<?php $__env->startSection('title','Claim Documents Verification | '); ?>
<?php $__env->startSection('content'); ?>
<!-- Content Header (Page header) -->
<div class="content-header">
    <div class="container-fluid">
        <div class="row mb-2">
            <div class="col-sm-6">
                <h1 class="m-0">Claim Documents</h1>
            </div><!-- /.col -->
            <div class="col-sm-6">
                <ol class="breadcrumb float-sm-right">
                    <li class="breadcrumb-item"><a href="#">Home</a></li>
                    <li class="breadcrumb-item active">Claim Management</li>
                </ol>
            </div><!-- /.col -->
        </div><!-- /.row -->
    </div><!-- /.container-fluid -->
</div>
<!-- /.content-header -->
<!-- Main content -->
<section class="content">
    <div class="container-fluid">
    <a class="btn btn-primary m-1" href="<?php echo e(route('list.all.claims')); ?>">Back</a>

        <div class="card card-default">
            <div class="card-header">
                <h3 class="card-title">Claim Documents</h3>
            </div>
            <!-- /.card-header -->
            <div class="card-body">
                <?php if(session('success')): ?>
                <div class="alert alert-success alert-dismissible fade show" role="alert">
                    <strong><?php echo e(session('success')); ?></strong>
                    <button type="button" class="close" data-dismiss="alert" aria-label="Close">
                        <span aria-hidden="true">&times;</span>
                    </button>
                </div>
                <?php endif; ?>
                <?php if(session('error')): ?>
                <div class="alert alert-danger alert-dismissible fade show" role="alert">
                    <strong><?php echo e(session('success')); ?></strong>
                    <button type="button" class="close" data-dismiss="alert" aria-label="Close">
                        <span aria-hidden="true">&times;</span>
                    </button>
                </div>
                <?php endif; ?>
                <?php if(session('warning')): ?>
                <div class="alert alert-warning alert-dismissible fade show" role="alert">
                    <strong><?php echo e(session('warning')); ?></strong>
                    <button type="button" class="close" data-dismiss="alert" aria-label="Close">
                        <span aria-hidden="true">&times;</span>
                    </button>
                </div>
                <?php endif; ?>
                <form action="<?php echo e(route('store.next.claim.form')); ?>" method="post" autocomplete="off">
                    <?php echo csrf_field(); ?>
                    <input type="hidden" id="claim_id" name="claim_id" value="<?php echo e($claim_data->claim_id); ?>">
                    <input type="hidden" name="claim_type" value="<?php echo e($claim_data->claim_type); ?>">
                    <div class="row">
                        <div class="col-md-6">
                            <div class="form-group">
                                <label for="claim_for">Claim For</label>
                                <select name="claim_for"
                                    class="custom-select form-control reset_form <?php if( $errors->has('claim_for')): ?> is-invalid border-danger  <?php endif; ?>"
                                    id="claim_for">
                                    <option value="" <?php echo e((old('claim_for') == '') ? 'selected' : ''); ?>>Select Claim For
                                    </option>
                                    <option value="EPF" <?php echo e((old('claim_for') == 'EPF') ? 'selected' : ''); ?>>EPF</option>
                                    <option value="ESI" <?php echo e((old('claim_for') == 'ESI') ? 'selected' : ''); ?>>ESI</option>
                                    <option value="WC" <?php echo e((old('claim_for') == 'WC') ? 'selected' : ''); ?>>WC</option>
                                    <option value="GPA" <?php echo e((old('claim_for') == 'GPA') ? 'selected' : ''); ?>>GPA</option>
                                </select>
                                <small class="text-danger claim_for_error"></small>
                                <?php if($errors->has('claim_for')): ?>
                                <span id="claim_for-error"
                                    class="error text-danger invalid-feedback"><?php echo e($errors->first('claim_for')); ?></span>
                                <small></small>
                                <?php endif; ?>
                            </div>
                        </div>
                    </div>
                    <div class="claim_by_epf">
                        <div class="row">
                            <div class="col-md-12 ">
                                <div class="form-group">
                                    <label for="document_for_claim">Document required for EPF Claim</label>
                                    <br><small class='text-muted'><strong>Important: </strong>All the documents are
                                        required
                                        for claim as mentioned below</small>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="epf_emp_aadhar" value="1"
                                            type="checkbox" id="epf_emp_aadhar"
                                            <?php echo e((old('epf_emp_aadhar') == '1') ? 'checked' : ''); ?>>
