{!! Form::open(['url' => '/transport/accident_traffic_detail/create','id'=>'myform','class' => 'form-horizontal', 'files' => true]) !!}

<div class="accident-form old">
    <div class="row col-md-12">
        <div class="form-group col-md-2 col-sm-6 col-xs-12">
            <label for="File Number">File Number</label>
            <div class="select">
            {!! Form::select('file_number',['' => 'Select File Number'] + $page_data['file_number'] ,null, ['id'=>'file_number','class' => 'form-control']) !!}
            <div class="help-block with-errors"></div>
            </div>
        </div>

        <div class="form-group col-md-1 col-sm-6 col-xs-12">
            <label for="Lawyer">Lawyer</label>
            <input type="text" class="form-control" name="lawyer">
            <div class="help-block with-errors"></div>
        </div>

        <div class="form-group col-md-1 col-sm-6 col-xs-12">
            <label for="Jurisdiction">Jurisdiction</label>
            <input type="text" class="form-control"  name="jurisdiction">
            <div class="help-block with-errors"></div>
        </div>

        <div class="form-group col-md-2 col-sm-6 col-xs-12 ">
            <label for="Trip Number">Trip Number</label>
            <div class="select">
                {!! Form::text('trip_number' ,null, ['id'=>'trip_number','class' => 'form-control','readonly'=>'true']) !!}
            </div>
            <div class="help-block with-errors"></div>
        </div> 

        <div class="form-group col-md-2 col-sm-6 col-xs-12">
            <label for="Violation">Violation</label>
            <div class="select">
                {!! Form::text('violation',null, ['id'=>'violation','class' => 'form-control','readonly'=>'true']) !!}
            </div>
            <div class="help-block with-errors"></div>
        </div> 

        <div class="form-group col-md-2 col-sm-6 col-xs-12">
            <label for="Date">Date</label>
            {!! Form::text('date', null,['id'=>'date','class' => ' form-control','readonly'=>'true']) !!}
            <div class="help-block with-errors"></div>
        </div>

         <div class="form-group col-md-2 col-sm-6 col-xs-12">
            <label for="Date">Location</label>
            {!! Form::text('location' ,null, ['id'=>'location','class' => ' form-control','readonly'=>'true']) !!}
            <div class="help-block with-errors"></div>
        </div>
        
    </div>

    <div class="row col-md-12">
        <div class="form-group col-md-2 col-sm-6 col-xs-12 hide">
            <label for="USD">Claim Amount (USD)</label>
            <input type="text" class="form-control" id="usd" name="claim_amount_usd" readonly="">
            <div class="help-block with-errors"></div>
        </div>

        <div class="form-group col-md-2 col-sm-6 col-xs-12 hide">
            <label for="MZM">Claim Amount (MZM)</label>
            <input type="text" class="form-control" id="mzm" name="claim_amount_mzm" readonly="">
            <div class="help-block with-errors"></div>
        </div>

        <div class="form-group col-md-2 col-sm-6 col-xs-12 hide">
            <label for="ZAR">Claim Amount (ZAR)</label>
            <input type="text" class="form-control" id="zar" name="claim_amount_zar" readonly="">
            <input type="text" class="form-control" id="driver" name="driver" readonly="">
            <input type="hidden" class="form-control" id="planning_id" name="planning_id" readonly="">
            <input type="hidden" class="form-control" id="article" name="article" readonly="">
            <div class="help-block with-errors"></div>
        </div>
        
        <center>{!! Form::submit(isset($submitButtonText) ? $submitButtonText : 'Save', ['class' => 'btn btn-primary']) !!}</center>      
    </div>

    <div class="clearfix"></div>

    <div class="insurance hide">
        <div class="row col-md-6">
            <h4>insurance</h4>
            <div class="form-group col-md-6 col-sm-6 col-xs-12">
                <label for="Name">Name</label>
                {!! Form::text('insurance_name',null,['class' => ' form-control']) !!}
                <div class="help-block with-errors"></div>
            </div>

            <div class="form-group col-md-6 col-sm-6 col-xs-12">
                <label for="Date">Notified Date</label>
                {!! Form::text('notify_date',null,['class' => ' form-control calander-icon','id'=>'datepicker2']) !!}
                <div class="help-block with-errors"></div>
            </div>
        </div>

        <div class="row col-md-6">
            <h4>3rd Party</h4>
            <div class="form-group col-md-6 col-sm-6 col-xs-12">
                <label for="Name">Name</label>
                {!! Form::text('third_party_name',null,['class' => ' form-control']) !!}
                <div class="help-block with-errors"></div>
            </div>

            <div class="form-group col-md-6 col-sm-6 col-xs-12">
                <label for="Name">Contact</label>
                {!! Form::text('third_party_contact',null,['class' => ' form-control']) !!}
                <div class="help-block with-errors"></div>
            </div>
        </div>
    </div>
</div>
       
