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✏️ Editing: individual.php

<?php
ob_start();
session_start();
include("includes/inall.php");
$page="individual.php";
if($_REQUEST['editid']=="" && isset($_POST['submitin']) && $_POST['submitin']=="Formyes") {
	$resr=mysqli_query($con,"select * from `insurancedata` where `applno` like 'INS%' and `applno`!='' order by `id` desc");
	if(mysqli_num_rows($resr)<1) {
		$newid="INS100001";
	}
	if(mysqli_num_rows($resr)>=1) {
		$rowr=mysqli_fetch_assoc($resr);
		$lastid=$rowr['applno'];
		$lastno=substr($lastid,3,8);
		$newno=$lastno+1;
		$newid="INS";
		$newid.=$newno;
	}
	$datavlar=$_POST;
	//print_r($datavl);exit();
	$count=1;
	$datavl="";
	foreach($datavlar as $k=>$val) {
		if($count==1) {
			$datavl=$val;
		} else {
			$datavl.="/seperator/".$val;
		}
		$count++;
	}
	//print $datavl;exit();
	$dt=date("Y-m-d");
	$panno=isset($_POST['fpanno'])?addslashes(trim($_POST['fpanno'])):'';
	$title=isset($_POST['title'])?addslashes(trim($_POST['title'])):'';
	$fname=isset($_POST['fname'])?addslashes(trim($_POST['fname'])):'';
	$mname=isset($_POST['mname'])?addslashes(trim($_POST['mname'])):'';
	$lname=isset($_POST['lname'])?addslashes(trim($_POST['lname'])):'';
	$sameas=isset($_POST['sameas'])?addslashes(trim($_POST['sameas'])):'';
	$procompany=isset($_POST['procompany'])?addslashes(trim($_POST['procompany'])):'';
	$productname=isset($_POST['productname'])?addslashes(trim($_POST['productname'])):'';
	$premium=isset($_POST['premium'])?addslashes(trim($_POST['premium'])):'';
	$finalsubmit=isset($_POST['finalsubmit'])?addslashes(trim($_POST['finalsubmit'])):'';
	$insert_sql_data=array('date'=>$dt,
	'doneby'=>$_SESSION['cusid'],
	'applno'=>$newid,
	'category'=>'Individual',
	'panno'=>$panno,
	'title'=>$title,
	'fname'=>$fname,
	'mname'=>$mname,
	'lname'=>$lname,
	'company'=>$procompany,
	'proname'=>$productname,
	'amount'=>$premium,
	'datavl'=>$datavl,
	'sameas'=>$sameas,
	'finalsubmit'=>$finalsubmit,
	'status'=>'1'
	);
	$ins_query=tep_db_perform("insurancedata",$insert_sql_data,"insert");
	$id=mysqli_insert_id($con);
	if(isset($_FILES['photo']['name']) && $_FILES['photo']['name']!="") {
		$userfile_name=$_FILES['photo']['name'];
		$userfile_tmp=$_FILES['photo']['tmp_name'];
		$img=$_FILES['photo']['tmp_name'];
		$userfile_size=$_FILES['photo']['size'];
		$userfile_type=$_FILES['photo']['type'];
		$t=explode("/",$userfile_type);
		if($t[0]=="image") {
			$path=time().$userfile_name; //original path
			$uppath="docs/".$path;
			move_uploaded_file($_FILES['photo']['tmp_name'],$uppath);
		}
		$insert_sql_data=array('photo'=>$path);
		tep_db_perform("insurancedata",$insert_sql_data,'update',"id='".(int)$id."'");	
	}
	$pan="";
	$total=count($_FILES['pan']['name']);
	for($i=0;$i<$total;$i++) {
		if(isset($_FILES['pan']['name'][$i]) && $_FILES['pan']['name'][$i]!="") {
			$userfile_name=$_FILES['pan']['name'][$i];
			$userfile_tmp=$_FILES['pan']['tmp_name'][$i];
			$img=$_FILES['pan']['tmp_name'][$i];
			$userfile_size=$_FILES['pan']['size'][$i];
			$userfile_type=$_FILES['pan']['type'][$i];
			$t=explode("/",$userfile_type);
			//if($t[0]=="image") {
				$path=time().$userfile_name; //original path
				$uppath="docs/".$path;
				move_uploaded_file($_FILES['pan']['tmp_name'][$i],$uppath);
			//}
			$pan.=$path."/";		
		}
	}
	$insert_sql_data=array('pan'=>$pan);
	tep_db_perform("insurancedata",$insert_sql_data,'update',"id='".(int)$id."'");
	$aadhaar="";
	$total=count($_FILES['aadhaar']['name']);
	for($i=0;$i<$total;$i++) {
		if(isset($_FILES['aadhaar']['name'][$i]) && $_FILES['aadhaar']['name'][$i]!="") {
			$userfile_name=$_FILES['aadhaar']['name'][$i];
			$userfile_tmp=$_FILES['aadhaar']['tmp_name'][$i];
			$img=$_FILES['aadhaar']['tmp_name'][$i];
			$userfile_size=$_FILES['aadhaar']['size'][$i];
			$userfile_type=$_FILES['aadhaar']['type'][$i];
			$t=explode("/",$userfile_type);
			//if($t[0]=="image") {
				$path=time().$userfile_name; //original path
				$uppath="docs/".$path;
				move_uploaded_file($_FILES['aadhaar']['tmp_name'][$i],$uppath);
			//}
			$aadhaar.=$path."/";		
		}
	}
	$insert_sql_data=array('aadhaar'=>$aadhaar);
	tep_db_perform("insurancedata",$insert_sql_data,'update',"id='".(int)$id."'");
	$pidproof="";
	$total=count($_FILES['pidproof']['name']);
	for($i=0;$i<$total;$i++) {
		if(isset($_FILES['pidproof']['name'][$i]) && $_FILES['pidproof']['name'][$i]!="") {
			$userfile_name=$_FILES['pidproof']['name'][$i];
			$userfile_tmp=$_FILES['pidproof']['tmp_name'][$i];
			$img=$_FILES['pidproof']['tmp_name'][$i];
			$userfile_size=$_FILES['pidproof']['size'][$i];
			$userfile_type=$_FILES['pidproof']['type'][$i];
			$t=explode("/",$userfile_type);
			//if($t[0]=="image") {
				$path=time().$userfile_name; //original path
				$uppath="docs/".$path;
				move_uploaded_file($_FILES['pidproof']['tmp_name'][$i],$uppath);
			//}
			$pidproof.=$path."/";		
		}
	}
	$insert_sql_data=array('pidproof'=>$pidproof);
	tep_db_perform("insurancedata",$insert_sql_data,'update',"id='".(int)$id."'");
	$adproof="";
	$total=count($_FILES['adproof']['name']);
	for($i=0;$i<$total;$i++) {
		if(isset($_FILES['adproof']['name'][$i]) && $_FILES['adproof']['name'][$i]!="") {
			$userfile_name=$_FILES['adproof']['name'][$i];
			$userfile_tmp=$_FILES['adproof']['tmp_name'][$i];
			$img=$_FILES['adproof']['tmp_name'][$i];
			$userfile_size=$_FILES['adproof']['size'][$i];
			$userfile_type=$_FILES['adproof']['type'][$i];
			$t=explode("/",$userfile_type);
			//if($t[0]=="image") {
				$path=time().$userfile_name; //original path
				$uppath="docs/".$path;
				move_uploaded_file($_FILES['adproof']['tmp_name'][$i],$uppath);
			//}
			$adproof.=$path."/";		
		}
	}
	$insert_sql_data=array('adproof'=>$adproof);
	tep_db_perform("insurancedata",$insert_sql_data,'update',"id='".(int)$id."'");