                                        <label for="epf_emp_aadhar" class="custom-control-label">Aadhar of
                                            Divyang
                                            Employee</label>
                                    </div>
                                    <?php if($claim_data->claim_type == 1): ?>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="epf_death_certificate" value="1"
                                            type="checkbox" id="epf_death_certificate"
                                            <?php echo e((old('epf_death_certificate') == '1') ? 'checked' : ''); ?>>
                                        <label for="epf_death_certificate" class="custom-control-label">Death
                                            Certificate</label>
                                    </div>
                                    <?php endif; ?>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="epf_nominee" value="1" type="checkbox"
                                            id="epf_nominee" <?php echo e((old('epf_nominee') == '1') ? 'checked' : ''); ?>>
                                        <label for="epf_nominee" class="custom-control-label">Nominee's
                                            Document</label>
                                    </div>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="epf_pan" value="1" type="checkbox"
                                            id="epf_pan" <?php echo e((old('epf_pan') == '1') ? 'checked' : ''); ?>>
                                        <label for="epf_pan" class="custom-control-label">PAN</label>
                                    </div>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="epf_bank_passbook" value="1"
                                            type="checkbox" id="epf_bank_passbook"
                                            <?php echo e((old('epf_bank_passbook') == '1') ? 'checked' : ''); ?>>
                                        <label for="epf_bank_passbook" class="custom-control-label">Bank Passbook(Only
                                            SBI)
                                            <br>
                                            <small class="text-muted">Join account in SBI with mother if child is
                                                minor</small>
                                        </label>
                                    </div>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="epf_ration_card" value="1"
                                            type="checkbox" id="epf_ration_card"
                                            <?php echo e((old('epf_ration_card') == '1') ? 'checked' : ''); ?>>
                                        <label for="epf_ration_card" class="custom-control-label">Ration Card</label>
                                    </div>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="epf_photos" value="1" type="checkbox"
                                            id="epf_photos" <?php echo e((old('epf_photos') == '1') ? 'checked' : ''); ?>>
                                        <label for="epf_photos" class="custom-control-label">3 Photos</label>
                                    </div>
                                    <?php if($errors->has('epf_emp_aadhar') || $errors->has('epf_death_certificate') ||
                                    $errors->has('epf_nominee') || $errors->has('epf_pan') ||
                                    $errors->has('epf_bank_passbook') || $errors->has('epf_ration_card') ||
                                    $errors->has('epf_photos')): ?>
                                    <small class="text-danger">All the above documents are required for EPF
                                        claim</small>
                                    <?php endif; ?>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="epf_member_id">Member ID</label>
                                    <input type="text" name="epf_member_id"
                                        class="form-control   <?php if( $errors->has('epf_member_id')): ?> is-invalid border-danger  <?php endif; ?>"
                                        value="<?php echo e(old('epf_member_id')); ?>" id="epf_member_id" placeholder="Member ID">
                                    <?php if($errors->has('epf_member_id')): ?>
                                    <span id="epf_member_id-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('epf_member_id')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="epf_uan_number">UAN Number</label>
                                    <input type="number" name="epf_uan_number"
                                        class="form-control <?php if( $errors->has('epf_uan_number')): ?> is-invalid border-danger  <?php endif; ?>"
                                        id="epf_uan_number" value="<?php echo e(old('epf_uan_number')); ?>"
                                        placeholder="EPF/UAN Number" max="<?php echo e(date('Y-m-d')); ?>">
                                    <?php if($errors->has('epf_uan_number')): ?>
                                    <span id="epf_uan_number-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('epf_uan_number')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="epf_intimation_date">Intimation Date <small
                                            class="text-muted">(Department Information Date)</small></label>