{!! Form::close() !!}  

{!! Form::open(['url' => '/transport/accident_traffic_detail/create','id'=>'newform','class' => 'form-horizontal', 'files' => true]) !!}

<div class="accident-form new">
    <div class="row col-md-12">
        <div class="form-group col-md-2 col-sm-6 col-xs-12">
            <label for="File Number">File Number</label>
            <input type="text" class="form-control"  name="file_number" value="{{ $serial }}" readonly="">
            <div class="help-block with-errors"></div>
        </div>

        <div class="form-group col-md-1 col-sm-6 col-xs-12">
            <label for="Lawyer">Lawyer</label>
            <input type="text" class="form-control" name="lawyer">
            <div class="help-block with-errors"></div>
        </div>

        <div class="form-group col-md-1 col-sm-6 col-xs-12">
            <label for="Jurisdiction">Jurisdiction</label>
            <input type="text" class="form-control"  name="jurisdiction">
            <div class="help-block with-errors"></div>
        </div>

        <div class="form-group col-md-2 col-sm-6 col-xs-12 ">
            <label for="Trip Number">Trip Number</label>
            {!! Form::text("trip_number",null, ["class" => "form-control"]) !!}
            <div class="help-block with-errors"></div>
        </div>

        <div class="form-group col-md-2 col-sm-6 col-xs-12 ">
            <label for="Trip Number">Driver</label>
            <div class="select">
                {!! Form::select('driver',['' => 'Select Driver'] + $page_data['name']->toArray() ,null, ['class' => 'form-control']) !!}
                <div class="help-block with-errors"></div>
            </div>
        </div>

        <div class="form-group col-md-1 col-sm-6 col-xs-12">
            <label for="Violation">Violation</label>
            {!! Form::text("violation",null, ["class" => "form-control"]) !!}
            <div class="help-block with-errors"></div>
        </div>
        
        <div class="form-group col-md-2 col-sm-6 col-xs-12">
            <label for="Date">Date</label>
            {!! Form::text("date" ,null, ["class" => "form-control",'id'=>'datepicker8']) !!}
            <div class="help-block with-errors"></div>
        </div>

        <div class="form-group col-md-1 col-sm-6 col-xs-12">
            <label for="Date">Location</label>
            {!! Form::text("location",null, ["class" => "form-control"]) !!}
            <div class="help-block with-errors"></div>
        </div>    
    </div>

    <div class="row col-md-12"> 
        <div class="form-group col-md-2 col-sm-6 col-xs-12 hide">
            <label for="USD">Claim Amount (USD)</label>
            <input type="text" class="form-control" id="usd" name="claim_amount_usd" readonly="">
            <div class="help-block with-errors"></div>
        </div>

        <div class="form-group col-md-2 col-sm-6 col-xs-12 hide">
            <label for="MZM">Claim Amount (MZM)</label>
            <input type="text" class="form-control" id="mzm" name="claim_amount_mzm" readonly="">
            <div class="help-block with-errors"></div>
        </div>

        <div class="form-group col-md-2 col-sm-6 col-xs-12 hide">
            <label for="ZAR">Claim Amount (ZAR)</label>
            <input type="text" class="form-control" id="zar" name="claim_amount_zar" readonly="">
            <input type="hidden" class="form-control" id="planning_id" name="planning_id" readonly="">
            <input type="hidden" class="form-control" id="article" name="article" readonly="">
            <div class="help-block with-errors"></div>
        </div>
        
        <center>{!! Form::submit(isset($submitButtonText) ? $submitButtonText : 'Save', ['class' => 'btn btn-primary']) !!}</center>    
    </div>

    <div class="clearfix"></div>

    <div class="insurance hide">
        <div class="row col-md-6">
            <h4>insurance</h4>
            <div class="form-group col-md-6 col-sm-6 col-xs-12">
                <label for="Name">Name</label>
                {!! Form::text('insurance_name',null,['class' => ' form-control']) !!}
                <div class="help-block with-errors"></div>
            </div>

            <div class="form-group col-md-6 col-sm-6 col-xs-12">
                <label for="Date">Notified Date</label>
                {!! Form::text('notify_date',null,['class' => ' form-control calander-icon','id'=>'datepicker2']) !!}
                <div class="help-block with-errors"></div>
            </div>
        </div>

        <div class="row col-md-6">
            <h4>3rd Party</h4>
            <div class="form-group col-md-6 col-sm-6 col-xs-12">
                <label for="Name">Name</label>
                {!! Form::text('third_party_name',null,['class' => ' form-control']) !!}
                <div class="help-block with-errors"></div>
            </div>

            <div class="form-group col-md-6 col-sm-6 col-xs-12">
                <label for="Name">Contact</label>
                {!! Form::text('third_party_contact',null,['class' => ' form-control']) !!}
                <div class="help-block with-errors"></div>
            </div>
        </div>
    </div>
</div>
       
{!! Form::close() !!}