@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">Motor Dispatch Stage</h3>
                    <div class="card-body">

                    <div class="row">

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

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

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

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

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

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

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

                      <div class="col-md-6">
                        <label for="" class="form-label">3S</label>
                        <input type="text" placeholder="3S" name="" class="form-control" id="" />
                        <p></p>
                      </div>

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

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

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

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

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

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

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

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

                      <div class="col-md-6">
                        <label for="" class="form-label">Provincial Sales Tax on Labour %</label>
                        <input type="text" placeholder="Provincial Sales Tax on Labour %" name="" class="form-control" id="" />
                        <p></p>
                      </div>

                      <div class="col-md-6">
                        <label for="" class="form-label">Discount on Parts (if any)</label>
                        <input type="text" placeholder="Discount on Parts (if any)" name="" class="form-control" id="" />
                        <p></p>
                      </div>

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

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

                       <div class="col-md-6">
                       <label for="" class="form-label">Report 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">Labor Settled / Not Settled</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-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')