                                    <input type="date" name="epf_intimation_date"
                                        class="form-control <?php if( $errors->has('epf_intimation_date')): ?> is-invalid border-danger  <?php endif; ?>"
                                        id="epf_intimation_date" value="<?php echo e(old('epf_intimation_date')); ?>"
                                        max="<?php echo e(date('Y-m-d')); ?>">
                                    <?php if($errors->has('epf_intimation_date')): ?>
                                    <span id="epf_intimation_date-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('epf_intimation_date')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="epf_submission_date">Submission Date <small class="text-muted">(Document
                                            Submission Date)</small></label>
                                    <input type="date" name="epf_submission_date"
                                        class="form-control <?php if( $errors->has('epf_submission_date')): ?> is-invalid border-danger  <?php endif; ?>"
                                        id="epf_submission_date" value="<?php echo e(old('epf_submission_date')); ?>"
                                        max="<?php echo e(date('Y-m-d')); ?>">
                                    <?php if($errors->has('epf_submission_date')): ?>
                                    <span id="epf_submission_date-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('epf_submission_date')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>

                        </div>
                    </div>
                    <div class="claim_by_esi">
                        <div class="row">
                            <div class="col-md-12 ">
                                <div class="form-group">
                                    <label for="document_for_claim">Document required for ESI Claim</label>
                                    <br><small class='text-muted'><strong>Important: </strong>All the documents are
                                        required
                                        for claim as mentioned below</small>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="esi_emp_aadhar" value="1"
                                            type="checkbox" id="esi_emp_aadhar"
                                            <?php echo e((old('esi_emp_aadhar') == '1') ? 'checked' : ''); ?>>
                                        <label for="esi_emp_aadhar" class="custom-control-label">Aadhar of
                                            Divyang
                                            Employee</label>
                                    </div>
                                    <?php if($claim_data->claim_type == 1): ?>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="esi_death_certificate" value="1"
                                            type="checkbox" id="esi_death_certificate"
                                            <?php echo e((old('esi_death_certificate') == '1') ? 'checked' : ''); ?>>
                                        <label for="esi_death_certificate" class="custom-control-label">Death
                                            Certificate</label>
                                    </div>
                                    <?php endif; ?>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="esi_nominee" value="1" type="checkbox"
                                            id="esi_nominee" <?php echo e((old('esi_nominee') == '1') ? 'checked' : ''); ?>>
                                        <label for="esi_nominee" class="custom-control-label">Nominee's
                                            Document</label>
                                    </div>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="esi_pan" value="1" type="checkbox"
                                            id="esi_pan" <?php echo e((old('esi_pan') == '1') ? 'checked' : ''); ?>>
                                        <label for="esi_pan" class="custom-control-label">PAN</label>
                                    </div>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="esi_bank_passbook" value="1"
                                            type="checkbox" id="esi_bank_passbook"
                                            <?php echo e((old('esi_bank_passbook') == '1') ? 'checked' : ''); ?>>
                                        <label for="esi_bank_passbook" class="custom-control-label">Bank Passbook(Only
                                            SBI)
                                            <br>
                                            <small class="text-muted">Join account in SBI with mother if child is
                                                minor</small>
                                        </label>
                                    </div>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="esi_ration_card" value="1"
                                            type="checkbox" id="esi_ration_card"
                                            <?php echo e((old('esi_ration_card') == '1') ? 'checked' : ''); ?>>
                                        <label for="esi_ration_card" class="custom-control-label">Ration Card</label>
                                    </div>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="esi_photos" value="1" type="checkbox"
