| Current Path : /home1/savoy/public_html/savoyglobal.net/piadraft/system/application/views/Claims/ |
Linux gator3171.hostgator.com 4.19.286-203.ELK.el7.x86_64 #1 SMP Wed Jun 14 04:33:55 CDT 2023 x86_64 |
| Current File : /home1/savoy/public_html/savoyglobal.net/piadraft/system/application/views/Claims/addclaimforms.php |
<?php if ( ! defined('BASEPATH')) exit('No direct script access allowed');?>
<div class="select-bar">
<label>
<img src="<?=base_url()?>/assets/images/backbutton.png" title="Back" class="clickimage" onclick="loadclaimforms('<?=$_SESSION['pagenum']?>','<?=$_SESSION['searchoption']?>','<?=$_SESSION['searchtxt']?>')" alt="Back" align = "center" width="25" height="25" /></label>
</div>
<fieldset>
<legend>Add Claim Forms</legend>
<?php
$attributes = array('id' => 'customForm');
echo form_open_multipart('claims/addclaimforms',$attributes);?>
<ul>
<li>
<?php echo '<label for="Segment">Insurance Classification</label>';
echo "<select name='segment_id' id='segment_id' onchange=\"showcover()\">";
echo "<option value='0'>Select Insurance Classification</option>";
if (count($segment))
{
foreach ($segment as $key => $list)
{
echo "<option value='". $list['id'] . "'>" . $list['segment'] . "</option>";
}
echo "</select>";
}
?>
<span id="segment_idInfo" class="red_bold">*</span>
</li>
<li id="coverlist">
<label for="country">Type Of Cover</label>
<?php
echo "<select name='cover_id' id='cover_id' >";
echo "<option value='0'>Select Type Of Cover</option></select>";
?>
<span id="cover_idInfo" class="red_bold">*</span>
</li>
<li>
<label for="country">Insurance Company</label>
<?php
echo "<select name='company_id' id='company_id'>";
echo "<option value='0'>Select Insurance Company</option>";
if (count($inscompany))
{
foreach ($inscompany as $key => $list)
{
echo "<option value='". $list['id'] . "'>" . $list['company_name'] . "</option>";
}
echo "</select>";
}
?>
</li>
<li>
<label for="country">Form Name</label>
<?php
$data = array(
'name' => 'formname',
'id' => 'formname',
);
?>
<?php
echo form_input($data).form_error($data); ?><span id="formnameInfo" class="red_bold">*</span>
</li>
<li></li>
<li><label for="submit"> </label>
<button type="submit" id="submit" class="clickimage" onclick="return validateform('formname');">Save</button>
</li>
</ul>
<?php echo form_close();?>
</fieldset>