	$_SESSION['msg']="Lead is saved successfully. Thank you.";
	header("location:".$page."?editid=".$id);
	exit();
}
if(isset($_REQUEST['editid']) && $_REQUEST['editid']!="" && isset($_POST['submitin']) && $_POST['submitin']=="Formyes") {
	$datavlar=$_POST;
	$count=1;
	$datavl="";
	foreach($datavlar as $k=>$val) {
		if($count==1) {
			$datavl=$val;
		} else {
			$datavl.="/seperator/".$val;
		}
		$count++;
	}
	$dt=date("Y-m-d");
	$panno=isset($_POST['fpanno'])?addslashes(trim($_POST['fpanno'])):'';
	$title=isset($_POST['title'])?addslashes(trim($_POST['title'])):'';
	$fname=isset($_POST['fname'])?addslashes(trim($_POST['fname'])):'';
	$mname=isset($_POST['mname'])?addslashes(trim($_POST['mname'])):'';
	$lname=isset($_POST['lname'])?addslashes(trim($_POST['lname'])):'';
	$sameas=isset($_POST['sameas'])?addslashes(trim($_POST['sameas'])):'';
	$finalsubmit=isset($_POST['finalsubmit'])?addslashes(trim($_POST['finalsubmit'])):'';
	$insert_sql_data=array('date'=>$dt,
	'doneby'=>$_SESSION['irid'],
	'panno'=>$panno,
	'title'=>$title,
	'fname'=>$fname,
	'mname'=>$mname,
	'lname'=>$lname,
	'datavl'=>$datavl,
	'sameas'=>$sameas,
	'finalsubmit'=>$finalsubmit,
	'status'=>'1'
	);
	$ins_query=tep_db_perform("insurancedata",$insert_sql_data,"update","id=".$_REQUEST['editid']);
	$id=$_REQUEST['editid'];
	if(isset($_FILES['photo']['name']) && $_FILES['photo']['name']!="") {
		$userfile_name=$_FILES['photo']['name'];
		$userfile_tmp=$_FILES['photo']['tmp_name'];
		$img=$_FILES['photo']['tmp_name'];
		$userfile_size=$_FILES['photo']['size'];
		$userfile_type=$_FILES['photo']['type'];
		$t=explode("/",$userfile_type);
		if($t[0]=="image") {
			$path=time().$userfile_name; //original path
			$uppath="docs/".$path;
			move_uploaded_file($_FILES['photo']['tmp_name'],$uppath);
		}
		$insert_sql_data=array('photo'=>$path);
		tep_db_perform("insurancedata",$insert_sql_data,'update',"id='".(int)$id."'");	
	}
	$pan="";
	$total=count($_FILES['pan']['name']);
	for($i=0;$i<$total;$i++) {
		if(isset($_FILES['pan']['name'][$i]) && $_FILES['pan']['name'][$i]!="") {
			$userfile_name=$_FILES['pan']['name'][$i];
			$userfile_tmp=$_FILES['pan']['tmp_name'][$i];
			$img=$_FILES['pan']['tmp_name'][$i];
			$userfile_size=$_FILES['pan']['size'][$i];
			$userfile_type=$_FILES['pan']['type'][$i];
			$t=explode("/",$userfile_type);
			//if($t[0]=="image") {
				$path=time().$userfile_name; //original path
				$uppath="docs/".$path;
				move_uploaded_file($_FILES['pan']['tmp_name'][$i],$uppath);
			//}
			$pan.=$path."/";		
		}
	}
	$insert_sql_data=array('pan'=>$pan);
	tep_db_perform("insurancedata",$insert_sql_data,'update',"id='".(int)$id."'");
	$aadhaar="";
	$total=count($_FILES['aadhaar']['name']);
	for($i=0;$i<$total;$i++) {
		if(isset($_FILES['aadhaar']['name'][$i]) && $_FILES['aadhaar']['name'][$i]!="") {
			$userfile_name=$_FILES['aadhaar']['name'][$i];
			$userfile_tmp=$_FILES['aadhaar']['tmp_name'][$i];
			$img=$_FILES['aadhaar']['tmp_name'][$i];
			$userfile_size=$_FILES['aadhaar']['size'][$i];
			$userfile_type=$_FILES['aadhaar']['type'][$i];
			$t=explode("/",$userfile_type);
			//if($t[0]=="image") {
				$path=time().$userfile_name; //original path
				$uppath="docs/".$path;
				move_uploaded_file($_FILES['aadhaar']['tmp_name'][$i],$uppath);
			//}
			$aadhaar.=$path."/";		
		}
	}
	$insert_sql_data=array('aadhaar'=>$aadhaar);
	tep_db_perform("insurancedata",$insert_sql_data,'update',"id='".(int)$id."'");
	$pidproof="";
	$total=count($_FILES['pidproof']['name']);
	for($i=0;$i<$total;$i++) {
		if(isset($_FILES['pidproof']['name'][$i]) && $_FILES['pidproof']['name'][$i]!="") {
			$userfile_name=$_FILES['pidproof']['name'][$i];
			$userfile_tmp=$_FILES['pidproof']['tmp_name'][$i];
			$img=$_FILES['pidproof']['tmp_name'][$i];
			$userfile_size=$_FILES['pidproof']['size'][$i];
			$userfile_type=$_FILES['pidproof']['type'][$i];
			$t=explode("/",$userfile_type);
			//if($t[0]=="image") {
				$path=time().$userfile_name; //original path
				$uppath="docs/".$path;
				move_uploaded_file($_FILES['pidproof']['tmp_name'][$i],$uppath);
			//}
			$pidproof.=$path."/";		
		}
	}
	$insert_sql_data=array('pidproof'=>$pidproof);
	tep_db_perform("insurancedata",$insert_sql_data,'update',"id='".(int)$id."'");
	$adproof="";
	$total=count($_FILES['adproof']['name']);
	for($i=0;$i<$total;$i++) {
		if(isset($_FILES['adproof']['name'][$i]) && $_FILES['adproof']['name'][$i]!="") {
			$userfile_name=$_FILES['adproof']['name'][$i];
			$userfile_tmp=$_FILES['adproof']['tmp_name'][$i];
			$img=$_FILES['adproof']['tmp_name'][$i];
			$userfile_size=$_FILES['adproof']['size'][$i];
			$userfile_type=$_FILES['adproof']['type'][$i];
			$t=explode("/",$userfile_type);
			//if($t[0]=="image") {
				$path=time().$userfile_name; //original path
				$uppath="docs/".$path;
				move_uploaded_file($_FILES['adproof']['tmp_name'][$i],$uppath);
			//}
			$adproof.=$path."/";		
		}
	}
	$insert_sql_data=array('adproof'=>$adproof);
	tep_db_perform("insurancedata",$insert_sql_data,'update',"id='".(int)$id."'");
	$_SESSION['msg']="Lead is submitted successfully. Thank you.";
	header("location:reports.php#go".$_REQUEST['flag']);
	exit();
}
if($_REQUEST['editid']!="") {
	$rowdt=mysqli_fetch_assoc(mysqli_query($con,"select * from `insurancedata` where `id`='".$_REQUEST['editid']."'"));
	$idata=explode("/seperator/",$rowdt['datavl']);
	$cfld=0;
}
if(isset($_REQUEST['fpanval']) && $_REQUEST['fpanval']!="") {
	$rowdt=mysqli_fetch_assoc(mysqli_query($con,"select * from `insurancedata` where `panno`='".$_REQUEST['fpanval']."' order by `id` desc"));
	$idata=explode("/seperator/",$rowdt['datavl']);
	$cfld=0;
}
include("includes/headermain.php"); 
?>
<?php if($_SESSION['msg']) { ?>
	<script src="//ajax.googleapis.com/ajax/libs/jquery/1.11.1/jquery.js"></script>
	<script>
	$(document).ready(function() {	
		var id = '#dialog';
			