                                            id="esi_photos" <?php echo e((old('esi_photos') == '1') ? 'checked' : ''); ?>>
                                        <label for="esi_photos" class="custom-control-label">3 Photos</label>
                                    </div>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="esi_fir_report" value="1"
                                            type="checkbox" id="esi_fir_report"
                                            <?php echo e((old('esi_fir_report') == '1') ? 'checked' : ''); ?>>
                                        <label for="esi_fir_report" class="custom-control-label">FIR(First Information
                                            Report)</label>
                                    </div>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="esi_scratch" value="1" type="checkbox"
                                            id="esi_scratch" <?php echo e((old('esi_scratch') == '1') ? 'checked' : ''); ?>>
                                        <label for="esi_scratch" class="custom-control-label">Scratch of the place where
                                            the accident happened</label>
                                    </div>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="esi_passbook_statement" value="1"
                                            type="checkbox" id="esi_passbook_statement"
                                            <?php echo e((old('esi_passbook_statement') == '1') ? 'checked' : ''); ?>>
                                        <label for="esi_passbook_statement" class="custom-control-label">Passbook 6
                                            Month(Statement)</label>
                                    </div>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="esi_member_id">Member ID</label>
                                    <input type="text" name="esi_member_id"
                                        class="form-control   <?php if( $errors->has('esi_member_id')): ?> is-invalid border-danger  <?php endif; ?>"
                                        value="<?php echo e(old('esi_member_id')); ?>" id="esi_member_id" placeholder="Member ID">
                                    <?php if($errors->has('esi_member_id')): ?>
                                    <span id="esi_member_id-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('esi_member_id')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="esi_number">ESI Number</label>
                                    <input type="number" name="esi_number"
                                        class="form-control <?php if( $errors->has('esi_number')): ?> is-invalid border-danger  <?php endif; ?>"
                                        id="esi_number" value="<?php echo e(old('esi_number')); ?>" placeholder="ESI Number"
                                        max="<?php echo e(date('Y-m-d')); ?>">
                                    <?php if($errors->has('esi_number')): ?>
                                    <span id="esi_number-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('esi_number')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="esi_intimation_date">Intimation Date <small
                                            class="text-muted">(Department Information Date)</small></label>
                                    <input type="date" name="esi_intimation_date"
                                        class="form-control <?php if( $errors->has('esi_intimation_date')): ?> is-invalid border-danger  <?php endif; ?>"
                                        id="esi_intimation_date" value="<?php echo e(old('esi_intimation_date')); ?>"
                                        max="<?php echo e(date('Y-m-d')); ?>">
                                    <?php if($errors->has('esi_intimation_date')): ?>
                                    <span id="esi_intimation_date-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('esi_intimation_date')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="esi_submission_date">Submission Date <small class="text-muted">(Document
                                            Submission Date)</small></label>
                                    <input type="date" name="esi_submission_date"
                                        class="form-control <?php if( $errors->has('esi_submission_date')): ?> is-invalid border-danger  <?php endif; ?>"
                                        id="esi_submission_date" value="<?php echo e(old('esi_submission_date')); ?>"
                                        max="<?php echo e(date('Y-m-d')); ?>">
                                    <?php if($errors->has('esi_submission_date')): ?>
                                    <span id="esi_submission_date-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('esi_submission_date')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>
                        </div>
                    </div>
                    <div class="claim_by_wc">
                        <div class="row">
                            <div class="col-md-12 ">
                                <div class="form-group">
                                    <label for="document_for_claim">Document required for WC Claim</label>
                                    <br><small class='text-muted'><strong>Important: </strong>All the documents are
                                        required
                                        for claim as mentioned below</small>
