allo/resources/views/customer-service/view_coverage_formB.blade.php

@extends('customer-service.layout.master')

@section('content')
<style type="text/css">
	.i_note {color: red;}
</style>

<div class="fluid">
	@if(count($errors) > 0)
	<div class="nNote nFailure">
		@foreach($errors->all() as $error)
		<p>{{$error}}</p>
		@endforeach
	</div>
	@endif

	@if(Session::get('error_msg'))
	<div class="nNote nFailure">
		<p>Email or Password is invalid</p>
	</div>
	@elseif(Session::get('success_msg'))
	<div class="nNote nSuccess">
		<p>Add new Coverage successful</p>
	</div>
	@endif
</div>

<div class="fluid">
	<form action="{{url('/CustomerService/coverage/add-coverage')}}" class="main cussPayment" method="post" enctype="multipart/form-data">
		<input type="hidden" name="Type" value="B">
		<input type="hidden" name="_token" value="<?php echo csrf_token(); ?>">
		<fieldset>
			<div class="widget grid2 widgetH"></div>
			<div class="widget grid8">
				<div class="whead"><h6>Add New Coverage (R)</h6></div>

				<div class="formRow">
					<div class="grid2">&nbsp;</div>
					<div class="grid2"><label><b>Building Name : </b></label></div>
					<div class="grid6"><input type="text" name="name" id="name" value="" required /></div>
					<div class="grid2">&nbsp;</div>
				</div>

				<div class="formRow">
					<div class="grid2">&nbsp;</div>
					<div class="grid2"><label><b>Street : </b></label></div>
					<div class="grid6"><textarea rows="3" cols="" name="street" id="street" class="auto" style="overflow: hidden; word-wrap: break-word; resize: horizontal; height: 70px;" required></textarea></div>
					<div class="grid2">&nbsp;</div>
				</div>

				<div class="formRow">
					<div class="grid2">&nbsp;</div>
					<div class="grid4">
						<label><b>Postcode : </b></label>
						<input type="text" name="postcode" id="postcode" value="" required />
					</div>
					<div class="grid4">
						<label><b>City : </b></label>
						<input type="text" name="city" id="city" value="" required />
					</div>
					<div class="grid2">&nbsp;</div>
				</div>

				<div class="formRow">
					<div class="grid2">&nbsp;</div>
					<div class="grid2"><label><b>State : </b></label></div>
					<div class="grid6"><input type="text" name="state" id="state" value="" required /></div>
					<div class="grid2">&nbsp;</div>
				</div>

				<div class="formRow">
					<div class="grid2">&nbsp;</div>
					<div class="grid2"><label><b>Installation Fee : </b></label></div>
					<div class="grid6"><input type="text" name="fee" id="fee" value="" required /></div>
					<div class="grid2">&nbsp;</div>
				</div>
				<div class="formRow">
					<div class="grid2">&nbsp;</div>
					<div class="grid2"><label><b>Select Status Building : </b></label></div>
					<div class="grid6">
						<select class="styled" id="status" name="status" style="opacity: 0;">
							<option value="">Please choose status building</option>
							<option value="prelaid">Prelaid</option>
							<option value="non prelaid">Non Prelaid</option>
						</select>
					</div>
					<div class="grid2">&nbsp;</div>
				</div>
				<div class="formRow">
					<div class="grid2">&nbsp;</div>
					<div class="grid2"><label><b>Email (JMB): </b></label></div>
					<div class="grid6"><input type="email" name="jmb" id="jmb" value="" /></div>
					<div class="grid2">&nbsp;</div>
				</div>

				<div class="formRow noBorderB" id="sendForm"><input type="submit" value="Add New Coverage" class="buttonM bPurple formSubmit" name="submit" id="submit"></div>
			</div>
			<div class="widget grid2 widgetH"></div>
		</fieldset>
	</form>
</div>
@endsection