@extends('layout.main')



            @section('main-section')


                <div class="content">

                    <!-- Start Content-->
                    <div class="container-fluid">

                        <!-- start page title -->
                        <div class="row">
                            <div class="col-12">
                                <div class="page-title-box">
                                    <div class="page-title-right">
                                        <ol class="breadcrumb m-0">
                                            <li class="breadcrumb-item"><a href="javascript: void(0);">EFU</a></li>

                                            <li class="breadcrumb-item active">Fire Form</li>
                                        </ol>
                                    </div>
                                    <h4 class="page-title">EFU PRCL Management Portal</h4>
                                </div>
                            </div>
                        </div>
                        <!-- end page title -->




                        <div class="row">
                            <div class="col-12">
                                <div class="card">
                                    <div class="card-body">
                                        <h4 class="header-title">Step 2 Fire Application</h4>
                                        <p class="sub-header">
                                          abcd
                                        </p>
                                        <form action="{{url('/fire_step2_post')}}" method="POST">
                                            @csrf
                                        <div class="row">


                                             <!--context-->

                <div class="col-lg-6" hidden>
                    <div class="form-group">
                      <label>id</label>
                      <input
                        type="text"
                        class="form-control"
                        id=""
                        name="jobid"
                        placeholder="Id"
                        value=""
                      />
                    </div>
                  </div>


                  <div class="col-lg-12">
                        <div class="form-group">
                        <label>Upload Document</label>
                        <input type="file" name="fileupload" class="form-control" />
                            </div>
                    </div>

                  <div class="col-lg-6">
                    <div class="form-group">
                      <label>Highest Location Sum Insured</label>
                      <input
                        type="text"
                        class="form-control"
                        id=""
                        name="_HighestLocationSumInsured"
                        placeholder="Highest Location Sum Insured"
                        value=""
                      />
                    </div>
                  </div>

                  <div class="col-lg-6">
                    <div class="form-group">
                      <label>MPL</label>
                      <input
                        type="text"
                        class="form-control"
                        id=""
                        name="_MPL"
                        placeholder="MPL"
                        value=""
                      />
                    </div>
                  </div>

                  <div class="col-lg-6">
                    <div class="form-group">
                      <label>Co-Insurance</label>
                      <input
                        type="text"
                        class="form-control"
                        id=""
                        name="_CoInsurance"
                        placeholder="Co-Insurance"
                        value=""
                      />
                    </div>
                  </div>

                  <div class="col-lg-12" hidden>
                    <div class="form-group">
                      <label>Deductibles</label>
                      <textarea
                        class="form-control"
                        id=""
                        name="Deductables"
                        placeholder="Deductibles"
                        value=""
                      ></textarea>
                    </div>
                  </div>

                  <div class="col-lg-6" hidden>
                    <div class="form-group">
                      <label>Premium 100%</label>
                      <input
                        type="text"
                        class="form-control"
                        id=""
                        name="Premium"
                        placeholder="Premium"
                        value=""
                      />
                    </div>
                  </div>

                  <div class="col-lg-12" hidden>
                    <div class="form-group">
                      <label>Terms and Conditions</label>
                      <textarea

                        class="form-control"
                        id=""
                        name="TermAndConditions"
                        placeholder="Terms and Conditions"

                      ></textarea>
                    </div>
                  </div>

                  <div class="col-lg-12">
                    <div class="form-group">
                      <label>Exclusion</label>
                      <textarea
                        class="form-control"
                        id=""
                        name="Exclusion"
                        placeholder="Exclusion"
                        value=""
                      ></textarea>
                    </div>
                  </div>

                  <div class="col-lg-6" hidden>
                    <div class="form-group">
                      <label>R / I Commission</label>
                      <input
                        type="text"
                        class="form-control"
                        id=""
                        name="RICommissiion"
                        placeholder="R / I Commission"
                        value=""
                      />
                    </div>
                  </div>

                  <div class="col-lg-6">
                    <div class="form-group">
                      <label>Re-Insurer</label>
                      <input
                        type="text"
                        class="form-control"
                        id=""
                        name="ReInsurer"
                        placeholder="ReInsurer"
                        value="Pakistan Reinsurance Company Limited"
                      />
                    </div>
                  </div>

                  <div class="col-lg-6">
                    <div class="form-group">
                      <label>PRCL Share</label>
                      <input
                        type="text"
                        class="form-control"
                        id=""
                        name="PRCLShare"
                        placeholder="PRCL Share"
                        value=""
                      />
                    </div>
                  </div>

                  <div class="col-lg-6">
                    <div class="form-group">
                      <label>Company Net Retention</label>
                      <input
                        type="text"
                        class="form-control"
                        id=""
                        name="CompanyNetRetention"
                        placeholder="Company Net Retention"
                        value=""
                      />
                    </div>
                  </div>

                  <div class="col-lg-6">
                    <div class="form-group">
                      <label>PRCL Treaty Share</label>
                      <input
                        type="text"
                        class="form-control"
                        id=""
                        name="PRCLTreatyShare"
                        placeholder="PRCL Treaty Share"
                        value=""
                      />
                    </div>
                  </div>

                  <div class="col-lg-12">
                    <div class="form-group">
                      <label>Loss History</label>
                      <textarea
                        type="text"
                        class="form-control"
                        id=""
                        name="LossHostory"
                        placeholder="Loss History"
                        value=""
                      ></textarea>
                    </div>
                  </div>


                                        <div class="col-lg-12">


                                            <div class="mb-12">
                                                <button type="submit" class="btn btn-success" onclick="GoodJob()" id="sa-success">Submit</button>

                                            </div>
                                            <p></p>
                                    </div> <!-- end col -->



                        </div>
                        <!-- end row -->
                    </form>

                    </div> <!-- container -->

                </div> <!-- content -->


@endsection('main-section')