		//Get the screen height and width
		var maskHeight = $(document).height();
		var maskWidth = $(window).width();
			
		//Set heigth and width to mask to fill up the whole screen
		$('#mask').css({'width':maskWidth,'height':maskHeight});
	
		//transition effect
		$('#mask').fadeIn(500);	
		$('#mask').fadeTo("slow",0.9);	
			
		//Get the window height and width
		var winH = $(window).height();
		var winW = $(window).width();
					  
		//Set the popup window to center
		$(id).css('top',  winH/2-$(id).height()/2);
		$(id).css('left', winW/2-$(id).width()/2);
		
		//transition effect
		$(id).fadeIn(2000); 	
		
		//if close button is clicked
		$('.window .close').click(function (e) {
			//Cancel the link behavior
			e.preventDefault();
		
			$('#mask').hide();
			$('.window').hide();
		});
	
		//if mask is clicked
		$('#mask').click(function () {
			$(this).hide();
			$('.window').hide();
		});
	});
	</script>
	<style>
	#mask {
		position: absolute;
		left: 0;
		top: 0;
		z-index: 9000;
		display: none;
	}
	#boxes .window {
		position: absolute;
		left: 0;
		top: 0;
		width: 300px;
		height: 200px;
		display: none;
		z-index: 9999;
		padding: 20px;
		border-radius: 5px;
		text-align: center;
	}
	#boxes #dialog {
		width: 300px;
		height: 200px;
		padding: 10px;
		background: #F9F9F9;
		font-size: 16px;
		font-weight: bold;
		webkit-box-shadow: 0 0 10px #999999;
  		box-shadow: 0 0 10px #999999;
	}
	#popupfoot {
		position: absolute;
		margin: auto;
		bottom: 20px;
		color: #005CB9;
	}
	.close {
		font-size: 12px !important;
	}
	</style>
	<div id="boxes">
		<div id="dialog" class="window">
			<?php if($_SESSION['msg']) { ?><span><?php print $_SESSION['msg']; $_SESSION['msg']=""; ?></span><?php } ?>
			<?php if($_SESSION['msgerr']) { ?><span class="redtxt"><?php print $_SESSION['msgerr']; $_SESSION['msgerr']=""; ?></span><?php } ?>
			<div id="popupfoot"><a href="#" class="close">Close</a></div>
		</div>
		<div id="mask"></div>
	</div>
<?php } ?>
<body class="body-bg">


<div id="preloader">
	<div class="loader"></div>
</div>


<div class="horizontal-main-wrapper">
	<?php include("includes/header.php"); ?>
	
	<div class="main-content">
	 	<div class="main-content-inner">
			
			<div> 
				<div class="col-lg-12 mt-5">
					<div class="card">
						<div class="card-body">
							<form action="#" method="post" name="rform" enctype="multipart/form-data">
								<input type="hidden" name="submitin" value="Formyes">
								<?php if($_SESSION['msgerr']) { ?><span class="redtxt"><?php print $_SESSION['msgerr']; $_SESSION['msgerr']=""; ?></span><div class="cleaner h10"></div><?php } ?>
								<?php if($_SESSION['msg']) { ?><span class="grtxt"><?php print $_SESSION['msg']; $_SESSION['msg']=""; ?></span><div class="cleaner h10"></div><?php } ?>
								<h4 class="header-title titlebg">Health Individual Login Data Sheet</h4>
								
