@extends('layouts.main') @push('styles') @endpush @section('content')

{{ __('insurance.new_premium') }}

@include('insurance::insurance_premiums.menu')
@include('flash::message') @include ('errors.list') @php $back_date = \Streamline\Models\HospitalInformation::first()->pluck('back_date'); @endphp
{{ Form::open(['route' => 'insurance_premiums.store','data-toggle'=>'validator']) }}
{{ Form::label('group_id', __('insurance.insurance_groups_lc')) }} {{ Form::select('group_id', $insurance_groups, null, ['class' => 'form-control compulsory', 'required', 'id' => 'group_id']) }}
{{ Form::label('amount', __('insurance.amount')) }} {{ Form::number('amount', '', ['class' => 'form-control compulsory', 'readonly', 'id' => 'amount']) }}
{{ Form::label('start_date', __('insurance.insurance_start_date')) }}
{{ Form::text('start_date', '', ['class'=>'form-control compulsory', 'readonly', 'required', 'id'=>'start_date']) }}
{{ Form::label('end_date', __('insurance.insurance_end_date')) }}
{{ Form::text('end_date', '', ['class'=>'form-control compulsory', 'readonly', 'required', 'id'=>'end_date']) }}
{{ Form::label('payment_date', __('insurance.payment_date')) }}
{{ Form::text('payment_date', '', ['class'=>'form-control compulsory', 'readonly', 'required', 'id'=>'payment_date']) }}
{{ __('insurance.proceed') }} {{ Form::hidden('is_submit_visible', 0, ['id' => 'is_submit_visible']) }}
{{ Form::close() }}
{{-- modal --}} @include('insurance::insurance_premiums.add_new_family_member_modal') @endsection @push('scripts') @endpush