@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">Claim Payment Details</h3>
                    <div class="card-body">

                    <div class="row">

                      <div id="" class="form-text text-danger">
                          <h5 class="text-success">Details</h5>
                          <p></p>
                        </div>

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


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


                         <div id="" class="form-text text-danger">
                          <h5 class="text-danger">Sign and Remarks</h5>
                          <p></p>
                        </div>


                       <div class="col-md-12">
                        <label for="" class="form-label">Remarks</label>
                        <textarea class="form-control" placeholder="Remarks" 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')