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">Date</label>
									<input type="hidden" name="date" id="date" value="<?php print date("Y-m-d"); ?>">
									<strong><?php print date("d-m-Y"); ?></strong>
								</div>
								<div class="form-group col-md-3 floatleft">	
									<?php $cfld+=2; ?>
									<label for="example-text-input" class="col-form-label"><span>*</span>Policy Type</label>
									<select class="form-control spslc" name="policytype" id="policytype" required>
										<option value="">Select
										<option value="New Policy" <?php if($idata[$cfld]=="New Policy") { ?>selected<?php } ?>>New Policy
										<option value="Port" <?php if($idata[$cfld]=="Port") { ?>selected<?php } ?>>Port
									</select>
								</div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>PAN No.</label>
									<input class="form-control" type="text" name="fpanno" id="fpanno" required value="<?php if($_REQUEST['fpanval']!="") { print $_REQUEST['fpanval']; } else { print $rowdt['panno']; } ?>" maxlength="10" onBlur="copypanno();">
									<div id="fpantxt"></div>
								</div>
								<div class="form-group col-md-2 floatleft">
									<button type="button" class="btn btn-primary mt-5 pr-4 pl-4" onClick="searchcus('fpanno','fpantxt','<?php print basename(__FILE__); ?>');">Search</button>
								</div>
								<div class="cleaner h20"></div>
								<h4 class="header-title titlebg">Insurer Details</h4>
								<div class="form-group col-md-3 floatleft">
									<?php $cfld+=2; ?>
									<label for="example-text-input" class="col-form-label"><span>*</span>Title</label>
									<select class="form-control spslc" name="title" id="title" required>
										<option value="">Select
										<option value="Mr." <?php if($idata[$cfld]=="Mr.") { ?>selected<?php } ?>>Mr.
										<option value="Mrs." <?php if($idata[$cfld]=="Mrs.") { ?>selected<?php } ?>>Mrs.
										<option value="Miss" <?php if($idata[$cfld]=="Miss") { ?>selected<?php } ?>>Miss
										<option value="Dr." <?php if($idata[$cfld]=="Dr.") { ?>selected<?php } ?>>Dr.
										<option value="Prof." <?php if($idata[$cfld]=="Prof.") { ?>selected<?php } ?>>Prof.
									</select>
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>First Name</label>
									<input class="form-control" type="text" name="fname" id="fname" required value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">Middle Name</label>
									<input class="form-control" type="text" name="mname" id="mname" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>Last Name</label>
									<input class="form-control" type="text" name="lname" id="lname" required value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-3 floatleft">
									<?php $cfld++; ?>
									<label for="example-text-input" class="col-form-label"><span>*</span>Gender</label>
									<select class="form-control spslc" name="gender" id="gender" autocomplete="off">
										<option value="">Select
										<option value="Male" <?php if($idata[$cfld]=="Male") { ?>selected<?php } ?>>Male
										<option value="Female" <?php if($idata[$cfld]=="Female") { ?>selected<?php } ?>>Female
										<option value="Other" <?php if($idata[$cfld]=="Other") { ?>selected<?php } ?>>Other
									</select>
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>DOB</label>
									<input class="form-control" type="date" name="dob" id="dob" required value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-3 floatleft">
									<?php $cfld++; ?>
									<label for="example-text-input" class="col-form-label"><span>*</span>Marital Status</label>
									<select class="form-control spslc" name="mstatus" id="mstatus" required>
										<option value="">Select
										<option value="Single" <?php if($idata[$cfld]=="Single") { ?>selected<?php } ?>>Single
										<option value="Married" <?php if($idata[$cfld]=="Married") { ?>selected<?php } ?>>Married
										<option value="Unmarried" <?php if($idata[$cfld]=="Unmarried") { ?>selected<?php } ?>>Unmarried
										<option value="Widow" <?php if($idata[$cfld]=="Widow") { ?>selected<?php } ?>>Widow
										<option value="Widow" <?php if($idata[$cfld]=="Divorced") { ?>selected<?php } ?>>Divorced
									</select>
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">Nationality</label>
									<input class="form-control" type="text" name="nationality" id="nationality" value="Indian" readonly>
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>Height (in cm)</label>
									<input class="form-control" type="number" name="height" id="height" maxlength="3" required value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>Weight (in kg)</label>
									<input class="form-control" type="text" name="weight" id="weight" maxlength="3" required value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-4 floatleft">
									<?php $cfld++; ?>
									<label for="example-text-input" class="col-form-label"><span>*</span>Education</label>
									<select class="form-control spslc" name="education" id="education" required>
										<option value="">Select
										<option value="Below 10th" <?php if($idata[$cfld]=="Below 10th") { ?>selected<?php } ?>>Below 10th
										<option value="10th Standard" <?php if($idata[$cfld]=="10th Standard") { ?>selected<?php } ?>>10th Standard
										<option value="12th Standard" <?php if($idata[$cfld]=="12th Standard") { ?>selected<?php } ?>>12th Standard
										<option value="Diploma" <?php if($idata[$cfld]=="Diploma") { ?>selected<?php } ?>>Diploma
										<option value="Graduate" <?php if($idata[$cfld]=="Graduate") { ?>selected<?php } ?>>Graduate
										<option value="Post Graduate" <?php if($idata[$cfld]=="Post Graduate") { ?>selected<?php } ?>>Post Graduate
										<option value="PHD" <?php if($idata[$cfld]=="PHD") { ?>selected<?php } ?>>PHD
									</select>
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>Mobile No.</label>
									<input class="form-control" type="number" name="mobile" id="mobile" required onBlur="checkmobile('mobile',this.value,'mobtxt');" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
									<div id="mobtxt"></div>
								</div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">Alternate Mobile No.</label>
									<input class="form-control" type="number" name="amobile" id="amobile" onBlur="checkmobile('amobile',this.value,'amobtxt');checkwmobile('mobile','amobile','amobtxt');" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
									<div id="amobtxt"></div>
								</div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>Email ID</label>
									<input class="form-control" type="email" name="email" id="email" required autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">House No.</label>
									<input class="form-control" type="text" name="holdingno" id="holdingno" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-9 floatleft">
									<label for="example-text-input" class="col-form-label">Street Name</label>
