@extends('layouts.frontend')
@section('title', 'Personal Details')
@section('content')  
<div class="clearfix"></div>
<section class="inner-content">
  <div class="clearfix"></div>
  <div class="container">
    <div class="form-block col-md-9 padding-left-none">
      <h2 class="product-title">Application</h2>
       @include('flash::message')
      @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="insuranceForm" class="form-horizontal"  id="insuranceForm" action="{{ url('personal-details-add') }}" method="post">
       {{ csrf_field() }}
        <div class="bg">

          <div class="steps-tabs">
            <ul >
              <li class="active">Personal Details <i class="fa fa-chevron-right" aria-hidden="true"></i></li>
              <li >Cover <i class="fa fa-chevron-right" aria-hidden="true"></i></li>
              <li >Bank Details <i class="fa fa-chevron-right" aria-hidden="true"></i></li>
              <li >Confirmation <i class="fa fa-chevron-right" aria-hidden="true"></i></li>
            </ul>
          </div>

          <!--personal fields added-->
          
          <div class="form-group">
            <!-- <label class="control-label col-sm-4">Home Post Code</label>
            <div class="col-sm-4 padding-right-none">                   
              <input name="postcode" class="form-control required " id="postcode" title="Please enter postcode" value="" 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> -->
            <label class="control-label col-sm-4"><span style="color:red">*</span> Home Post Code</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>

          <div class="form-group" id="POAddress" style="display:none;">
            <label class="control-label col-sm-4">Highlight the address that matches your selection and click &quot;Select&quot;</label>
                  
            <div class="col-sm-4 padding-right-none">
              <div class="address-results"></div>
              <div class="small-btn2 margin-top-5"><a href="javascript:void(0)" id="btnPOFetch">Select</a>
              </div>
            </div>
          </div> 
          @if($personal_data->postcode != '')
          <div class="form-group"  id="tblFullAddress" style="display:block; ">
          @else
          <div class="form-group"  id="tblFullAddress" style="display:none; ">
          @endif
          
            <label class="control-label col-sm-4">Address Information</label>
            <div class="col-sm-4 padding-right-none">
              <p id="CompleteAddress">
                @if($complete_address != '')
                    {!!$complete_address!!}
                @endif
              </p>
            </div>

            <input type="hidden" name="formattedPO" class="" id="fullPO" value="{{$personal_data->formattedPO}}" title="Address Information Required: Please Select Your Address"/>
            <input type="hidden" name="premise" class="" id="popremise" value="{{ $personal_data->premiseName }}" />
            <input type="hidden" name="line1" class="" id="poline1" value="{{ $personal_data->address1 }}" />
            <input type="hidden" name="line2" class="" id="poline2" value="{{ $personal_data->address2 }}" />
            <input type="hidden" name="line3" class="" id="poline3" value="{{ $personal_data->address3 }}" />
            <input type="hidden" name="line4" class="" id="poline4" value="{{ $personal_data->address4 }}" />
            <input type="hidden" name="town" class="" id="potown" value="{{ $personal_data->postaltown }}" />
            <input type="hidden" name="county" class="" id="pocounty" value="{{ $personal_data->county }}" />
          </div> 

          <div class="form-group">
            <label class="control-label col-sm-4"><span style="color:red">*</span> Email</label>
            <div class="col-sm-4 padding-right-none">
              <input name="email" type="text" class="form-control required" id="email" title="Please enter email" value="{{ old('email',  isset($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">
            <label class="control-label col-sm-4"><span style="color:red">*</span> Employment Status</label>
            <div class="col-sm-8">
              <div class="radio">
                <div class="radio-inline padding-left-none">
                  <input name="emp_status" type="radio" id="emp1"  onclick="showEmployer()" value="Employed" checked="checked" />
                  