                                    <?php if($claim_data->claim_type == 1): ?>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="wc_death_certificate" value="1"
                                            type="checkbox" id="wc_death_certificate"
                                            <?php echo e((old('wc_death_certificate') == '1') ? 'checked' : ''); ?>>
                                        <label for="wc_death_certificate" class="custom-control-label">Death
                                            Certificate</label>
                                    </div>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="wc_post_mortem_report" value="1"
                                            type="checkbox" id="wc_post_mortem_report"
                                            <?php echo e((old('wc_post_mortem_report') == '1') ? 'checked' : ''); ?>>
                                        <label for="wc_post_mortem_report" class="custom-control-label">POST Mortem
                                            Report</label>
                                    </div>
                                    <?php endif; ?>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="wc_bills" value="1" type="checkbox"
                                            id="wc_bills" <?php echo e((old('wc_bills') == '1') ? 'checked' : ''); ?>>
                                        <label for="wc_bills" class="custom-control-label">Bills</label>
                                    </div>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="wc_policy_number">Policy Number</label>
                                    <input type="text" name="wc_policy_number"
                                        class="form-control   <?php if( $errors->has('wc_policy_number')): ?> is-invalid border-danger  <?php endif; ?>"
                                        value="<?php echo e(old('wc_policy_number')); ?>" id="wc_policy_number"
                                        placeholder="Policy Number">
                                    <?php if($errors->has('wc_policy_number')): ?>
                                    <span id="wc_policy_number-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('wc_policy_number')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="wc_company_name">Company Name</label>
                                    <input type="text" name="wc_company_name"
                                        class="form-control <?php if( $errors->has('wc_company_name')): ?> is-invalid border-danger  <?php endif; ?>"
                                        id="wc_company_name" value="<?php echo e(old('wc_company_name')); ?>"
                                        placeholder="Company Name" max="<?php echo e(date('Y-m-d')); ?>">
                                    <?php if($errors->has('wc_company_name')): ?>
                                    <span id="wc_company_name-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('wc_company_name')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="wc_intimation_date">Intimation Date <small
                                            class="text-muted">(Department Information Date)</small></label>
                                    <input type="date" name="wc_intimation_date"
                                        class="form-control <?php if( $errors->has('wc_intimation_date')): ?> is-invalid border-danger  <?php endif; ?>"
                                        id="wc_intimation_date" value="<?php echo e(old('wc_intimation_date')); ?>"
                                        max="<?php echo e(date('Y-m-d')); ?>">
                                    <?php if($errors->has('wc_intimation_date')): ?>
                                    <span id="wc_intimation_date-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('wc_intimation_date')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="wc_submission_date">Submission Date <small class="text-muted">(Document
                                            Submission Date)</small></label>
                                    <input type="date" name="wc_submission_date"
                                        class="form-control <?php if( $errors->has('wc_submission_date')): ?> is-invalid border-danger  <?php endif; ?>"
                                        id="wc_submission_date" value="<?php echo e(old('wc_submission_date')); ?>"
                                        max="<?php echo e(date('Y-m-d')); ?>">
                                    <?php if($errors->has('wc_submission_date')): ?>
                                    <span id="wc_submission_date-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('wc_submission_date')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>
                        </div>
                    </div>
                    <div class="claim_by_gpa">
                        <div class="row">
                            <div class="col-md-12">
                                <div class="form-group">
                                    <label for="document_for_claim">Document required for GPA Claim</label>
                                    <br><small class='text-muted'><strong>Important: </strong>All the documents are
                                        required
                                        for claim as mentioned below</small>
                                    <?php if($claim_data->claim_type == 1): ?>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="gpa_death_certificate" value="1"