									<input class="form-control" type="text" name="streetname" id="streetname" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-12 floatleft">
									<label for="example-text-input" class="col-form-label">Address Line 1</label>
									<input class="form-control" type="text" name="addresslinea" id="addresslinea" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-12 floatleft">
									<label for="example-text-input" class="col-form-label">Address Line 2</label>
									<input class="form-control" type="text" name="addresslineb" id="addresslineb" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-4 floatleft">
									<?php $cfld++; ?>
									<label for="example-text-input" class="col-form-label">State</label>
									<?php /*?><input class="form-control" type="text" name="state" id="state" autocomplete="off"><?php */?>
									<select class="form-control spslc" name="state" id="state" onChange="fetchdistrict('disblock','district',this.value);">
										<option value="">Select
										<?php
										$resst=mysqli_query($con,"select distinct `state` from `statedis` where 1");
										while($rowst=mysqli_fetch_array($resst)) {
										?>
											<option value="<?php print $rowst['state']; ?>" <?php if($idata[$cfld]==$rowst['state']) { ?>selected<?php } ?>><?php print $rowst['state']; ?>
										<?php } ?>	
									</select>
								</div>
								<?php $cfld++; ?>
								<div class="form-group col-md-4 floatleft" id="disblock">	
									<label for="example-text-input" class="col-form-label">District</label>
									<?php /*?><input class="form-control" type="text" name="district" id="district" autocomplete="off"><?php */?>
									<select class="form-control spslc" name="district" id="district">
										<option value="">Select
										<?php
										$resst=mysqli_query($con,"select distinct `district` from `statedis` where 1");
										while($rowst=mysqli_fetch_array($resst)) {
										?>
											<option value="<?php print $rowst['district']; ?>" <?php if($idata[$cfld]==$rowst['district']) { ?>selected<?php } ?>><?php print $rowst['district']; ?>
										<?php } ?>	
									</select>
								</div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">PIN</label>
									<input class="form-control" type="number" name="pin" id="pin" onBlur="checkpin('pin',this.value,'pintxt');" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
									<div id="pintxt"></div>
								</div>
								<div class="cleaner h20"></div>
								<div class="form-group col-md-12">
									<?php if($rowdt['sameas']=="Yes") { $cfld++; } ?>
									<input type="checkbox" name="sameas" id="sameas" value="Yes" onClick="pastepaddress();">&nbsp;&nbsp;<label><strong>Permanent Address is same.</strong></label>
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">House No. (Permanent Address)</label>
									<input class="form-control" type="text" name="pholdingno" id="pholdingno" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-9 floatleft">
									<label for="example-text-input" class="col-form-label">Street Name (Permanent Address)</label>
									<input class="form-control" type="text" name="pstreetname" id="pstreetname" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-12 floatleft">
									<label for="example-text-input" class="col-form-label">Permanent Address Line 1</label>
									<input class="form-control" type="text" name="paddresslinea" id="paddresslinea" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-12 floatleft">
									<label for="example-text-input" class="col-form-label">Permanent Address Line 2</label>
									<input class="form-control" type="text" name="paddresslineb" id="paddresslineb" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-4 floatleft">
									<?php $cfld++; ?>
									<label for="example-text-input" class="col-form-label">State</label>
									<?php /*?><input class="form-control" type="text" name="pstate" id="pstate" autocomplete="off"><?php */?>
									<select class="form-control spslc" name="pstate" id="pstate" onChange="fetchdistrict('disblockp','pdistrict',this.value);">
										<option value="">Select
										<?php
										$resst=mysqli_query($con,"select distinct `state` from `statedis` where 1");
										while($rowst=mysqli_fetch_array($resst)) {
										?>
											<option value="<?php print $rowst['state']; ?>" <?php if($idata[$cfld]==$rowst['state']) { ?>selected<?php } ?>><?php print $rowst['state']; ?>
										<?php } ?>	
									</select>
								</div>
								<?php $cfld++; ?>
								<div class="form-group col-md-4 floatleft" id="disblockp">
									<label for="example-text-input" class="col-form-label">District</label>
									<?php /*?><input class="form-control" type="text" name="pdistrict" id="pdistrict" autocomplete="off"><?php */?>
									<select class="form-control spslc" name="pdistrict" id="pdistrict">
										<option value="">Select
										<?php
										$resst=mysqli_query($con,"select distinct `district` from `statedis` where 1");
										while($rowst=mysqli_fetch_array($resst)) {
										?>
											<option value="<?php print $rowst['district']; ?>" <?php if($idata[$cfld]==$rowst['district']) { ?>selected<?php } ?>><?php print $rowst['district']; ?>
										<?php } ?>	
									</select>
								</div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">PIN</label>
									<input class="form-control" type="number" name="ppin" id="ppin" onBlur="checkpin('ppin',this.value,'ppintxt');" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
									<div id="ppintxt"></div>
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>PAN No.</label>
									<input class="form-control" type="text" name="panno" id="panno" required <?php if(isset($_REQUEST['fpanval']) && $_REQUEST['fpanval']!="") { ?>value="<?php print $_REQUEST['fpanval']; ?>" disabled<?php } if($rowdt['panno']!="") { ?>value="<?php print $rowdt['panno']; ?>" disabled<?php } ?>>
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">Upload PAN</label>
									<input class="form-control" type="file" name="pan[]" id="pan[]" multiple><br>
									<?php 
									if($rowdt['pan']!="") { 
										$pan=explode("/",$rowdt['pan']);
										foreach($pan as $val) {
											if($val!="") {
									?>
												<a href="docs/<?php print $val; ?>" target="_blank">View File</a>&nbsp;&nbsp;&nbsp;
									<?php } } } ?>
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label"><span>*</span>Aadhaar No.</label>
									<input class="form-control" type="text" name="aadhaarno" id="aadhaarno" required value="<?php $cfld++; print $idata[$cfld]; ?>" maxlength="16">
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">Upload Aadhaar</label>
									<input class="form-control" type="file" name="aadhaar[]" id="aadhaar[]" multiple><br>
									<?php 
									if($rowdt['aadhaar']!="") { 
										$aadhaar=explode("/",$rowdt['aadhaar']);
