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<script>$(function() {var date = new Date();var currentDate = date.getDate();var currentMonth = date.getMonth();var currentYear = date.getFullYear();$('input[name="dateOfBirth"]').daterangepicker({maxDate : new Date(currentYear - 18, currentMonth, currentDate),startDate : new Date(currentYear - 18, currentMonth, currentDate),singleDatePicker : true}, dateRangeCallback);$('input[name="dgmfgdate"]').daterangepicker({minDate : new Date(currentYear, currentMonth - 6, currentDate),maxDate : new Date(currentYear, currentMonth, currentDate),singleDatePicker : true,}, function(start, end) {startMoment = start;mfgDate = start.format(moment.HTML5_FMT.DATETIME_LOCAL_SECONDS);});formLoaded();});</script><section class="wrapper"><div class="row"><div class="col-lg-12"><h3 class="page-header"><i class="icon_document_alt"></i>Create Insurance</h3><ol class="breadcrumb"><li><i class="fa fa-home"></i><a href="${rc.contextPath}/dashboard">Home</a></li><li><i class="icon_document_alt"></i>CREATE INSURANCE</li></ol></div></div><div class="col-lg-8"><div class="row" style="background: white; font-size: 14px;"><div class="col-lg-4" style="border-left: 1px solid #f0f0f0;"><h4>ORDER DETAILS</h4><div class="row"><div class="col-lg-4"><p class="bold-details">Order ID</p></div><div class="col-lg-6"><p class="normal-details">#$fofoOrder.getId()($fofoOrderItems.size() item)</p></div></div><div class="row"><div class="col-lg-4"><p class="bold-details">Order Date</p></div><div class="col-lg-6"><script>document.getElementById('createTimestamp').appendChild(document.createTextNode(new Date('$fofoOrder.getCreateTimestamp()').toLocaleString("en-US", $options)))</script><p class="normal-details" id="createTimestamp"></p></div></div><div class="row"><div class="col-lg-4"><p class="bold-details">Amount Paid</p></div><div class="col-lg-6"><p class="normal-details"><span class="normal-details">₹ </span>$fofoOrder.getTotalAmount()</p></div></div></div><div class="col-lg-4" style="border-left: 1px solid #f0f0f0;"><h4>BILLING DETAILS</h4><p class="bold-details">$customerBillingAddressObj.getName()</p><p class="normal-details">$customerBillingAddress</p>#if($fofoOrder.getCustomerGstNumber() &&$fofoOrder.getCustomerGstNumber() != "")<p class="bold-details">GST Number <span class="normal-details extra-margin">$fofoOrder.getCustomerGstNumber()</span></p>#end<p class="bold-details">Phone <span class="normal-details extra-margin">$customerBillingAddressObj.getPhoneNumber()</span></p></div></div><div><div class="row"><h4 class="modelHeaderCustom" style="font-size: 22px;">CustomerInformation</h4></div></div><div class="row"><div class="col-lg-2 form-group"><input placeholder="Mobile Number" type="number" name="mobile"class="form-control phone input-sm" value = "$customer.getMobileNumber()" readonly></div><div class="col-lg-3 form-group"><input placeholder="First Name" name="firstName" type="text"class="form-control input-sm firstName" value = "$customer.getFirstName()" required readonly></div>#if($customer.getLastName())<div class="col-lg-3 form-group"><input placeholder="Last Name" name="lastName" type="text"class="form-control input-sm lastName" value = "$customer.getLastName()" readonly></div>#else<div class="col-lg-3 form-group"><input placeholder="Last Name" name="lastName" type="text"value="" class="form-control input-sm lastName" readonly></div>#end#if($customer.getEmailId())<div class="col-lg-2 form-group"><input name="emailId" type="email"class="form-control input-sm email" value="$customer.getEmailId()"placeholder="Email(xyz@gmail.com)" readonly></div>#else<div class="col-lg-2 form-group"><input name="emailId" type="email" value=""class="form-control input-sm