                                            type="checkbox" id="gpa_death_certificate"
                                            <?php echo e((old('gpa_death_certificate') == '1') ? 'checked' : ''); ?>>
                                        <label for="gpa_death_certificate" class="custom-control-label">Death
                                            Certificate</label>
                                    </div>
                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="gpa_post_mortem_report" value="1"
                                            type="checkbox" id="gpa_post_mortem_report"
                                            <?php echo e((old('gpa_post_mortem_report') == '1') ? 'checked' : ''); ?>>
                                        <label for="gpa_post_mortem_report" class="custom-control-label">POST Mortem
                                            Report</label>
                                    </div>
                                    <?php endif; ?>

                                    <div class="custom-control custom-checkbox">
                                        <input class="custom-control-input" name="gpa_bills" value="1" type="checkbox"
                                            id="gpa_bills" <?php echo e((old('gpa_bills') == '1') ? 'checked' : ''); ?>>
                                        <label for="gpa_bills" class="custom-control-label">Bills</label>
                                    </div>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="gpa_policy_number">Policy Number</label>
                                    <input type="text" name="gpa_policy_number"
                                        class="form-control   <?php if( $errors->has('gpa_policy_number')): ?> is-invalid border-danger  <?php endif; ?>"
                                        value="<?php echo e(old('gpa_policy_number')); ?>" id="gpa_policy_number"
                                        placeholder="Policy Number">
                                    <?php if($errors->has('gpa_policy_number')): ?>
                                    <span id="gpa_policy_number-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('gpa_policy_number')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="gpa_company_name">Company Name</label>
                                    <input type="text" name="gpa_company_name"
                                        class="form-control <?php if( $errors->has('gpa_company_name')): ?> is-invalid border-danger  <?php endif; ?>"
                                        id="gpa_company_name" value="<?php echo e(old('gpa_company_name')); ?>"
                                        placeholder="Company Name" max="<?php echo e(date('Y-m-d')); ?>">
                                    <?php if($errors->has('gpa_company_name')): ?>
                                    <span id="gpa_company_name-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('wc_company_name')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="gpa_intimation_date">Intimation Date <small
                                            class="text-muted">(Department Information Date)</small></label>
                                    <input type="date" name="gpa_intimation_date"
                                        class="form-control <?php if( $errors->has('gpa_intimation_date')): ?> is-invalid border-danger  <?php endif; ?>"
                                        id="gpa_intimation_date" value="<?php echo e(old('gpa_intimation_date')); ?>"
                                        max="<?php echo e(date('Y-m-d')); ?>">
                                    <?php if($errors->has('gpa_intimation_date')): ?>
                                    <span id="gpa_intimation_date-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('gpa_intimation_date')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="gpa_submission_date">Submission Date <small class="text-muted">(Document
                                            Submission Date)</small></label>
                                    <input type="date" name="gpa_submission_date"
                                        class="form-control <?php if( $errors->has('gpa_submission_date')): ?> is-invalid border-danger  <?php endif; ?>"
                                        id="gpa_submission_date" value="<?php echo e(old('gpa_submission_date')); ?>"
                                        max="<?php echo e(date('Y-m-d')); ?>">
                                    <?php if($errors->has('gpa_submission_date')): ?>
                                    <span id="gpa_submission_date-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('gpa_submission_date')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="gpa_hand_over_date">Date of hand over the lawyer</label>
                                    <input type="date" name="gpa_hand_over_date"
                                        class="form-control <?php if( $errors->has('gpa_hand_over_date')): ?> is-invalid border-danger  <?php endif; ?>"
                                        id="gpa_hand_over_date" value="<?php echo e(old('gpa_hand_over_date')); ?>"
                                        max="<?php echo e(date('Y-m-d')); ?>">
                                    <?php if($errors->has('gpa_hand_over_date')): ?>
                                    <span id="gpa_hand_over_date-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('gpa_hand_over_date')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>