										foreach($aadhaar as $val) {
											if($val!="") {
									?>
												<a href="docs/<?php print $val; ?>" target="_blank">View File</a>&nbsp;&nbsp;&nbsp;
									<?php } } } ?>
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-12 floatleft">
									<label for="example-text-input" class="col-form-label">Upload Photo</label>
									<input class="form-control" type="file" name="photo" id="photo">
									<?php if($rowdt['photo']!="") { ?><br><a href="docs/<?php print $rowdt['photo']; ?>" target="_blank">View Photo</a><?php } ?>
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-3 floatleft">
									<?php $cfld++; ?>
									<label for="example-text-input" class="col-form-label">Photo ID Proof Type</label>
									<select class="form-control spslc" name="pidprooftype" id="pidprooftype">
										<option value="">Select
										<option value="PAN" <?php if($idata[$cfld]=="PAN") { ?>selected<?php } ?>>PAN	
										<option value="Aadhaar" <?php if($idata[$cfld]=="Aadhaar") { ?>selected<?php } ?>>Aadhaar
										<option value="Voter ID" <?php if($idata[$cfld]=="Voter ID") { ?>selected<?php } ?>>Voter ID
										<option value="Driving License" <?php if($idata[$cfld]=="Driving License") { ?>selected<?php } ?>>Driving License
										<option value="Passport" <?php if($idata[$cfld]=="Passport") { ?>selected<?php } ?>>Passport
										<option value="Others" <?php if($idata[$cfld]=="Others") { ?>selected<?php } ?>>Others
									</select>
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">If Photo ID Proof Others</label>
									<input class="form-control" type="text" name="pidproofoth" id="pidproofoth" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">Photo ID Proof No.</label>
									<input class="form-control" type="text" name="pidproofno" id="pidproofno" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">Upload Photo ID Proof</label>
									<input class="form-control" type="file" name="pidproof[]" id="pidproof[]" multiple><br>
									<?php 
									if($rowdt['pidproof']!="") { 
										$pidproof=explode("/",$rowdt['pidproof']);
										foreach($pidproof as $val) {
											if($val!="") {
									?>
												<a href="docs/<?php print $val; ?>" target="_blank">View File</a>&nbsp;&nbsp;&nbsp;
									<?php } } } ?>
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-3 floatleft">
									<?php $cfld++; ?>
									<label for="example-text-input" class="col-form-label">Address Proof Type</label>
									<select class="form-control spslc" name="adprooftype" id="adprooftype">
										<option value="">Select
										<option value="Aadhaar" <?php if($idata[$cfld]=="Daughter") { ?>selected<?php } ?>>Aadhaar
										<option value="Voter ID" <?php if($idata[$cfld]=="Voter ID") { ?>selected<?php } ?>>Voter ID
										<option value="Driving License" <?php if($idata[$cfld]=="Driving License") { ?>selected<?php } ?>>Driving License
										<option value="Ration Card" <?php if($idata[$cfld]=="Ration Card") { ?>selected<?php } ?>>Ration Card
										<option value="Bank Statement" <?php if($idata[$cfld]=="Bank Statement") { ?>selected<?php } ?>>Bank Statement
										<option value="Passport" <?php if($idata[$cfld]=="Passport") { ?>selected<?php } ?>>Passport
										<option value="Others" <?php if($idata[$cfld]=="Others") { ?>selected<?php } ?>>Others
									</select>
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">If Address Proof Others</label>
									<input class="form-control" type="text" name="adproofoth" id="adproofoth" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">Address Proof ID No.</label>
									<input class="form-control" type="text" name="adproofno" id="adproofno" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">Upload Address Proof</label>
									<input class="form-control" type="file" name="adproof[]" id="adproof[]" multiple><br>
									<?php 
									if($rowdt['adproof']!="") { 
										$adproof=explode("/",$rowdt['adproof']);
										foreach($adproof as $val) {
											if($val!="") {
									?>
												<a href="docs/<?php print $val; ?>" target="_blank">View File</a>&nbsp;&nbsp;&nbsp;
									<?php } } } ?>
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-3 floatleft">
									<?php $cfld++; ?>
									<label for="example-text-input" class="col-form-label"><span>*</span>Smoking Habit</label>
									<select class="form-control spslc" name="smkhabit" id="smkhabit" required>
										<option value="">Select
										<option value="Yes" <?php if($idata[$cfld]=="Yes") { ?>selected<?php } ?>>Yes
										<option value="No" <?php if($idata[$cfld]=="No") { ?>selected<?php } ?>>No
									</select>
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">Details (if Smoking Habit exists)</label>
									<input class="form-control" type="text" name="smkhabitdet" id="smkhabitdet" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-3 floatleft">
									<?php $cfld++; ?>
									<label for="example-text-input" class="col-form-label"><span>*</span>Drinking Habit</label>
									<select class="form-control spslc" name="drnhabit" id="drnhabit" required>
										<option value="">Select
										<option value="Yes" <?php if($idata[$cfld]=="Yes") { ?>selected<?php } ?>>Yes
										<option value="No" <?php if($idata[$cfld]=="No") { ?>selected<?php } ?>>No
									</select>
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">Details (if Drinking Habit exists)</label>
									<input class="form-control" type="text" name="drnhabitdet" id="drnhabitdet" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-3 floatleft">
									<?php $cfld++; ?>
									<label for="example-text-input" class="col-form-label"><span>*</span>Narcotic</label>
									<select class="form-control spslc" name="narcotic" id="narcotic" required>
										<option value="">Select
										<option value="Yes" <?php if($idata[$cfld]=="Yes") { ?>selected<?php } ?>>Yes
										<option value="No" <?php if($idata[$cfld]=="No") { ?>selected<?php } ?>>No
									</select>
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">Details (if Narcotic)</label>
									<input class="form-control" type="text" name="narcoticdet" id="narcoticdet" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-3 floatleft">
									<?php $cfld++; ?>
									<label for="example-text-input" class="col-form-label"><span>*</span>Permanent Disability</label>
									<select class="form-control spslc" name="pdisability" id="pdisability" required>
										<option value="">Select
										<option value="Yes" <?php if($idata[$cfld]=="Yes") { ?>selected<?php } ?>>Yes
										<option value="No" <?php if($idata[$cfld]=="No") { ?>selected<?php } ?>>No
									</select>
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">Details (if Permanent Disability exists)</label>
									<input class="form-control" type="text" name="pdisabilitydet" id="pdisabilitydet" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-3 floatleft">