                  <label for="emp1">Employed</label>
                </div>
                <div class="radio-inline">
                  <input type="radio" name="emp_status" id="emp2" value="Self-Employed"  onclick="showEmployer()" {{ ($personal_data->emp_status == 'Self-Employed' ? "checked":"") }} />
                  <label for="emp2">Self Employed</label>
                </div>
                <div class="radio-inline">
                  <input type="radio" name="emp_status" id="emp3" value="Contract Worker"  onclick="showEmployer()" {{ ($personal_data->emp_status == 'Contract Worker' ? "checked":"") }} />
                  <label for="emp3">Contractor</label> 
                </div>
              </div>
            </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>


            @if ($product_details->id == $simple_income )
              <div class="form-group">
                <label class="control-label col-sm-4"><span class="asterisk">*</span> When would you like this Insurance to start? </label>  
                <div class="col-sm-8 padding-left-none"> 
                  <div class="col-sm-3 padding-right-none">
                    @if ($insurance_startdate[2] == '00')
                        <input type="hidden" id="insurance_start_day" value="{{ date('d') }}">
                    @else
                        <input type="hidden" id="insurance_start_day" value="{{ $insurance_startdate[2] }}">
                    @endif

                    @if ($insurance_startdate[1] == '00')
                        <input type="hidden" id="insurance_start_month" value="{{ date('m') }}">
                    @else
                        <input type="hidden" id="insurance_start_month" value="{{ $insurance_startdate[1] }}">
                    @endif

                    @if ($insurance_startdate[2] == '0000')
                        <input type="hidden" id="insurance_start_year" value="{{ date('Y') }}">
                    @else
                        <input type="hidden" id="insurance_start_year" value="{{ $insurance_startdate[0] }}">
                    @endif
                    
                    <select class="form-control required" id="insurance_dd" name="insurance_dd"  title="Select Insurance Day">
                              <option value="">DD</option>
                                                            <option value="1">1 </option>
                                                            <option value="2">2 </option>
                                                            <option value="3">3 </option>
                                                            <option value="4">4 </option>
                                                            <option value="5">5 </option>
                                                            <option value="6">6 </option>
                                                            <option value="7">7 </option>
                                                            <option value="8">8 </option>
                                                            <option value="9">9 </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>
                                                        </select>
                  </div>

                  <div class="col-sm-3 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>
                     
                    </select>
                  </div>

                  <div class="col-sm-3 padding-right-none">
                    <select name="insurance_yy" id="insurance_yy" class="form-control required" title="Select Insurance Year">
                      <option value="">YYYY</option>
                      <option value="2025">2025</option>

                      <option value="2019">2019</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>
          

              @if ($product_details->id != $instaprotect)
                
              

                <div class="form-group">
                  <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? {{$profile_id}}</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()" {{ ($personal_data->transfer == 'Yes' ? "checked":"") }} />
                        <label for="transfer1">Yes</label>
                      </div>
                      <div class="radio-inline">
                        <input type='radio' value='No' name="transfer"  id="transfer2" onclick="javascript:currentprovider()" {{ ($personal_data->transfer == 'No' || $personal_data->transfer == '' ? "checked":"") }} />
                        <label for="transfer2">No</label>
                      </div>
                    </div>
                  </div>  
                </div>

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

                </div>
               

              @endif

          @endif


             

          @if ($product_details->id != $best_mortgage && $product_details->id != $best_loan &&  $product_details->id != $simple_income)
              <!-- <div class="form-group">
                <label class="control-label col-sm-4"><span class="asterisk">*</span> When would you like this Insurance to start? </label>  
                <div class="col-sm-8 padding-left-none"> 
                  <div class="col-sm-3 padding-right-none">
                    @if ($insurance_startdate[2] == '00')
                        <input type="hidden" id="insurance_start_day" value="{{ date('d') }}">
                    @else
                        <input type="hidden" id="insurance_start_day" value="{{ $insurance_startdate[2] }}">
                    @endif

                    @if ($insurance_startdate[1] == '00')
                        <input type="hidden" id="insurance_start_month" value="{{ date('m') }}">
                    @else
                        <input type="hidden" id="insurance_start_month" value="{{ $insurance_startdate[1] }}">
                    @endif