                        </div>
                    </div>
                    <div class="if_accident">
                        <div class="row">
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="claim_date">Claim Date <small class="text-muted">(Claim Received
                                            Date)</small></label>
                                    <input type="date" name="claim_date"
                                        class="form-control   <?php if( $errors->has('claim_date')): ?> is-invalid border-danger  <?php endif; ?>"
                                        value="<?php echo e(old('claim_date')); ?>" max="<?php echo e(date('Y-m-d')); ?>" id="claim_date">
                                    <?php if($errors->has('claim_date')): ?>
                                    <span id="claim_date-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('claim_date')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="claim_by">Claim By</label>
                                    <input type="text" name="claim_by"
                                        class="form-control   <?php if( $errors->has('claim_by')): ?> is-invalid border-danger  <?php endif; ?>"
                                        value="<?php echo e(old('claim_by')); ?>" id="claim_by" placeholder="Claim By">
                                    <?php if($errors->has('claim_by')): ?>
                                    <span id="claim_by-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('claim_by')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>
                            <div class="col-md-6">
                                <div class="form-group">
                                    <label for="relation_with_emp">Relation With Employee</label>
                                    <select name="relation_with_emp"
                                        class="custom-select form-control reset_form <?php if( $errors->has('relation_with_emp')): ?> is-invalid border-danger  <?php endif; ?>"
                                        id="relation_with_emp">
                                        <option value="" <?php echo e((old('relation_with_emp') == '') ? 'selected' : ''); ?>>Select
                                            Relation</option>
                                        <?php $relations = loadRelations(); ?>
                                        <?php $__currentLoopData = $relations; $__env->addLoop($__currentLoopData); foreach($__currentLoopData as $key => $value): $__env->incrementLoopIndices(); $loop = $__env->getLastLoop(); ?>
                                        <option value="<?php echo e($key); ?>"
                                            <?php echo e((old('relation_with_emp') == $key) ? 'selected' : ''); ?>><?php echo e($value); ?>

                                        </option>
                                        <?php endforeach; $__env->popLoop(); $loop = $__env->getLastLoop(); ?>
                                    </select>
                                    <small class="text-danger relation_with_emp_error"></small>
                                    <?php if($errors->has('relation_with_emp')): ?>
                                    <span id="relation_with_emp-error"
                                        class="error text-danger invalid-feedback"><?php echo e($errors->first('relation_with_emp')); ?></span>
                                    <small></small>
                                    <?php endif; ?>
                                </div>
                            </div>
                        </div>
                    </div>
                    <div class="col-md-12">
                        <div class="form-group">
                            <input type="submit" name="save" value="Save" class="btn btn-primary">
                        </div>
                        <small class="text-muted"><strong>Note: </strong>Verify the details entered by you before
                            saving and proceeding with the form</small><br>
                        <small class="text-muted"><strong>नोट: </strong>फॉर्म को सेव और आगे बढ़ाने से पहले आपके
                            द्वारा भरी गई डिटेल्स की पुष्टि कर ले</small>
                    </div>
                </form>
            </div>
        </div>
        <!-- /.card -->
    </div>
    <!--/. container-fluid -->
</section>
<!-- /.content -->
<?php $__env->stopSection(); ?>

<?php $__env->startPush('js'); ?>
<script>
$('#claim_for').change(function() {
    checkClaim();
});
$('#claim_for').ready(function() {
    checkClaim();
});

function checkClaim() {
    let claim_for = $('#claim_for').find('option:selected').val();
    let claim_id = $('#claim_id').val();
    error_tag = $('.claim_for_error');
    let url = "<?php echo e(route('check.claim')); ?>";
    $.ajax({
        url: url,
        type: "GET",
        data: {
            claim_for: claim_for,
            claim_id: claim_id
        },
        dataType: "json",
        success: function(response) {
            if (response.status == 'success') {
                error_tag.text(response.message);
            }
        }
    });
}
</script>

<?php $__env->stopPush(); ?>
<?php echo $__env->make('layouts.app', \Illuminate\Support\Arr::except(get_defined_vars(), ['__data', '__path']))->render(); ?><?php /**PATH /var/www/html/claim_and_case_management/resources/views/pages/claims/claimDocForm.blade.php ENDPATH**/ ?>