									<?php $cfld++; ?>
									<label for="example-text-input" class="col-form-label"><span>*</span>Hospitalization</label>
									<select class="form-control spslc" name="hospitalztn" id="hospitalztn" required>
										<option value="">Select
										<option value="Yes" <?php if($idata[$cfld]=="Yes") { ?>selected<?php } ?>>Yes
										<option value="No" <?php if($idata[$cfld]=="No") { ?>selected<?php } ?>>No
									</select>
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">Details (if Hospitalization was there)</label>
									<input class="form-control" type="text" name="hospitalztndet" id="hospitalztndet" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-3 floatleft">
									<?php $cfld++; ?>
									<label for="example-text-input" class="col-form-label"><span>*</span>Daily Medicine</label>
									<select class="form-control spslc" name="dailymedic" id="dailymedic" required>
										<option value="">Select
										<option value="Yes" <?php if($idata[$cfld]=="Yes") { ?>selected<?php } ?>>Yes
										<option value="No" <?php if($idata[$cfld]=="No") { ?>selected<?php } ?>>No
									</select>
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">Details (if Daily Medicine exists)</label>
									<input class="form-control" type="text" name="dailymedicdet" id="dailymedicdet" autocomplete="off" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="cleaner h20"></div>
								<h4 class="header-title titlebg">Insurer Occupation Details</h4>
								<div class="form-group col-md-4 floatleft">
									<?php $cfld++; ?>
									<label for="example-text-input" class="col-form-label">Occupation</label>
									<select class="form-control spslc" name="occutype" id="occutype" required>
										<option value="">Select
										<option value="Salaried" <?php if($idata[$cfld]=="Salaried") { ?>selected<?php } ?>>Salaried
										<option value="Business" <?php if($idata[$cfld]=="Business") { ?>selected<?php } ?>>Business
										<option value="Self Employed" <?php if($idata[$cfld]=="Self Employed") { ?>selected<?php } ?>>Self Employed
									</select>
								</div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">Organization Name (if Salaried/Business)</label>
									<input class="form-control" type="text" name="organame" id="organame" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">Exact Nature of Duties/Business</label>
									<input class="form-control" type="text" name="naturebd" id="naturebd" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">Designation</label>
									<input class="form-control" type="text" name="designation" id="designation" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">Work Experience (in Yrs)</label>
									<input class="form-control" type="text" name="workexp" id="workexp" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">Annual Income</label>
									<input class="form-control" type="numeric" name="aincome" id="aincome" onBlur="checkaincome(this.value,'aincome','aintxt');" value="<?php $cfld++; print $idata[$cfld]; ?>">
									<div id="aintxt"></div>
								</div>
								<div class="form-group col-8 floatleft">
									<label for="example-text-input" class="col-form-label">Organization Address</label>
									<input class="form-control" type="text" name="orgaaddress" id="orgaaddress" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">Landmark</label>
									<input class="form-control" type="text" name="landmark" id="landmark" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="cleaner h20"></div>
								<h4 class="header-title titlebg">Nominee Details</h4>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">Name</label>
									<input class="form-control" type="text" name="nomname" id="nomname" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-4 floatleft">
									<?php $cfld++; ?>
									<label for="example-text-input" class="col-form-label">Relationship with LA</label>
									<select class="form-control spslc" name="nomrelationla" id="nomrelationla">
										<option value="">Select
										<option value="Father" <?php if($idata[$cfld]=="Father") { ?>selected<?php } ?>>Father
										<option value="Mother" <?php if($idata[$cfld]=="Mother") { ?>selected<?php } ?>>Mother
										<option value="Husband" <?php if($idata[$cfld]=="Husband") { ?>selected<?php } ?>>Husband
										<option value="Wife" <?php if($idata[$cfld]=="Wife") { ?>selected<?php } ?>>Wife
										<option value="Son" <?php if($idata[$cfld]=="Son") { ?>selected<?php } ?>>Son
										<option value="Daughter" <?php if($idata[$cfld]=="Daughter") { ?>selected<?php } ?>>Daughter
									</select>
								</div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">Nominee DOB</label>
									<input class="form-control" type="date" name="nomdob" id="nomdob" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">Appointee Name (if Nominee Minor)</label>
									<input class="form-control" type="text" name="appname" id="appname" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">DOB</label>
									<input class="form-control" type="date" name="appdob" id="appdob" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-3 floatleft">
									<?php $cfld++; ?>
									<label for="example-text-input" class="col-form-label">Relationship</label>
									<select class="form-control spslc" name="apprelation" id="apprelation">
										<option value="">Select
										<option value="Father" <?php if($idata[$cfld]=="Father") { ?>selected<?php } ?>>Father
										<option value="Mother" <?php if($idata[$cfld]=="Mother") { ?>selected<?php } ?>>Mother
										<option value="Husband" <?php if($idata[$cfld]=="Husband") { ?>selected<?php } ?>>Husband
										<option value="Wife" <?php if($idata[$cfld]=="Wife") { ?>selected<?php } ?>>Wife
										<option value="Son" <?php if($idata[$cfld]=="Son") { ?>selected<?php } ?>>Son
										<option value="Daughter" <?php if($idata[$cfld]=="Daughter") { ?>selected<?php } ?>>Daughter
										<option value="Others" <?php if($idata[$cfld]=="Others") { ?>selected<?php } ?>>Others
									</select>
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">If Others</label>
									<input class="form-control" type="text" name="apprelationoth" id="apprelationoth" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="cleaner h20"></div>
								<h4 class="header-title titlebg">Product Details</h4>
								<div class="form-group col-md-3 floatleft">
									<?php $cfld++; ?>
									<label for="example-text-input" class="col-form-label">Company Name</label></label>
									<select class="form-control spslc" name="procompany" id="procompany" onChange="fetchprohli(this.value);">
										<option value="">Select
										<option value="Care Health Insurance" <?php if($idata[$cfld]=="Care Health Insurance") { ?>selected<?php } ?>>Care Health Insurance

