@extends('master')

@section('title')
   Insurance Quote
@stop

@section('styles')
 <style>

input[type="text"], input[type="password"], input[type="date"], input[type="datetime"], input[type="datetime-local"], input[type="month"], input[type="week"], input[type="email"], input[type="number"], input[type="search"], input[type="tel"], input[type="time"], input[type="url"], input[type="color"], textarea {
    width: 220%;
}
 </style>
@stop

@section('content')

@include('partials.nav')

<h1>Request an Insurance Quote</h1>

<hr style="margin-top: 10px;">

{{ Form::open(['url' => '/quote', 'method' => 'POST', 'data-abide' => '','files' => true]) }}


<div class="row">
     <div class="large-6 columns">
          <label class="" for="business_name">Company Name <small class="red">{{ $errors->first('company_name') }}</small>
                 {{ Form::text('company_name', '', ['class' => '']) }}
          </label>
     </div>
     <div class="large-6 columns">
          <label class="" for="registration_number">Registration Number <small class="red">{{ $errors->first('registration_number') }}</small>
                 {{ Form::text('registration_number', '', ['class' => '']) }}
          </label>
     </div>
</div>


<div class="row">
     <div class="large-6 columns">
          <label class="" for="industry">Contact Name <small class="red">{{ $errors->first('contact_name') }}</small>
                 {{ Form::text('contact_name', '', ['class' => '']) }}
          </label>
     </div>
     <div class="large-6 columns">
          <label class="" for="insured_book_amount">Designation <small class="red">{{ $errors->first('designation') }}</small>
                 {{ Form::text('designation', '', ['class' => '']) }}
          </label>
     </div>
</div>

<div class="row">
     <div class="large-6 columns">
          <label class="" for="current_overdue_amount">Contact Number <small class="red">{{ $errors->first('contact_number') }}</small>
                 {{ Form::text('contact_number', '', ['class' => '']) }}
          </label>
     </div>
     <div class="large-6 columns">
          <label class="" for="percentage_overdue">Email<small class="red">{{ $errors->first('email') }}</small>
                 {{ Form::email('email', '', ['class' => '']) }}
          </label>
     </div>
</div>

<div class="row">
    <div class="large-12 columns">
        <button class="myButton" type="submit">SUBMIT</button>
    </div>
</div>

{{ Form:: close() }}

@include('partials.footer')

@stop