@extends('layout.main')


@section('main-section')


 <!-- Content wrapper -->
          <div class="content-wrapper">
            <!-- Content -->
            <div class="container-xxl flex-grow-1 container-p-y">




            <div class="row g-12">
                <div class="col-md-12">
                  <div class="card">
                    <h3 class="card-header text-warning">Pre-Inspection Claim</h3>
                    <div class="card-body">

                    <div class="row">

                      <div id="" class="form-text text-danger">
                          <h5 class="text-success">Vehicle Info.</h5>
                          <p></p>
                        </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Registration Number</label>
                        <input type="text" placeholder="Registration Number" name="" class="form-control" id="" />
                        <p></p>
                      </div>

                       <div class="col-md-6">
                        <label for="" class="form-label">Owner Name</label>
                        <input type="text" placeholder="Owner Name" name="" class="form-control" id="" />
                        <p></p>
                      </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Make</label>
                        <input type="text" placeholder="Make" name="" class="form-control" id="" />
                        <p></p>
                      </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Colour</label>
                        <input type="text" placeholder="Colour" name="" class="form-control" id="" />
                        <p></p>
                      </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Year of Manf.</label>
                        <input type="text" placeholder="Year of Manf." name="" class="form-control" id="" />
                        <p></p>
                      </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Chasis No.</label>
                        <input type="text" placeholder="Chasis No." name="" class="form-control" id="" />
                        <p></p>
                      </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Engine No.</label>
                        <input type="text" placeholder="Engine No." name="" class="form-control" id="" />
                        <p></p>
                      </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Horse Power</label>
                        <input type="text" placeholder="Horse Power" name="" class="form-control" id="" />
                        <p></p>
                      </div>

                      <div id="" class="form-text text-danger">
                          <h5 class="text-danger">Client Info.</h5>
                          <p></p>
                        </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Client</label>
                         <select class="form-control">
                            <option value="">Please Select</option>
                            <option value="Insurer">Insurer</option>
                            <option value="Takaful">Takaful</option>
                            <option value="Other">Other</option>
                        </select>
                        <p></p>
                      </div>

                      <div class="col-md-6">
                       <label for="" class="form-label">Client Branch</label>
                         <select class="form-control">
                            <option value="">Please Select</option>
                            <option value="Insurer">Insurer</option>
                            <option value="Takaful">Takaful</option>
                            <option value="Other">Other</option>
                        </select>
                        <p></p>
                      </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Email Address</label>
                        <input type="text" placeholder="Email Address" name="" class="form-control" id="" />
                        <p></p>
                      </div>

                      <div id="" class="form-text text-success">
                          <h5 class="text-danger">Job Info.</h5>
                          <p></p>
                        </div>

                        <div class="col-md-6">
                        <label for="" class="form-label">Date of Intimation</label>
                        <input type="text" placeholder="Date of Intimation" name="" class="form-control" id="" />
                        <p></p>
                      </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Corporate / Insured Access</label>
                         <select class="form-control">
                            <option value="">Please Select</option>
                            <option value="Insurer">Insurer</option>
                            <option value="Takaful">Takaful</option>
                            <option value="Other">Other</option>
                        </select>
                        <p></p>
                      </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Job Specification</label>
                        <input type="text" placeholder="Job Specification" name="" class="form-control" id="" />
                        <p></p>
                      </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Insured / Participant</label>
                        <input type="text" placeholder="Insured / Participant" name="" class="form-control" id="" />
                        <p></p>
                      </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Policy / PMD No</label>
                        <input type="text" placeholder="Policy / PMD No" name="" class="form-control" id="" />
                        <p></p>
                      </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Loss / Benefit No.</label>
                        <input type="text" placeholder="Loss / Benefit No." name="" class="form-control" id="" />
                        <p></p>
                      </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Contact Details</label>
                        <input type="text" placeholder="Contact Details" name="" class="form-control" id="" />
                        <p></p>
                      </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Repairer / Workshop</label>
                        <input type="text" placeholder="Repairer / Workshop" name="" class="form-control" id="" />
                        <p></p>
                      </div>


                       <div id="" class="form-text text-danager">
                          <h5 class="text-danger">Assign Info.</h5>
                          <p></p>
                        </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Selected Branch</label>
                        <input type="text" placeholder="Selected Branch" name="" class="form-control" id="" />
                        <p></p>
                      </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Assign to Team Member</label>
                        <input type="text" placeholder="Assign to Team Member" name="" class="form-control" id="" />
                        <p></p>
                      </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Select Appointment</label>
                        <input type="text" placeholder="Select Appointment" name="" class="form-control" id="" />
                        <p></p>
                      </div>

                      <div class="col-md-12">
                        <label for="" class="form-label">Message for Surveyor / Loss Adjuster</label>
                        <textarea class="form-control" placeholder="Message for Surveyor / Loss Adjuster" name="" id=""></textarea>
                        <p></p>
                      </div>


                      <div class="col-md-12">
                        <button type="submit" class="btn btn-success">Submit</button>
                      </div>

                    </div>
                    </div>
                  </div>
                </div>
             </div>
            </div>
          </div>

          @endsection('main-section')