                    @if ($insurance_startdate[2] == '0000')
                        <input type="hidden" id="insurance_start_year" value="{{ date('Y') }}">
                    @else
                        <input type="hidden" id="insurance_start_year" value="{{ $insurance_startdate[0] }}">
                    @endif
                    
                    <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-3 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-3 padding-right-none">
                    <select name="insurance_yy" id="insurance_yy" class="form-control required" title="Select Insurance Year">
                      <option value="">YYYY</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> -->
          

              @if ($product_details->id != $instaprotect)
              
              @if($profile_id=="3" && $product_details->id=="20")
              <div></div>
              @else
                <div class="form-group">
                  <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()" {{ ($personal_data->transfer == 'Yes' ? "checked":"") }} />
                        <label for="transfer1">Yes</label>
                      </div>
                      <div class="radio-inline">
                        <input type='radio' value='No' name="transfer"  id="transfer2" onclick="javascript:currentprovider()" {{ ($personal_data->transfer == 'No' || $personal_data->transfer == '' ? "checked":"") }} />
                        <label for="transfer">No</label>
                      </div>
                    </div>
                  </div>  
                </div>
                @endif
                <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="{{ $personal_data->current_provider }}" maxlength="35">
                    </div>
                    <div class="clearfix"></div>
                    <br>
                    <label class="control-label col-sm-4"><span style="color:red">*</span> Date on which the current policy was incepted </label>
                    <div class="col-sm-4 padding-right-none">   
                      <input name="current_policy_date" class="form-control required" id="current_policy_date" value="{{ $personal_data->current_policy_date }}"   title="Please Enter Policy Date">
                    </div>

                </div>
                
              @endif

          @endif

          <div class="form-group" >
            <div class="col-sm-12">
              <p>{{$product_details->product_info1}}</p>
              <ul class="links">
                <li><a target="_blank" href="{{ URL::asset('assets/policydocuments') }}/{{$product_details->policy_wordings_doc}}" > Policy Wordings</a> <i class="fa fa-file-pdf-o" style="color:red" aria-hidden="true"></i></li>
                <li><a target="_blank" href="{{ URL::asset('assets/policydocuments') }}/{{$product_details->keyfacts_doc}}">IPID Document</a> <i class="fa fa-file-pdf-o" style="color:red" aria-hidden="true"></i></li>
                
              </ul>
              <p>{{$product_details->product_info2}}</p>
            </div>
          </div>

          <div class="form-group" id="declaration">

            <label class="control-label col-sm-12 text-left"><strong>Declaration</strong></label>
            <div class="col-sm-12">
              <div style="height:125px;overflow:auto;border:5px solid #ccc;-moz-border-radius:5px;padding-left:10px;">

              {!!$product_details->disclaimer!!} 
              <!-- @if($product_details->id == Config::get('constant.SHEPHERDS_FRIENDLY_LONGTERM') || $product_details->id == Config::get('constant.SHEPHERDS_FRIENDLY_SHORTERM'))

                <p style="color:#e87300"> Important Information</p>
                <ul>
                <li>You are applying for an income protection policy and the answers provided in this application form are your responsibility. It is important that you take reasonable care to answer the questions honestly and to the best of your knowledge; failure to do so may result in your policy being canceled, the terms of your policy being amended, your claim rejected or not fully paid. If you are unsure whether or not any details are relevant, you should include them or you may wish to consult your doctor before completing the application.</li>
                <li>If there are any changes to your health or other circumstances prior to your policy starting please inform us immediately. These include a change in occupation, earnings, employment status, travel or residence, the taking up of a hazardous pastime, a change in your own health or that of your father, mother and / or siblings (including half-siblings) and changes to your alcohol consumption and / or smoking habits.</li>
                <li>The Society reserves the right to apply special terms or higher premiums or postpone or decline any application.</li>
                <li>Please note that no cover is effective until your policy starts. We also recommend that any existing cover is not canceled until this policy starts and you are satisfied that it meets your needs.</li>
                <p><b>Long Term and Short Term Protect Policies only </b>- The Society will only cover you for benefit payments up to 70% of annual taxable income in the 12 months prior to your incapacity (“the Maximum Benefit Level”). Therefore, in the event of a claim, the Society will only make benefit payments up to the Maximum Benefit Level, regardless of the amount of benefit payments which you have asked for under the Policy. In the event of a claim you will be asked to provide evidence of your income in the 12 months immediately prior to your incapacity. Failure to provide such evidence will result in your claim not being paid. When assessing your benefit, we will also take into account any continuing payments from your employment or business such as sick pay, payments from other insurance policies and any other sources of income. State benefits will be taken into account if a claim extends beyond 12 months.</p>
                @else
                  {!!$product_details->disclaimer!!}  

