{{View::make('layout.header')}}
<style>
    .required {
    background-color: #FFFFE0 !important;
}
</style>
    <!-- BEGIN: Content-->
    <div class="app-content content ">
        <div class="content-overlay"></div>
        <div class="header-navbar-shadow"></div>
        <div class="content-wrapper">
            <div class="content-header row">
                <div class="content-header-left col-md-9 col-12 mb-2">
                    <div class="row breadcrumbs-top">
                        <div class="col-12">
                            <div class="breadcrumb-wrapper">
                                <ol class="breadcrumb">
                                    <li class="breadcrumb-item">E-Claim
                                    </li>
                                </ol>
                            </div>
                        </div>
                    </div>
                </div>
            </div>
            <div class="content-body">
                <!-- Dashboard Ecommerce Starts -->
                <section id="multiple-column-form">
                    
                <div class="row">
                  <div class="col-12 col-md-8">
                    
                  </div>
                </div>
                <div class="row" style="margin:0px;">
                <div class="card col-md-12" style="">
                                <div class="card-body">
                                    <div class="row">
                                    <div class="col-md-12">
                                        <ul class="nav nav-tabs nav-justified" id="myTab2" role="tablist" style="display:none;border-bottom: 1px solid #ebe9f1; border-radius: 0px;">
                                            <li class="nav-item" >
                                                <a class="nav-link active" style=" text-align:left;" id="home-tab-justified" data-toggle="tab" href="#home-just" role="tab" aria-controls="home-just" aria-selected="true">Add/Edit Claim</a>
                                            </li>
                                        </ul>
                                    </div></div>
                                    <!-- Tab panes -->
                                    <div class="tab-content pt-1">
                                        <div class="tab-pane active" id="home-just" role="tabpanel" aria-labelledby="home-tab-justified">
                                            <div class="card" style="margin-bottom:0px; border: 0px;"> 
                                                <div class="card-header" style="padding-top:0px;">
                                                    <h4 class="card-title" >Edit Claim</h4>
                                                </div>
                                                <div class="col-md-12">
                                                    @if (\Session::has('statusMsg'))
                                                    
                                                    <div class="alert alert-success alert-dismissible" style="margin-top:18px;">
                                                        <a href="#" class="close" data-dismiss="alert" aria-label="close" title="close">×</a>
                                                        <strong>Success!</strong> {{ Session::get('statusMsg') }}
                                                    </div>
                                                    
                                                    @endif
                                                </div>
                                                <div class="card-body" style="padding-top:0px;">
                                                    
                                                    <form  id="all-filter11"  enctype="multipart/form-data">
                                                        <div class="row">
                                                            <input type="hidden" name="_token" id="token" value="{{ csrf_token() }}">
                                                            <div class="col-md-12 col-12">
                                                                <div class="form-group">
                                                                    <label class="form-label" for="payment-date">Type :*</label>
                                                                     <select id="eclaimtype_id" name="eclaimtype_id" class="form-control" required onchange="claimTypeChange()">
                                                                         @foreach($eclaimtypes as $eclaimtype)
                                                                    	    <option value="{{ $eclaimtype->id }}">{{ $eclaimtype->type_name }}</option>
                                                                    	 @endforeach
                                                                    </select>
                                                                </div>
                                                            </div>
                                                            </div>
                                                            <div id="fields" class="row">
                                                            </div>
                                                            <div class="row">
                                                            <div class="col-md-6 col-6">
                                                                <div class="form-group">
                                                                    <label class="form-label" for="payment-date">Billing Date :*</label>
                                                                          <input type="date" name="billing_date" id="billing_date" class="tcal form-control flatpickr-basic" value="{{$billdate[0]->billingDate}}" placeholder="DD-MM-YYYY" data-dateformat="dd-mm-yy" required>
                                                                </div>
                                                            </div>
                                                            <div class="col-md-6 col-6">
                                                                <div class="form-group">
                                                                    <label class="form-label" for="payment-date">Total Amount :*</label>
                                                                    <input type="text" name="total_amount" id="total_amount" class="form-control" value="" style="padding-left: 10px;" value="" placeholder="" required>
                                                                    
                                                                </div>
                                                            </div>
                                                            <div class="col-md-12 col-12">
                                                                <div class="form-group">
                                                                    <span id="filespan">
                                                                        <label>Bill Slip (if Any)</label>
                                                                          <div>
                                                                            <input type="file" name="slip_file" id="slip_file" value="" />
                                                                          </div>
                                                                          <div id="slip_info"></div>
                                                                    </span>
                                                                </div>
                                                            </div>
                                                        
                                                            <div class="col-md-12 col-12">
                                                                <div class="form-group d-flex flex-wrap mb-0">
                                                                    <button type="button" onclick="updateDetails()" class="btn btn-primary mr-1" id="apply">Update</button>&nbsp;
                                                                    <a href="{{route('e-claim.claim')}}" class="btn btn-warning mr-1">Back</a>
                                                                    
                                                                    
                                                                </div>
                                                                <div id="msg" style="margin-top:15px;"></div>
                                                            </div>
                                                        </div>
                                                    </form>
                                                </div>
                                            </div>
                              
                                            </div>
                                        </div>
                                    </div>
                                </div>
                            </div>
                </div>
              </section>
 <div class="modal fade" id="exampleModal" tabindex="-1" role="dialog" aria-labelledby="exampleModalLabel" aria-hidden="true">
                    <div class="modal-dialog" role="document">
                        <div class="modal-content">
                        <div class="modal-header">

                            <button type="button" class="close" data-dismiss="modal" aria-label="Close">
                            <span aria-hidden="true">&times;</span>
                            </button>
                        </div>
                        <div class="modal-body">
                        <h5 class="modal-title" id="exampleModalLabel">Are you sure to delete this File ?</h5>
                        <div id="delete-modal">
                        </div>
                        </div>
                        <div class="modal-footer">
                            <button type="button" class="btn btn-primary yes-btn">Yes</button>
                            <button type="button" class="btn btn-secondary" data-dismiss="modal">Cancel</button>
                        </div>
                        </div>
                    </div>
                </div>
            </div>
            </div>
            </div>
        </div>
    </div>
    <!-- END: Content-->
    {{View::make('layout.footer')}}
    <script>
    var fields = [];
    var resObjs = '';
    var id = '<br />
<b>Fatal error</b>:  Uncaught Error: Call to undefined function request() in /home/ecoleave/public_html/backup/v6/resources/views/E-Claim/edit-eclaim.blade.php:159
Stack trace:
#0 {main}
  thrown in <b>/home/ecoleave/public_html/backup/v6/resources/views/E-Claim/edit-eclaim.blade.php</b> on line <b>159</b><br />