<?php $this->load->view('header');?>
		
    <section class="content-header">
      <div class="container-fluid">
        <div class="row mb-2">
          <div class="col-sm-6">
            &nbsp;
          </div>
          <div class="col-sm-6">
            <ol class="breadcrumb float-sm-right">
              <li class="breadcrumb-item"><a href="<?php echo base_url();?>"><?php echo $this->lang->line('hf_home');?></a></li>
              <li class="breadcrumb-item"><?php echo $this->lang->line('hf_insurance_manager');?></li>
			  <li class="breadcrumb-item active"><?php echo $this->lang->line('hf_claim_insurance');?></li>
            </ol>
          </div>
        </div>
      </div><!-- /.container-fluid -->
    </section>

	<!-- Main content -->
    <section class="content">
      <div class="container-fluid">
        <div class="card card-default">
          <div class="card-header">
            <h3 class="card-title"><?php echo $this->lang->line('hf_claim_insurance');?></h3>

            <div class="card-tools">
              
            </div>
          </div>
          <!-- /.card-header -->
          <div class="card-body">
			<form class="form-horizontal" id="insurance-form" enctype="multipart/form-data">
				<p class="text-danger"><?php echo $this->lang->line('insurance_notice');?></p>
				<div class="form-group row">
					<label for="claim_slip_1" class="col-sm-2 col-form-label"><?php echo $this->lang->line('insurance_claim_picture');?> 1</label>
					<div class="col-sm-3">
					  <div class="custom-file">
                        <input type="file" class="custom-file-input" id="claim_slip_1" name="claim_slip_1">
                        <label class="custom-file-label" for="claim_slip_1"><?php echo $this->lang->line('insurance_choose_image');?></label>
                      </div>
					</div>
				</div>
				<div class="form-group row">
					<label for="claim_slip_2" class="col-sm-2 col-form-label"><?php echo $this->lang->line('insurance_claim_picture');?> 2</label>
					<div class="col-sm-3">
					  <div class="custom-file">
                        <input type="file" class="custom-file-input" id="claim_slip_2" name="claim_slip_2">
                        <label class="custom-file-label" for="claim_slip_2"><?php echo $this->lang->line('insurance_choose_image');?></label>
                      </div>
					</div>
				</div>
				<div class="form-group row">
					<label for="claim_slip_3" class="col-sm-2 col-form-label"><?php echo $this->lang->line('insurance_claim_picture');?> 3</label>
					<div class="col-sm-3">
					  <div class="custom-file">
                        <input type="file" class="custom-file-input" id="claim_slip_3" name="claim_slip_3">
                        <label class="custom-file-label" for="claim_slip_3"><?php echo $this->lang->line('insurance_choose_image');?></label>
                      </div>
					</div>
				</div>
				<div class="form-group row">
					<label for="claim_slip_4" class="col-sm-2 col-form-label"><?php echo $this->lang->line('insurance_claim_picture');?> 4</label>
					<div class="col-sm-3">
					  <div class="custom-file">
                        <input type="file" class="custom-file-input" id="claim_slip_4" name="claim_slip_4">
                        <label class="custom-file-label" for="claim_slip_4"><?php echo $this->lang->line('insurance_choose_image');?></label>
                      </div>
					</div>
				</div>
				<div class="form-group row">
					<label for="claim_slip_5" class="col-sm-2 col-form-label"><?php echo $this->lang->line('insurance_claim_picture');?> 5</label>
					<div class="col-sm-3">
					  <div class="custom-file">
                        <input type="file" class="custom-file-input" id="claim_slip_5" name="claim_slip_5">
                        <label class="custom-file-label" for="claim_slip_5"><?php echo $this->lang->line('insurance_choose_image');?></label>
                      </div>
					</div>
				</div>
				<div class="form-group row">
					<label for="claim_slip_6" class="col-sm-2 col-form-label"><?php echo $this->lang->line('insurance_claim_picture');?> 6</label>
					<div class="col-sm-3">
					  <div class="custom-file">
                        <input type="file" class="custom-file-input" id="claim_slip_6" name="claim_slip_6">
                        <label class="custom-file-label" for="claim_slip_6"><?php echo $this->lang->line('insurance_choose_image');?></label>
                      </div>
					</div>
				</div>
				<div class="form-group row">
					<label for="remark" class="col-sm-2 col-form-label"><?php echo $this->lang->line('insurance_remark');?></label>
					<div class="col-sm-6">
					  <input type="text" class="form-control" id="remark" name="remark" placeholder="<?php echo $this->lang->line('insurance_remark_fill_in_message');?>">
					</div>
				</div>
				<div class="form-group row">
					<label for="security_password" class="col-sm-2 col-form-label"><?php echo $this->lang->line('insurance_security_password');?></label>
					<div class="col-sm-3">
					  <input type="password" class="form-control" id="security_password" name="security_password" placeholder="<?php echo $this->lang->line('insurance_security_password_must_fill_in_message');?>">
					</div>
				</div>
				<div class="form-group row">
					<div class="offset-sm-2 col-sm-10">
					  <input type="hidden" name="<?php echo $this->security->get_csrf_token_name(); ?>" value="<?php echo $this->security->get_csrf_hash(); ?>" />
					  <button onclick="claim_insurance_submit()" type="button" class="btn btn-primary"><?php echo $this->lang->line('insurance_claim');?></button>
					</div>
				</div>
			</form>
          </div>
          <!-- /.card-body -->
        </div>
      </div><!-- /.container-fluid -->
    </section>
    <!-- /.content -->
		
<?php $this->load->view('footer');?>		