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claim.php
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claim.php
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<?php include('header.php'); ?>
<body>
<link rel="stylesheet" type="text/css" href="css/claim.css">
<script src="js/newform.js"></script>
<div class="container">
<img src="images/claimbg.jpg" alt="" style="width:100%">
<button class="open-button" onclick="openForm()">Claim Here</button> <!--claim button-->
<div class="centered">
<h2>Was the vehicle involved in accident?
Is the agent late?</h2><br>
<h4>No need to worry about that anymore.
YSN Insurance has introduced the latest
claim method <br>to our valuble customers.</h4><br>
<h4>Personal Accident Cover</h4><br>
<h3>This secures your family's future in the event of a permanent disablement or in the unfortunate circumstance of your death. You can get coverage of up to 2 lakhs for any damage caused to the driver while travelling, mounting, or dismounting from the car. Some insurers also offer optional accidental covers for co-passengers.</h3><br>
<h4>Third Party Legal Liability</h4><br>
<h3>Mandatory by law, this cover protects you against the legal liability of accidental damages that have resulted in permanent injury or death of a third party. It also covers damage caused to any surrounding property.</h4>
</div>
</div>
<div class="form-popup" id="myForm">
<form action="insert.php" method="POST" enctype="multipart/form-data" class="form-container">
<h2>Claim Form</h2><br>
<label for="insurancenumber"><b>Insurance Number</b></label>
<input type="text" placeholder="Enter Insurance Number" name="insurancenumber" pattern="[y][s][n][0-9]{7}" required>
<label for="contacnumber"><b>Contact Number</b></label>
<input type="text" placeholder="Contac Number" name="contactnumber" pattern="[0][0-9]{9}"required>
<label for="location"><b>Location</b></label>
<input type="text" placeholder="Location" name="location" required>
<label for="description"><b>Description</b></label>
<input type="text" placeholder="Description" name="description" required>
<label for="uploadphoto"><b>Upload Photo</b></label><br><br>
<input type="file" name="photo" required><br><br>
<button type="submit" name="insert" class="btn">Submit</button>
<button type="button" class="btn cancel" onclick="closeForm()">Cancel</button>
</form>
</div>
</body>
<!-- Footer -->
<?php include('footer.php'); ?>