General Insurance Limited on behalf of Ageas Insurance Limited
  Policy Renewal Date:
{{ Form::text('editapppolicystartdate',$renwalday, array( 'id' => 'policyStartdate', 'class'=>'form-control')) }}
{!! Form::label('Policy End Date:') !!}
{{ Form::text('txtPolicyEndDate',$renewalEndDay, array( 'readOnly' => true, 'class'=>'form-control')) }}
  Cover type:
{{ Form::select('typeofcover', [ '0' => 'select', 'ASU' => 'Unemployment, Accident & Sickness', 'U' => 'Unemployment only', 'AS' => 'Accident & Sickness only' ],$information->typeofcover, array('class'=>'form-control','id' => 'typeofcover')) }}
  Excess Period:
  Monthly Benefit:
{{ Form::text('monthlybenefit', $information->monthlybenefit, array( 'class'=>'form-control')) }}
  Maximum Benefit Period:
12 months
  Monthly premium:
{{ Form::text('monthlycost', $information->monthlycost, array( 'class'=>'form-control')) }}
{!! Form::label('Payment option:') !!}
Monthly direct debit
    {{ Form::submit('Confirm',array('class'=>'btn btn-success','rows' => '4')) }}
@if(isset($downloadBtn)) {!! $downloadBtn !!} @endif @stop @section('pageBottomJs') @stop