email"placeholder="Email(xyz@gmail.com)"></div>#end<div class="col-lg-2 form-group"><button class="btn btn-block btn-primary customer-details-update" data-customerid = "$customer.getId()"type="submit">Submit</button></div></div><div><div class="row"><h4 class="modelHeaderCustom" style="font-size: 22px;">AddressInformation</h4></div></div><div class="row">#if($customerBillingAddressObj.getName())<div class="col-lg-2 form-group"><input placeholder="First Name" name="firstName"type="text" value="$customerBillingAddressObj.getName()" class="form-control input-sm" readonly></div>#else<div class="col-lg-2 form-group"><input placeholder="First Name" name="firstName"type="text" value="" class="form-control input-sm"></div>#end#if($customerBillingAddressObj.getLastName())<div class="col-lg-2 form-group"><input placeholder="Last Name" name="lastName"type="text" value="$customerBillingAddressObj.getLastName()" class="form-control input-sm" readonly></div>#else<div class="col-lg-2 form-group"><input placeholder="Last Name" id="lastName" name="lastName"type="text" value="" class="form-control input-sm"></div>#end#if($customerBillingAddressObj.getPhoneNumber())<div class="col-lg-2 form-group"><input placeholder="Mobile Number"name="alternatePhone" type="text" value="$customerBillingAddressObj.getPhoneNumber()"class="form-control input-sm" readonly></div>#else<div class="col-lg-2 form-group"><input placeholder="Mobile Number"name="alternatePhone" type="text" value=" "class="form-control input-sm"></div>#end#if($customerBillingAddressObj.getLine1())<div class="col-lg-3 form-group"><input placeholder="Address Line 1" name="line1"type="text" size="50" value="$customerBillingAddressObj.getLine1()" class="form-control input-sm" readonly></div>#else<div class="col-lg-3 form-group"><input placeholder="Address Line 1" name="line1"type="text" size="50" value="" class="form-control input-sm"></div>#end#if($customerBillingAddressObj.getLine2())<div class="col-lg-3 form-group"><input placeholder="Address Line 2" name="line2"type="text" value="$customerBillingAddressObj.getLine2()" class="form-control input-sm" readonly></div>#else<div class="col-lg-3 form-group"><input placeholder="Address Line 2" name="line2"type="text" value="" class="form-control input-sm"></div>#end#if($customerBillingAddressObj.getLandmark())<div class="col-lg-3 form-group"><input placeholder="Landmark" name="landmark"type="text" value="$customerBillingAddressObj.getLandmark()" class="form-control input-sm" readonly></div>#else<div class="col-lg-3 form-group"><input placeholder="Landmark" name="landmark"type="text" value="" class="form-control input-sm"></div>#end#if($customerBillingAddressObj.getPinCode())<div class="col-lg-2 form-group"><input placeholder="Pin Code" name="pinCode"type="number" value="$customerBillingAddressObj.getPinCode()" class="form-control input-sm" readonly></div>#else<div class="col-lg-2 form-group"><input placeholder="Pin Code" name="pinCode"type="number" value="" class="form-control input-sm"></div>#end#if($customerBillingAddressObj.getCity())<div class="col-lg-2 form-group"><input placeholder="City" id="city" name="city" type="text"value="$customerBillingAddressObj.getCity()" class="form-control input-sm" readonly></div>#else<div class="col-lg-2 form-group"><input placeholder="City" id="city" name="city" type="text"value="" class="form-control input-sm"></div>#end<div class="col-lg-2 form-group"><select class="form-control input-sm" name="state"placeholder="State"><option value="" disabled selected>State</option>#foreach($stateName in $stateNames) #if($customerBillingAddressObj.getState() ==$stateName)<option value="$stateName" selected>$stateName</option> #else<option value="$stateName">$stateName</option> #end #end</select></div><div class="col-lg-2 form-group"><button class="btn btn-block btn-primary customer-address-details-update" data-customeraddressid ="$customerBillingAddressObj.getId()"type="submit">Submit</button></div></div><div><div class="row"><h4 class="modelHeaderCustom" style="font-size: 22px;">InsuranceInformation</h4></div></div><div class="row mk_insurance_row" ><div class="col-lg-3 form-group"><label for="gender">Gender</label> <selectclass="form-control input-sm" id="gender" name="gender"placeholder="Gender"><option value="" disabled selected>Gender</option><option value="1" selected>Male</option><option value="2" selected>Female</option></select></div><div class="col-lg-3 form-group"><label for="dateOfBirth">Date Of Birth</label> <inputplaceholder="Date Of Birth" id="dateOfBirth" name="dateOfBirth"type="text" value="" class="form-control"></div></div><div class="row iteminsurancedetails"><div class="row col-lg-3"><div class="col-lg-6"><h4>*Ram(GB):</h4></div><div class="col-lg-6 form-group"><input type="number" class="dgram form-control input-sm"name="ram" value="0"></div></div><div class="row col-lg-4"><div class="col-lg-6"><h4>*Memory(GB):</h4></div><div class="col-lg-5 form-group"><input type="number" class="dgmemory form-control input-sm"name="memory" value="0"></div></div><div class="col-lg-4"><div class="col-lg-3"><h4>*Mfg Date:</h4></div><div class="col-lg-6 form-group"><input placeholder="Mfg Date" id="dgmfgdate" name="dgmfgdate"type="text" value="" class="form-control input-sm dgmfgdate"></div></div></div><div #foreach( $plan in $plans.entrySet())><div #foreach( $pl in $plan.getValue())><div class="col-lg-3"><div class="thumbnail"><img class="card-img-top" src="logosmapping.mobile_insurance_providers[$pl.getProviderId()]" alt="$pl.getProviderName()"><div class="caption" style="padding:9px 0 0"><div style="margin:0 0 -2px -2px"><button class="btn btn-lg btn-default mk_insurance_plan_select" style="width:100%"data-key="$pl.getProductId()"data-amount="$pl.getPremium()">$pl.getDuration() Rs.<span class="currency">@ $pl.getPremium()</span></button></div></div></div></div></div></div>#end</div>#end</div></div><div class="col-lg-4 row"><div class="col-lg-1"></div><div id="payment-details"style="background: white; background-color: white;"class="col-lg-10"><h4 class="modelHeaderCustom" style="font-size: 22px;">PaymentDetails</h4><div id="payment-option-id-amount-container"paymentOptionSize=$paymentOptions.size()>#set($a = 0) #set($b = $paymentOptions.size() - 1) #set($range =[$a..$b]) #foreach($index in $range)<div class="row">#set($paymentOption = $paymentOptions[$index])#if($paymentOption.getName() == 'ONLINE')<div class="col-lg-7"><h4>$paymentOption.getName() :</h4></div><div class="col-lg-5"><input type="number" id="paymentOptionIdAmount${index}"name="paymentOptionIdAmount${index}"class="form-control paymentOptionAmount amount input-sm"value="$pendingOrderItem.getSellingPrice()"paymentOptionId="$paymentOption.getId()" readonly></div>#else<div class="col-lg-7"><h4>$paymentOption.getName() :</h4></div><div class="col-lg-5"><input type="number" id="paymentOptionIdAmount${index}"name="paymentOptionIdAmount${index}"class="form-control paymentOptionAmount amount input-sm"value="" paymentOptionId="$paymentOption.getId()"></div>#end</div>#end</div><div class="row"><div class="col-lg-7"><h4>Total Amount :</h4></div><div class="col-lg-5"><input type="number"class="netPayableAmount form-control input-sm" name="" id="totalamount"value="0" readonly></div></div><div class="row"><div class="form-group col-lg-10"><button class="btn btn-block btn-primary insurance-checkout"type="submit">Create Insurance</button></div></div></div></div></div></section>