Employee Mediclaim | Aarya Agriculture

{!! Form::open([ 'route' => 'employee-master.store-mediclaim', 'method' => 'POST', 'id' => 'employee-insurance-form', 'enctype' => 'multipart/form-data', ]) !!} @csrf {!! Form::hidden('id', $employee->id) !!}

Employee Code:

Name (As Per Aadhar Card):

Gender:

Date Of Birth:

{!! Form::label('personal_insurance', 'Do you have Personal Insurance?', ['class' => 'form-label fw-bold']) !!} *

{{ Form::radio('personal_insurance', 1, old('personal_insurance') == '1', [ 'class' => 'form-check-input', 'data-parsley-required' => true, 'data-parsley-required-message' => 'Please choose any one option.', 'data-parsley-errors-container' => '#personal_insurance_error', ]) }} Yes

{{ Form::radio('personal_insurance', 0, old('personal_insurance') == '0', [ 'class' => 'form-check-input', 'data-parsley-errors-container' => '#personal_insurance_error', ]) }} No

{!! Form::label('insurance_company', 'Insurance Company Name', ['class' => 'form-label fw-bold']) !!} * {!! Form::text('insurance_company', old('insurance_company'), [ 'class' => 'form-control', 'placeholder' => 'Enter Company Name', 'data-parsley-required' => true, 'data-parsley-required-message' => 'Please enter insurance company name.', 'data-parsley-errors-container' => '#insurance_company_error', ]) !!} {{ $errors->first('insurance_company') }}

{!! Form::label('policy_number', 'Policy Number', ['class' => 'form-label fw-bold']) !!} * {!! Form::text('policy_number', old('policy_number'), [ 'class' => 'form-control', 'placeholder' => 'Enter Policy Number', 'data-parsley-required' => true, 'data-parsley-required-message' => 'Please enter policy number.', 'data-parsley-errors-container' => '#policy_number_error', ]) !!} {{ $errors->first('policy_number') }}

{!! Form::label('sum_insured', 'Sum Insured (Other Policy)', ['class' => 'form-label fw-bold']) !!} * {!! Form::text('sum_insured', old('sum_insured'), [ 'class' => 'form-control', 'placeholder' => 'Enter Sum Insured', 'data-parsley-required' => true, 'data-parsley-required-message' => 'Please enter sum insured.', 'data-parsley-errors-container' => '#sum_insured_error', ]) !!} {{ $errors->first('sum_insured') }}

{!! Form::label('dependent_relation', 'Dependent', ['class' => 'form-label fw-bold']) !!} *

{{ Form::radio('dependent_relation', 'Husband', old('dependent_relation') == 'Husband', [ 'class' => 'form-check-input', 'data-parsley-required' => true, 'data-parsley-required-message' => 'Please choose any one dependent.', 'data-parsley-errors-container' => '#dependent_relation_error', ]) }} Husband

{{ Form::radio('dependent_relation', 'Wife', old('dependent_relation') == 'Wife', [ 'class' => 'form-check-input', 'data-parsley-errors-container' => '#dependent_relation_error', ]) }} Wife

{!! Form::label('dependent_name', 'Name', ['class' => 'form-label fw-bold']) !!} * {!! Form::text('dependent_name', old('dependent_name'), [ 'class' => 'form-control', 'placeholder' => 'Enter Dependent Name', 'data-parsley-required' => true, 'data-parsley-required-message' => 'Please enter dependent name.', 'data-parsley-errors-container' => '#dependent_name_error', ]) !!} {{ $errors->first('dependent_name') }}

{!! Form::label('dependent_date_of_birth', 'Date Of Birth', ['class' => 'form-label fw-bold']) !!} * {!! Form::text('dependent_date_of_birth', old('dependent_date_of_birth'), [ 'class' => 'form-control datepicker', 'placeholder' => 'Select Date Of Birth', 'data-parsley-required' => true, 'data-parsley-required-message' => 'Please select dependent date of birth.', 'data-parsley-errors-container' => '#dependent_date_of_birth_error', ]) !!} {{ $errors->first('dependent_date_of_birth') }}

Children Details

@if (old('child_name')) @foreach (old('child_name') as $i => $childName)

@endforeach @else {{-- Default first child row --}}

{!! Form::text('child_name[]', null, [ 'class' => 'form-control child-field', 'placeholder' => 'Child Name', 'data-parsley-required' => true, 'data-parsley-required-message' => 'Please enter child name.', 'data-parsley-errors-container' => '#child_name_0_error', ]) !!}

{!! Form::select('child_gender[]', ['' => 'Select Gender', 'Male' => 'Male', 'Female' => 'Female'], null, [ 'class' => 'form-control child-field', 'data-parsley-required' => true, 'data-parsley-required-message' => 'Please select child gender.', 'data-parsley-errors-container' => '#child_gender_0_error', ]) !!}

{!! Form::text('child_dob[]', null, [ 'class' => 'form-control datepicker child-field', 'placeholder' => 'Select Date Of Birth', 'data-parsley-required' => true, 'data-parsley-required-message' => 'Please select child date of birth.', 'data-parsley-errors-container' => '#child_dob_0_error', ]) !!}

@endif

Notes:

Insurance coverage will be covered for Employee, Spouse and 2 children only.
For team members having CTC up to Rs. 8 Lacs, premium will be paid by the company.
For team members having CTC above Rs. 8 Lacs, premium will be shared equally between company and employees.
You are eligible for the benefits of the company's mediclaim policy from your date of joining.
Participation in the company's mediclaim policy is optional only if you already have an equivalent personal mediclaim policy. In such a case, you are required to submit a copy of your existing policy for our records.
If you do not provide proof of personal mediclaim policy, enrollment in the company's mediclaim policy will be mandatory.

{!! Form::close() !!}