@extends('layouts.admin')
@section('pageCss')
<link rel="stylesheet" href="{{ URL::asset('assets/plugins/datepicker/datepicker3.css') }}">
@stop
@section('content')
<section class="content">
  <div class="box">
            <div class="box-body no-padding">
            </div>
             <div class="box">
            
            <!-- /.box-header -->
            <div class="box-body">
                <div class="box box-warning">
            <div class="box-header with-border">
              <h3 class="box-title">User Details</h3>
            </div>
            <!-- /.box-header -->
            <div class="box-body">
              {!! Form::open(array('url' => 'admin/leads/view')) !!}
                <!-- text input -->
                <div class="form-group">
                    {!! Form::label('Type of Protection') !!}
                    {{ Form::select('typeofprotection', [
                       'income_protection' => 'Income Protection',
                       'payment_protection' => 'Payment Protection',
                       'payment_protection_plus' => 'Payment Protection Plus'],null,
                       ['class' => 'form-control select2 select2-hidden-accessible']
                    ) }}
                </div>
                <div class="form-group">
                    {!! Form::label('Insurer') !!}
                    {{ Form::select('typeofprotection', [
                       '0' => 'Select',
                       'UKGI' => 'UKGI',
                       'Alpha' => 'Alpha',
                       'Alpha' => 'Alpha',
                       'Keystone' => 'Keystone'],null,
                       ['class' => 'form-control select2 select2-hidden-accessible']
                    ) }}
                </div>
                <div class="form-group">
                    {!! Form::label('Title') !!}
                    {{ Form::select('typeofprotection', [
                       '0' => 'Select',
                       'Mr' => 'Mr',
                       'Ms' => 'Ms',
                       'Mrs' => 'Mrs',
                       'Dr' => 'Dr',
                       'Rev' => 'Rev',
                       'Miss' => 'Miss'],null,
                       ['class' => 'form-control select2 select2-hidden-accessible']
                    ) }}
                </div>
                <div class="form-group">
                    {{ Form::label('First Name') }}
                    {{ Form::text('fname', null, 
                       array('required', 
                      'class'=>'form-control', 
                      'placeholder'=>'Please Enter First name')) 
                    }}
                </div>
                <div class="form-group">
                    {{ Form::label('Last Name') }}
                    {{ Form::text('lname', null, 
                       array('required', 
                      'class'=>'form-control', 
                      'placeholder'=>'Please Enter Last name')) 
                    }}
                </div>
                <div class="form-group">
                    {{ Form::label('Date Of Birth') }}
                    {{ Form::text('dob', null, 
                       array('required', 'readOnly' => 'true',
                      'class'=>'form-control', 'id' => 'datepicker',
                      )) 
                    }}
                </div>
                <div class="form-group">
                    {{ Form::label('Employed') }}
                    {{ Form::radio('emp_status', 'Employed') }}
                    {{ Form::label('Self-Employed') }}
                    {{ Form::radio('emp_status', 'Self-Employed') }}
                    {{ Form::label('Contractor') }}
                    {{ Form::radio('emp_status', 'Contractor',true) }}
                </div>
                <div class="form-group">
                    {{ Form::label('Occupation') }}
                    {{ Form::text('occupation', null, 
                       array('required', 
                      'class'=>'form-control', 
                      'placeholder'=>'Please Enter occupation')) 
                    }}
                </div>
                <div class="form-group">
                    {{ Form::label('Employer Name') }}
                    {{ Form::text('employer_name', null, 
                       array('required', 
                      'class'=>'form-control', 
                      'placeholder'=>'Please Enter employer name')) 
                    }}
                </div>
                <div class="form-group">
                    {{ Form::label('Last Name') }}
                    {{ Form::text('lname', null, 
                       array('required', 
                      'class'=>'form-control', 
                      'placeholder'=>'Please Enter Last name')) 
                    }}
                </div>
                <div class="form-group">
                    {{ Form::label('Last Name') }}
                    {{ Form::text('lname', null, 
                       array('required', 
                      'class'=>'form-control', 
                      'placeholder'=>'Please Enter Last name')) 
