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

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

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

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

<h1>Request an Insurance Quote</h1>

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

<?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>

<div class="row">
    <div class="large-12 colums">
        <label>Upload Age Analysis</label>
        <?php echo Form::file('ageAnalysis'); ?>

    </div>
</div>

    <button class="myButton" 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(); ?>