<option value="Star Health Insurance" <?php if($idata[$cfld]=="Star Health Insurance") { ?>selected<?php } ?>>Star Health Insurance
									</select>
								</div>
								<?php $cfld++; ?>
								<div class="form-group col-md-3 floatleft" id="product">
									<label for="example-text-input" class="col-form-label">Product Name</label></label>
									<select class="form-control spslc" name="productname" id="productname">
										<option value="">Select
									</select>
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">Premium</label></label>
									<input class="form-control" type="number" name="premium" id="premium" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-3 floatleft">
									<label for="example-text-input" class="col-form-label">Sum Assured</label></label>
									<input class="form-control" type="number" name="sumassured" id="sumassured" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="cleaner h20"></div>
								<h4 class="header-title titlebg">Payment Details</h4>
								<div class="form-group col-md-6 floatleft">
									<label for="example-text-input" class="col-form-label">Payer Name</label>
									<input class="form-control" type="text" name="payername" id="payername" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-6 floatleft">
									<?php $cfld++; ?>
									<label for="example-text-input" class="col-form-label">Relationship</label>
									<select class="form-control spslc" name="payerrelationla" id="payerrelationla">
										<option value="">Select
										<option value="Self" <?php if($idata[$cfld]=="Self") { ?>selected<?php } ?>>Self
										<option value="Father" <?php if($idata[$cfld]=="Father") { ?>selected<?php } ?>>Father
										<option value="Mother" <?php if($idata[$cfld]=="Mother") { ?>selected<?php } ?>>Mother
										<option value="Son" <?php if($idata[$cfld]=="Son") { ?>selected<?php } ?>>Son
										<option value="Daughter" <?php if($idata[$cfld]=="Daughter") { ?>selected<?php } ?>>Daughter
									</select>
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-4 floatleft">
									<?php $cfld++; ?>
									<label for="example-text-input" class="col-form-label">Mode of Payment</label></label>
									<select class="form-control spslc" name="paymentmode" id="paymentmode">
										<option value="">Select
										<option value="Cheque" <?php if($idata[$cfld]=="Cheque") { ?>selected<?php } ?>>Cheque
										<option value="Credit Card"> <?php if($idata[$cfld]=="Credit Card") { ?>selected<?php } ?>Credit Card
										<option value="Debit Card" <?php if($idata[$cfld]=="Debit Card") { ?>selected<?php } ?>>Debit Card
										<option value="Net Banking" <?php if($idata[$cfld]=="Net Banking") { ?>selected<?php } ?>>Net Banking
										<option value="UPI" <?php if($idata[$cfld]=="UPI") { ?>selected<?php } ?>>UPI
										<option value="DD" <?php if($idata[$cfld]=="DD") { ?>selected<?php } ?>>DD
									</select>
								</div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">Cheque No. (only for Cheque)</label></label>
									<input class="form-control" type="text" name="chequeno" id="chequeno" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-4 floatleft">
									<?php 
									$dc=date("Y-m-d");
									$exdate=date("Y-m-d",strtotime($dc."-180 days"));
									?>
									<label for="example-text-input" class="col-form-label">Cheque Date (only for Cheque)</label></label>
									<input class="form-control" type="date" name="cdate" id="cdate" value="<?php $cfld++; print $idata[$cfld]; ?>" max="<?php print date("Y-m-d"); ?>" min="<?php print $exdate; ?>">
								</div>
								<div class="cleaner"></div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">Bank Name (only for Cheque)</label></label>
									<input class="form-control" type="text" name="cbankname" id="cbankname" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">Branch (only for Cheque)</label></label>
									<input class="form-control" type="text" name="cbranch" id="cbranch" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">Amount</label></label>
									<input class="form-control" type="text" name="amount" id="amount" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">Name</label>
									<input class="form-control" type="text" name="gstname" id="gstname" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-8 floatleft">
									<label for="example-text-input" class="col-form-label">Address</label>
									<input class="form-control" type="text" name="gstaddress" id="gstaddress" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">City</label>
									<input class="form-control" type="text" name="gstcity" id="gstcity" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">PIN</label>
									<input class="form-control" type="text" name="gstpin" id="gstpin" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-4 floatleft">
									<label for="example-text-input" class="col-form-label">GSTIN</label>
									<input class="form-control" type="text" name="gstin" id="gstin" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="cleaner h20"></div>
								<h4 class="header-title titlebg">Previous Policy Details (If present)</h4>
								<div class="form-group col-md-12 floatleft">
									<label for="example-text-input" class="col-form-label">Policy 1 Details</label></label>
									<input class="form-control" type="text" name="policya" id="policya" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-12 floatleft">
									<label for="example-text-input" class="col-form-label">Policy 2 Details</label></label>
									<input class="form-control" type="text" name="policyb" id="policyb" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="form-group col-md-12 floatleft">
									<label for="example-text-input" class="col-form-label">Policy 3 Details</label></label>
									<input class="form-control" type="text" name="policyc" id="policyc" value="<?php $cfld++; print $idata[$cfld]; ?>">
								</div>
								<div class="cleaner h20"></div>
								<div class="form-group col-md-12 floatleft">
									
									<input type="checkbox" name="finalsubmit" id="finalsubmit" value="Yes">&nbsp;I have reviewed all the datas and ready to submit it.
								</div>
								<div class="cleaner"></div>
								<input type="hidden" name="editid" id="editid" value="<?php print $_REQUEST['editid']; ?>">
								<input type="hidden" name="flag" id="flag" value="<?php print $_REQUEST['flag']; ?>">
								<?php if($rowdt['finalsumit']!="Yes") { ?>
									<button type="submit" class="btn btn-primary mt-2 pr-4 pl-4">Submit</button>
									<button type="button" class="btn btn-primary mt-2 pr-4 pl-4" onClick="save();">Save</button>
								<?php } ?>	
							</form>	
						</div>
					</div>
				</div>
			</div>
			
		</div>
	</div>
	
	<?php include("includes/footer.php"); ?>
</div>


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