@extends('layouts.base')

@section('title')
    Réclamation/initiate
@endsection

@section('style')

@endsection

@section('content')
    <!-- Breadcrumb start -->
    <div class="row m-1">
        <div class="col-12 ">
            <h4 class="main-title">Réclamation de gain</h4>
            <ul class="app-line-breadcrumbs mb-3">
                <li class="">
                    <a class="f-s-14 f-w-500" href="{{ route('reclamation.index') }}">
                        <span>
                            <i class="ph-duotone  ph-stack f-s-16 "></i> Tableau de bord
                        </span>
                    </a>
                </li>
                {{-- <li>
                    <a class="f-s-14 f-w-500" href="{{ route('reclamation.list') }}">Toutes Réclamations</a>
                </li> --}}
                <li class="active">
                    <a class="f-s-14 f-w-500" href="#">Initier une réclamation</a>
                </li>
            </ul>
        </div>
    </div>
    <div class="row">
        <div class="col-lg-12">
            <div class="card">
                @if (isset($claim))
                    <div class="card-header">
                            <div class="row">
                                <div class="col-md-8">
                                    <h5>Modifier la reclamation : {{ $claim->claim_reference }}</h5>
                                </div>
                                <div class="col-md-4 text-end">
                                    <a href="{{ route('reclamation.initiate.list') }}" class="btn btn-sm btn-outline-secondary"> <i class="ph-light ph-arrow-left"></i> &nbsp; Retour</a>
                                </div>
                            </div>
                    </div>
                @endif
                <div class="card-body">
                    <form class="g-3 app-form" method="POST"
                        action="{{ isset($claim) ? route('reclamation.claim.initiated.update', ['id' => encryptId($claim->id)]) : route('reclamation.claim.initiated') }}">
                        @csrf
                        <div class="form-group row">
                            <div class="col-md-4">
                                <label for="ticket_number">Numéro du ticket <span class="text-danger">*</span></label>
                                <input type="text" value="{{ old('ticket_number', $claim->ticket_number ?? '') }}"
                                    name="ticket_number" id="ticket_number" class="form-control"
                                    placeholder="Entrez le numéro du ticket" required>
                                <span class="text-danger">@error('ticket_number'){{ $message }}@enderror</span>
                            </div>

                            <div class="col-md-4">
                                <label for="firstname">Nom <span class="text-danger">*</span></label>
                                <input type="text" value="{{ old('firstname', $claim->claimant_first_name ?? '') }}"
                                    name="firstname" id="firstname" class="form-control" placeholder="Entrez votre nom"
                                    required>
                                <span class="text-danger">@error('firstname'){{ $message }}@enderror</span>
                            </div>
                            <div class="col-md-4">
                                <label for="lastname">Prénom <span class="text-danger">*</span></label>
                                <input type="text" value="{{ old('lastname', $claim->claimant_last_name ?? '') }}"
                                    name="lastname" id="lastname" class="form-control" placeholder="Entrez votre prénom"
                                    required>
                                <span class="text-danger">@error('lastname'){{ $message }}@enderror</span>
                            </div>
                        </div>

                        <div class="row form-group mt-3">
                            <div class="col-md-4">
                                <label for="npi">NPI <span class="text-danger">*</span></label>
                                <input type="text" value="{{ old('npi', $claim->claimant_npi ?? '') }}" name="npi"
                                    maxlength="10" id="npi" class="form-control" placeholder="Entrez votre NPI" required>
                                <span class="text-danger">@error('npi'){{ $message }}@enderror</span>
                            </div>
                            <div class="col-md-4">
                                <label for="telephone">Téléphone <span class="text-danger">*</span></label>
                                <input type="tel" value="{{ old('phone', $claim->claimant_phone ?? '') }}" name="phone"
                                    id="telephone" class="form-control" placeholder="Entrez votre numéro de téléphone"
                                    required>
                                <span class="text-danger">@error('phone'){{ $message }}@enderror</span>
                            </div>
                            <div class="col-md-4">
                                <label for="email">Email</label>
                                <input type="email" id="email"
                                    value="{{ old('claimant_email', $claim->claimant_mail ?? '') }}" class="form-control"
                                    name="claimant_email" placeholder="Entrez votre email">
                                <span class="text-danger">@error('claimant_email'){{ $message }}@enderror</span>
                            </div>
                        </div>

                        <div class="row mt-3">
                            <div class="col-md-12 text-end">
                                <button type="submit" class="btn btn-outline-primary">
                                    @if(isset($claim))
                                        <i class="ph-light ph-floppy-disk"></i> Mettre à jour
                                    @else
                                        <i class="ph-duotone ph-paper-plane"></i> Soumettre
                                    @endif
                                </button>
                            </div>
                        </div>
                    </form>
                </div>
            </div>
        </div>
    </div>
@endsection

@section('script')

@endsection