

		 {!! Form::open(array('url'=>'workplaceaccidents', 'class'=>'form-horizontal','files' => true , 'parsley-validate'=>'','novalidate'=>' ')) !!}

	@if(Session::has('messagetext'))
	  
		   {!! Session::get('messagetext') !!}
	   
	@endif
	<ul class="parsley-error-list">
		@foreach($errors->all() as $error)
			<li>{{ $error }}</li>
		@endforeach
	</ul>		


<div class="col-md-12">
						<fieldset><legend> Dossier AT</legend>
									
									  <div class="form-group row  " >
										<label for="Id" class=" control-label col-md-4 text-left"> Id <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='id' id='id' value='{{ $row['id'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Compagnie" class=" control-label col-md-4 text-left"> Compagnie <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='cie' id='cie' value='{{ $row['cie'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Police" class=" control-label col-md-4 text-left"> Police <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='police' id='police' value='{{ $row['police'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Assuré" class=" control-label col-md-4 text-left"> Assuré <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='insured' id='insured' value='{{ $row['insured'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Date sinistre" class=" control-label col-md-4 text-left"> Date sinistre <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  
				<div class="input-group input-group-sm m-b" style="width:150px !important;">
					{!! Form::text('sinister_date', $row['sinister_date'],array('class'=>'form-control form-control-sm datetime')) !!}
					<div class="input-group-append">
					 	<div class="input-group-text"><i class="fa fa-calendar"></i></span></div>
					 </div>
				</div>
				 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Date declaration" class=" control-label col-md-4 text-left"> Date declaration <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  
				<div class="input-group input-group-sm m-b" style="width:150px !important;">
					{!! Form::text('declaration_date', $row['declaration_date'],array('class'=>'form-control form-control-sm datetime')) !!}
					<div class="input-group-append">
					 	<div class="input-group-text"><i class="fa fa-calendar"></i></span></div>
					 </div>
				</div>
				 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Victime" class=" control-label col-md-4 text-left"> Victime <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='vicitim' id='vicitim' value='{{ $row['vicitim'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Date de naissance" class=" control-label col-md-4 text-left"> Date de naissance <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  
				<div class="input-group input-group-sm m-b" style="width:150px !important;">
					{!! Form::text('birthday', $row['birthday'],array('class'=>'form-control form-control-sm datetime')) !!}
					<div class="input-group-append">
					 	<div class="input-group-text"><i class="fa fa-calendar"></i></span></div>
					 </div>
				</div>
				 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Age" class=" control-label col-md-4 text-left"> Age <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='age' id='age' value='{{ $row['age'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Lieu" class=" control-label col-md-4 text-left"> Lieu <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='place' id='place' value='{{ $row['place'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Circonstances" class=" control-label col-md-4 text-left"> Circonstances <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='circumstances' id='circumstances' value='{{ $row['circumstances'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Nature lesion" class=" control-label col-md-4 text-left"> Nature lesion <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='lesion_nature' id='lesion_nature' value='{{ $row['lesion_nature'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Affectation" class=" control-label col-md-4 text-left"> Affectation <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <textarea name='affectation' rows='5' id='affectation' class='form-control form-control-sm '  
				           >{{ $row['affectation'] }}</textarea> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Frais médicaux" class=" control-label col-md-4 text-left"> Frais médicaux <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='medical_fees' id='medical_fees' value='{{ $row['medical_fees'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Nombre jours arrêt" class=" control-label col-md-4 text-left"> Nombre jours arrêt <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='days' id='days' value='{{ $row['days'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Montant Reg Client" class=" control-label col-md-4 text-left"> Montant Reg Client <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='payment_customer_amont' id='payment_customer_amont' value='{{ $row['payment_customer_amont'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Taux IPP" class=" control-label col-md-4 text-left"> Taux IPP <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='IPPRate' id='IPPRate' value='{{ $row['IPPRate'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Montant rachat" class=" control-label col-md-4 text-left"> Montant rachat <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='purchase_amount' id='purchase_amount' value='{{ $row['purchase_amount'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Décès" class=" control-label col-md-4 text-left"> Décès <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='death' id='death' value='{{ $row['death'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Statut" class=" control-label col-md-4 text-left"> Statut <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <input  type='text' name='sinister_events' id='sinister_events' value='{{ $row['sinister_events'] }}' 
						     class='form-control form-control-sm ' /> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Observations" class=" control-label col-md-4 text-left"> Observations <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  <textarea name='observations' rows='5' id='observations' class='form-control form-control-sm '  
				           >{{ $row['observations'] }}</textarea> 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> 					
									  <div class="form-group row  " >
										<label for="Date de reprise" class=" control-label col-md-4 text-left"> Date de reprise <span class="asterix"> * </span></label>
										<div class="col-md-6">
										  
				<div class="input-group input-group-sm m-b" style="width:150px !important;">
					{!! Form::text('recovery_date', $row['recovery_date'],array('class'=>'form-control form-control-sm datetime')) !!}
					<div class="input-group-append">
					 	<div class="input-group-text"><i class="fa fa-calendar"></i></span></div>
					 </div>
				</div>
				 
										 </div> 
										 <div class="col-md-2">
										 	
										 </div>
									  </div> </fieldset>
			</div>
			
			

			<div style="clear:both"></div>	
				
					
				  <div class="form-group">
					<label class="col-sm-4 text-right">&nbsp;</label>
					<div class="col-sm-8">	
					<button type="submit" name="apply" class="btn btn-default btn-sm" ><i class="fa  fa-check-circle"></i> {{ Lang::get('core.sb_apply') }}</button>
					<button type="submit" name="submit" class="btn btn-default btn-sm" ><i class="fa  fa-save "></i> {{ Lang::get('core.sb_save') }}</button>
				  </div>	  
			
		</div> 
		 <input type="hidden" name="action_task" value="public" />
		 {!! Form::close() !!}
		 
   <script type="text/javascript">
	$(document).ready(function() { 
		
		 

		$('.removeCurrentFiles').on('click',function(){
			var removeUrl = $(this).attr('href');
			$.get(removeUrl,function(response){});
			$(this).parent('div').empty();	
			return false;
		});		
		
	});
	</script>		 
