<?php $__env->startSection('title'); ?>
   Insurance Quote
<?php $__env->stopSection(); ?>

<?php $__env->startSection('styles'); ?>
    
<?php $__env->stopSection(); ?>

<?php $__env->startSection('content'); ?>
<img style="max-width: 30%;display: block; margin-top: -3rem; margin-left: auto; margin-right: auto;" src="/img/Prestige_Logo.jpg" />

<hr>
 <h1 style="margin-top: 6px; text-align: center; font-size: 28px;">Insurance Quote Request</h1>

 <a  href="/dashboard"><button style="    margin-left: 31rem;
                                                             padding-bottom: 0.01rem;
                                                             padding-left: 0rem;"><i style="font-size: 1rem;" class="fa fa-arrow-circle-left" aria-hidden="true"></i>Back</button></a>



<?php echo Form::open(['url' => '/quote', 'method' => 'POST', 'data-abide' => '','files' => true]); ?>



<div class="row">
     <div class="large-6 columns">
          <label class="" for="business_name">Business Name <small class="red"><?php echo $errors->first('business_name'); ?></small>
                 <?php echo Form::text('business_name', '', ['class' => '']); ?>

          </label>
     </div>
     <div class="large-6 columns">
          <label class="" for="registration_number">Registration Number <small class="red"><?php echo $errors->first('registration_number'); ?></small>
                 <?php echo Form::text('registration_number', '', ['class' => '']); ?>

          </label>
     </div>
</div>


<div class="row">
     <div class="large-6 columns">
          <label class="" for="industry">Industry <small class="red"><?php echo $errors->first('industry'); ?></small>
                 <?php echo Form::text('industry', '', ['class' => '']); ?>

          </label>
     </div>
     <div class="large-6 columns">
          <label class="" for="insured_book_amount">Insured Book Amount R <small class="red"><?php echo $errors->first('insured_book_amount'); ?></small>
                 <?php echo Form::text('insured_book_amount', '', ['class' => '']); ?>

          </label>
     </div>
</div>

<div class="row">
     <div class="large-6 columns">
          <label class="" for="current_overdue_amount">Current Overdue Amount <small class="red"><?php echo $errors->first('current_overdue_amount'); ?></small>
                 <?php echo Form::text('current_overdue_amount', '', ['class' => '']); ?>

          </label>
     </div>
     <div class="large-6 columns">
          <label class="" for="percentage_overdue">Percentage Overdue<small class="red"><?php echo $errors->first('percentage_overdue'); ?></small>
                 <?php echo Form::text('percentage_overdue', '', ['class' => '']); ?>

          </label>
     </div>
</div>

<div class="row">
     <div class="large-6 columns">
          <label class="" for="debtors">Number of Debtors <small class="red"><?php echo $errors->first('debtors'); ?></small>
                 <?php echo Form::text('debtors', '', ['class' => '']); ?>

          </label>
     </div>
     <div class="large-6 columns">
          <label class="" for="previous_insurer">Previous Insurer <small class="red"><?php echo $errors->first('previous_insurer'); ?></small>
                 <?php echo Form::text('previous_insurer', '', ['class' => '']); ?>

          </label>
     </div>
</div>

<div class="row">
     <div class="large-6 columns">
          <label class="" for="current_insurer">Current Insurer <small class="red"><?php echo $errors->first('current_insurer'); ?></small>
                 <?php echo Form::text('current_insurer', '', ['class' => '']); ?>

          </label>
     </div>
     <div class="large-6 columns">
          <label class="" for="contact_person">Contact Person <small class="red"><?php echo $errors->first('contact_person'); ?></small>
                 <?php echo Form::text('contact_person', '', ['class' => '']); ?>

          </label>
     </div>
</div>

<div class="row">
     <div class="large-6 columns">
          <label class="" for="telephone">Telephone <small class="red"><?php echo $errors->first('telephone'); ?></small>
                 <?php echo Form::text('telephone', '', ['class' => '']); ?>

          </label>
     </div>
     <div class="large-6 columns">
          <label class="" for="fax">Fax <small class="red"><?php echo $errors->first('fax'); ?></small>
                 <?php echo Form::text('fax', '', ['class' => '']); ?>

          </label>
     </div>
</div>

<div class="row">
     <div class="large-6 columns">
          <label class="" for="cell">Cell <small class="red"><?php echo $errors->first('cell'); ?></small>
                 <?php echo Form::text('cell', '', ['class' => '']); ?>

          </label>
     </div>
     <div class="large-6 columns">
          <label class="" for="email">Email <small class="red"><?php echo $errors->first('email'); ?></small>
                 <?php echo Form::email('email', '', ['class' => '']); ?>

          </label>
     </div>
</div>

<div class="row">
     <div class="large-6 columns">
          <label class="" for="postal_address">Postal Address <small class="red"><?php echo $errors->first('postal_address'); ?></small>
                 <?php echo Form::textarea('postal_address', '', ['class' => '']); ?>

          </label>
     </div>
     <div class="large-6 columns">
          <label class="" for="physical_address">Physical Address <small class="red"><?php echo $errors->first('physical_address'); ?></small>
                 <?php echo Form::textarea('physical_address', '', ['class' => '']); ?>

          </label>
     </div>
</div>

    <button style="margin-left: 31rem;" type="submit">SUBMIT</button>




</div>

<?php echo Form:: close(); ?>

<?php $__env->stopSection(); ?>
<?php echo $__env->make('master', array_except(get_defined_vars(), array('__data', '__path')))->render(); ?>