                @endif   -->
              </div><br />
                      
                <!--div>Please note that until further notice, all claims directly or indirectly due to Coronavirus will be excluded. This Insurance does not cover any claim in any way caused by or resulting from:<br>

                a) Coronavirus disease (COVID-19);<br>

                b) Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2);<br>

                c) Any mutation or variation of SARS-CoV-2;</br>

                d) Any fear or threat of a), b) or c) above.<br><br></div-->

              <input type="checkbox" name="declaration_confirm" id="declaration_confirm"  class="required"    {{ ($personal_data->declaration_confirm == 'on' ? "checked":"") }} />
                {{$product_details->self_decleration}}
                            
              <div class="clearfix"></div>
              <label for="declaration_confirm" generated="true" class="error"style="display:none;"></label>
                       
            </div>        
            
          </div>

          <!-- <div class="form-group">

            <label class="control-label col-sm-12 text-left"> 
              <strong> 
                <i class="fa fa-unlock-alt" aria-hidden="true"></i>
       Keeping you informed
              </strong>
            </label>
            <div class="col-sm-12">
              <p>We would like to keep you informed about products, services and additional benefits that we believe may be of interest to you. If you want us to do this, please tick this box.
                <input type=checkbox value='Y' name="marketingOptOut" id="marketingOptOut"  {{ ($personal_data->marketingOptOut == 'Y' ? "checked":"") }} />
              </p>
              <label for="marketingOptOut" generated="true" class="error"style="display:none;"></label>
            </div>

          </div> -->

        </div><!-- class bg end-->

        <input type="hidden" name="product_id" id="product_id" value="{{ $product_details->id}}">
        <input type="hidden" name="quot_id" id="quot_id" value="{{ $quote_details['id']}}">

        <div class="form-btns">
            <button type="submit" class="medium-btn btn-default" >Continue</button>
        </div>
      </form>
    </div> 

    
    <input type="hidden"  id="instaprotect" value="{{ $instaprotect}}">
    <input type="hidden"  id="best_mortgage" value="{{ $best_mortgage}}">
    <input type="hidden"  id="best_loan" value="{{ $best_loan}}">

    <input type="hidden" id="current_year" value="{{ $current_year }}">
    <input type="hidden" id="current_month" value="{{ $current_month }}">
    <input type="hidden" id="current_date" value="{{ $current_date }}">
    
    
    <div class="col-md-3 padding-none right-col border-left-none">
      @include('slices.frontend.get-a-quot.right_top')
      @include('slices.frontend.get-a-quot.right_bottom')
      
    </div>

  </div>
  <!-- Reject button modal -->
 <!-- <a data-target="#sharelink" role="button" data-toggle="modal" id="rejectTrigger"></a> -->
<div class="modal fade" id="sharelink">
    <div class="modal-dialog">
      <div class="modal-content">
          <!-- modal header -->
          <div class="modal-header">Copy the Link (or) share the Link via Email
            <button type="button" class="close" data-dismiss="modal" aria-label="Close">
              <span aria-hidden="true">×</span>
            </button>
            <!-- modal title -->
            <div class="modal-title" id="reject-modal-title">  </div>
          </div>
          <!-- modal body -->
          <div class="modal-body" id="reject-modal-body">
          </div>

          <div class="modal-body" id="comment-btn">