Server : Apache System : Linux server2.corals.io 4.18.0-348.2.1.el8_5.x86_64 #1 SMP Mon Nov 15 09:17:08 EST 2021 x86_64 User : corals ( 1002) PHP Version : 7.4.33 Disable Function : exec,passthru,shell_exec,system Directory :  /home/corals/syn.corals.io/storage/framework/views/

Upload File : current_dir [ Writeable ] document_root [ Writeable ]

<div class="insurance-section border p-2 my-1" data-id="<?php echo e($insuranceMember->id??'new-item'); ?>">
    <div class="row">
        <input type="hidden" value="<?php echo e($insuranceMember->id??'new-item'); ?>" name="insurances[<?php echo e($index); ?>][id]">
        <div class="col-md-4">
            <?php echo CoralsForm::text("insurances[$index][name]", 'Syndicate::attributes.insurance.name', true,$insuranceMember->name??null); ?>

        </div>
        <div class="col-md-4">
            <?php echo CoralsForm::text("insurances[$index][id_number]", 'Syndicate::attributes.insurance.id_number', true,$insuranceMember->id_number??null); ?>

        </div>
    </div>
    <div class="row">
        <div class="col-md-4">
            <?php echo CoralsForm::select("insurances[$index][relationship_code]", 'Syndicate::attributes.insurance.relation', ListOfValues::get('Syndicate::insurance_relation', false, 'active', true), true, $insuranceMember->relationship_code??null, [], 'select2'); ?>

        </div>
        <div class="col-md-4">
            <?php echo CoralsForm::date("insurances[$index][birthdate]", 'Syndicate::attributes.insurance.date', true,$insuranceMember->birthdate??null); ?>

        </div>
        <div class="col-md-4">
            <label class="d-block">&nbsp;</label>
            <a href="<?php echo e(route('delete_insurance_record')); ?>" class="btn btn-danger remove-section-insurance">
                <i class="fa fa-trash-o"></i>
            </a>
        </div>
    </div>
</div>
<?php /**PATH /home/corals/public_html/syn.corals.io/Corals/modules/Syndicate/resources/views/partials/user_insurance_fields.blade.php ENDPATH**/ ?>