@extends('layout.base', ['title' => 'Assurance - Nouveau Affilier'])
@section('content')
        <div id="page-wrapper" >
            <div id="page-inner">
                <div class="row">
                    <div class="col-md-12">
        <h2 style="color: blue;font-weight: bold;text-align: center;">Nouveau Affilier</h2>
        </div>
                </div>
                 <!-- /. ROW  -->
                 <hr />
               <div class="row">
                <div class="col-md-12">
                    <!-- Form Elements -->
                    <div class="panel panel-default">
                        <div class="panel-heading">
                             Ajout d'un Affilier
                             <a href="{{ route('Affiliers.index') }}" style="text-decoration: none;color: white">
                             <div class="btn btn-info pull-right"  style="margin-top: -5px">
                            <i class="fa fa-book"></i> Liste des Affiliers
                            </a>
                        </div>
                        <div class="panel-body">
                            <div class="row">
                                <div class="col-md-6">
                                    <form role="form" method="POST" action="{{ route('Affiliers.store')}}">
                                      {{ csrf_field() }}
                                        <div class="form-group">
                                            <label>Code</label>
                                            <input class="form-control" placeholder="Code de L'Affilier" name="Code" value="{{ old('Code') }}"/>

                                            {!! $errors->first('Code', '<span class="error">:message</span>') !!}
                                        </div>

                                        <div class="form-group">
                                            <label>Nom</label>
                                            <input class="form-control" placeholder="Nom de L'Affilier" name="Nom" value="{{ old('Nom') }}" />

                                            {!! $errors->first('Nom', '<span class="error">:message</span>') !!}
                                        </div>

                                        <div class="form-group">
                                            <label>Prenom</label>
                                            <input class="form-control" placeholder="Prenom de L'Affilier" name="Prenom" value="{{ old('Prenom') }}" />

                                            {!! $errors->first('Prenom', '<span class="error">:message</span>') !!}
                                        </div>
                                        

                                        <div class="form-group">
                                            <label>Année de naissance</label>
                                            <input type="number" class="form-control" placeholder="Année de naissance" name="DateNaiss"/>

                                            {!! $errors->first('DateNaiss', '<span class="error">:message</span>') !!}
                                        </div>
 
                                        <div class="form-group">
                                          <label>Adresse</label>
                                            <input  class="form-control" placeholder="Adresse Affilié" name="Adresse" value="{{ old('Adresse') }}" />

                                            {!! $errors->first('Adresse', '<span class="error">:message</span>') !!}
                                        </div>

                                        <div class="form-group">
                                        <label>Origine</label>
                                        <select class="form-control" name="Origine">
                                            <option></option>
                                            @foreach($Origines as $O)
                                            <option value="{{ $O->id}}">{{$O->Origine}}</option>
                                            @endforeach
                                        </select>
                                            {!! $errors->first('Origine', '<span class="error">:message</span>') !!}
                                        </div>

                                        <div class="form-group">
                                            <label>N° Piece</label>
                                            <input class="form-control" placeholder=" N° Piece Indentite" name="Piece" value="{{ old('Piece') }}" />

                                            {!! $errors->first('Piece', '<span class="error">:message</span>') !!}
                                        </div>

                                        <div class="form-group">
                                            <label>Telephone</label>
                                            <input class="form-control" placeholder="Telephone" name="Telephone" value="{{ old('Telephone') }}" />

                                            {!! $errors->first('Telephone', '<span class="error">:message</span>') !!}
                                        </div>

                                        <div class="form-group">
                                            <label>Date Entrée</label>
                                            <input type="date" class="form-control" name="DateEntree" value="{{ old('DateEntree') }}" />

                                            {!! $errors->first('DateEntree', '<span class="error">:message</span>') !!}
                                        </div>

                                        <label></label><br>
                                        <button type="submit" class="btn btn-primary">Enregistrer</button>
                                        <button type="reset" class="btn btn-default">Annuler</button>
                                </div>

                                      <div class="col-md-6">
                                        <div class="form-group">
                                    <label>Cotisation Mensuelle</label>
                                            <input type="number" class="form-control" name="Cotisation" placeholder="Cotisation Mensuelle" value="{{ old('Cotisation') }}" />

                                            {!! $errors->first('Cotisation', '<span class="error">:message</span>') !!}
                                        </div>

                                        <div class="form-group">
                                            <label>S.A</label>
                                            <input type="number" class="form-control" placeholder="Soins Ambulatoire" name="SA" value="{{ old('SA') }}" />

                                            {!! $errors->first('SA', '<span class="error">:message</span>') !!}
                                        </div>
                                        <div class="form-group">
                                            <label>Hop.Plaf.Chambre</label>
                                            <input type="number" class="form-control" placeholder="Hopital Plafond Chambre" name="HPC" value="{{ old('HPC') }}" />

                                            {!! $errors->first('HPC', '<span class="error">:message</span>') !!}
                                        </div>

                                        <div class="form-group">
                                            <label>HPC/nuit</label>
                                            <input class="form-control" placeholder="Hopital Plafond Chambre/Nuit" name="HPCN" value="{{ old('HPCN') }}" />

                                            {!! $errors->first('HPCN', '<span class="error">:message</span>') !!}
                                        </div>

                                        <div class="form-group">
                                            <label>Maternité</label>
                                            <input type="number" class="form-control" placeholder="Maternité" name="Maternite" value="{{ old('Maternite') }}" />

                                            {!! $errors->first('Maternite', '<span class="error">:message</span>') !!}
                                        </div>

                                        <div class="form-group">
                                            <label>% Maternité</label>
                                            <input type="number" class="form-control" placeholder="Pourcentage Maternité" name="MaterniteP" value="{{ old('MaterniteP') }}" />

                                            {!! $errors->first('MaterniteP', '<span class="error">:message</span>') !!}
                                        </div>

                                        <div class="form-group">
                                            <label>Pharmacie</label>
                                            <input type="number" class="form-control" placeholder="Pharmacie" name="Pharmacie" value="{{ old('Pharmacie') }}" />

                                            {!! $errors->first('Pharmacie', '<span class="error">:message</span>') !!}
                                        </div>

                                        <div class="form-group">
                                    <label>Limites Medicaments</label>
                                            <input type="number" class="form-control" placeholder="Limites Medicaments" name="Medicament" value="{{ old('Medicament') }}" />

                                            {!! $errors->first('Medicament', '<span class="error">:message</span>') !!}
                                        </div>

                                        <div class="form-group">
                                    <label>Limites Lunettes( Verre + Monture)</label>
                                            <input type="number" class="form-control" placeholder="Limites Lunettes" name="Lunette" value="{{ old('Lunette') }}" />

                                            {!! $errors->first('Lunette', '<span class="error">:message</span>') !!}
                                        </div>

                                        <div class="form-group">
                                    <label>Limites dents</label>
                                            <input type="number" class="form-control" placeholder="Limites dents" name="dents" value="{{ old('dents') }}" />

                                            {!! $errors->first('dents', '<span class="error">:message</span>') !!}
                                        </div>
                                    </form>
                                    <br />                    
    </div>

                            </div>
                        </div>
                    </div>
                     <!-- End Form Elements -->
                </div>
            </div>
    </div>
             <!-- /. PAGE INNER  -->
            </div>
         <!-- /. PAGE WRAPPER  -->
@endsection