                    }}
                </div>
                <div class="form-group">
                    {{ Form::label('Last Name') }}
                    {{ Form::text('lname', null, 
                       array('required', 
                      'class'=>'form-control', 
                      'placeholder'=>'Please Enter Last name')) 
                    }}
                </div>
                <div class="form-group">
                    {{ Form::label('Last Name') }}
                    {{ Form::text('lname', null, 
                       array('required', 
                      'class'=>'form-control', 
                      'placeholder'=>'Please Enter Last name')) 
                    }}
                </div>
                <div class="form-group">
                    {{ Form::label('Last Name') }}
                    {{ Form::text('lname', null, 
                       array('required', 
                      'class'=>'form-control', 
                      'placeholder'=>'Please Enter Last name')) 
                    }}
                </div>
                <div class="form-group">
                    {{ Form::label('Last Name') }}
                    {{ Form::text('lname', null, 
                       array('required', 
                      'class'=>'form-control', 
                      'placeholder'=>'Please Enter Last name')) 
                    }}
                </div>
                <div class="form-group">
                    {{ Form::label('Last Name') }}
                    {{ Form::text('lname', null, 
                       array('required', 
                      'class'=>'form-control', 
                      'placeholder'=>'Please Enter Last name')) 
                    }}
                </div>
                <div class="form-group">
                    {{ Form::label('Last Name') }}
                    {{ Form::text('lname', null, 
                       array('required', 
                      'class'=>'form-control', 
                      'placeholder'=>'Please Enter Last name')) 
                    }}
                </div>
                <div class="form-group">
                    {{ Form::label('Last Name') }}
                    {{ Form::text('lname', null, 
                       array('required', 
                      'class'=>'form-control', 
                      'placeholder'=>'Please Enter Last name')) 
                    }}
                </div>
                <div class="form-group">
                    {{ Form::label('Last Name') }}
                    {{ Form::text('lname', null, 
                       array('required', 
                      'class'=>'form-control', 
                      'placeholder'=>'Please Enter Last name')) 
                    }}
                </div>
                <!-- textarea -->
                <div class="form-group">
                  <label>Textarea</label>
                  <textarea class="form-control" rows="3" placeholder="Enter ..."></textarea>
                </div>
                <!-- radio -->
                <div class="form-group">
                  <div class="radio">
                    <label>
                      <input type="radio" name="optionsRadios" id="optionsRadios1" value="option1" checked="">
                      Option one is this and that—be sure to include why it's great
                    </label>
                  </div>
                  <div class="radio">
                    <label>
                      <input type="radio" name="optionsRadios" id="optionsRadios2" value="option2">
                      Option two can be something else and selecting it will deselect option one
                    </label>
                  </div>
                  <div class="radio">
                    <label>
                      <input type="radio" name="optionsRadios" id="optionsRadios3" value="option3" disabled="">
                      Option three is disabled
                    </label>
                  </div>
                </div>
                <div class="form-group">
                <label>Disabled Result</label>
                <select class="form-control select2 select2-hidden-accessible" style="width: 100%;" tabindex="-1" aria-hidden="true">
                  <option selected="selected">Alabama</option>
                  <option>Alaska</option>
                  <option disabled="disabled">California (disabled)</option>
                  <option>Delaware</option>
                  <option>Tennessee</option>
                  <option>Texas</option>
                  <option>Washington</option>
              </div>
               

              </form>
            </div>
            <!-- /.box-body -->
          </div>
          </div>
            <!-- /.box-body -->
        </div>
    </div>
</section>

@stop
@section('pageBottomJs')

<script src="{{ URL::asset('assets/plugins/datepicker/bootstrap-datepicker.js') }}"></script>
<script>
    $(document).ready(function () {
        $('#datepicker').datepicker({
          autoclose: true
        });
    });
</script>
@stop