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<?php session_start();?>
<?php ob_start();?>
<?php
if($_SESSION["granted"] != "granted")
{
$_SESSION["unauthorised"] = "Unauthorized Access, Please log in";
header("Location:dealer_login.php");
exit;
}
?>
<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<title></title>
<script type="text/javascript" src="datepickercontrol.js"></script>
<link type="text/css" rel="stylesheet" href="datepickercontrol.css">
<link href="styles.css" rel="stylesheet" type="text/css">
</head>
<body>
<!-- Change default Date Picker to English -->
<input type="hidden" id="DPC_TODAY_TEXT" value="today">
<input type="hidden" id="DPC_BUTTON_TITLE" value="Open calendar...">
<input type="hidden" id="DPC_MONTH_NAMES" value="['January', 'February', 'March', 'April', 'May', 'June', 'July', 'August', 'September', 'October', 'November', 'December']">
<input type="hidden" id="DPC_DAY_NAMES" value="['Sun', 'Mon', 'Tue', 'Wed', 'Thu', 'Fri', 'Sat']">
<input type="hidden" id="DPC_DEFAULT_FORMAT" value="YYYY-MM-DD">
<form method="post" action="policy_app_proc.php">
<div id="form">
<div id="toperror"><?php print"<font color='#FF0000'><b>{$_SESSION['Imei_unique_error']}</b></font>";?></div>
<div id="logo">
<img src="images/24hr.jpg"/>
</div>
<div id="top_text">
Insurer: Constantia Insurance Company Ltd * Reg. No. 1952/001514/06 * VAT No. 4920108935 * FSP No. 31111<br>
Broker: Pinnacle Marketing (Pty) Ltd * Reg No. 1997/007463/07 * VAT No. 4760167744 * FSP No. 15017<br>
Underwriting Manager: Administration Plus (Pty) Ltd * Reg. No. 2004/023852/07 * Vat No. 4190243008 * FSP No. 36841
</div>
<div id="policy_number">
POLICY NUMBER <input type="text" name="PolicyNumber" style="color: <?php print $TextColour;?>" value="<?php print $_SESSION['PolicyNumber'] ;?>" id="PolicyNumber" style="border:0;" readonly />
</div>
<?php
$_SESSION['AppDate'] = date("Y-m-d H:m:s");
$_SESSION['InceptionDate'] = date("Y-m-d");
//check If error sessions are set then change background colour of text
//Consultant info and dealer code
if($_SESSION['ConsultantName_error'] == "*")
$ConsultantName_error = "#FF0000";
if($_SESSION['ConsultantSurname_error'] == "*")
$ConsultantSurname_error = "#FF0000";
//Contract holder details
if($_SESSION['AppType_error'] == "*")
$ApplicationType_error = "#FF0000";
if($_SESSION['ContractID_error'] == "*")
$ContractID_error = "#FF0000";
if($_SESSION['ContractHolder_error'] == "*")
$ContractHolder_error = "#FF0000";
if($_SESSION['ContractSurname_error'] == "*")
$ContractSurname_error = "#FF0000";
//User details
if($_SESSION['UserName_error'] == "*")
$UserName_error = "#FF0000";
if($_SESSION['UserSurname_error'] == "*")
$UserSurname_error = "#FF0000";
if($_SESSION['Postal1_error'] == "*")
$Postal1_error = "#FF0000";
if($_SESSION['Tel_error'] == "*")
$Tel_error = "#FF0000";
if($_SESSION['Postal2_error'] == "*")
$Postal2_error = "#FF0000";
if($_SESSION['Fax_error'] == "*")
$Fax_error = "#FF0000";
if($_SESSION['PostalCode_error'] == "*")
$PostalCode_error = "#FF0000";
if($_SESSION['UserID_error'] == "*")
$UserID_error = "#FF0000";
if($_SESSION['email_error'] == "*")
$Email_error = "#FF0000";
//Device details
if($_SESSION['Imei_error'] == "*")
$Imei_error = "#FF0000";
if($_SESSION['Make_error'] == "*")
$Make_error = "#FF0000";
if($_SESSION['CellNumber1_error'] == "*")
$CellNumber1_error = "#FF0000";
if($_SESSION['Model_error'] == "*")
$Model_error = "#FF0000";
if($_SESSION['CellNumber2_error'] == "*")
$CellNumber2_error = "#FF0000";
//Debit details
if($_SESSION['AccountHolder_error'] == "*")
$AccountHolder_error = "#FF0000";
if($_SESSION['BankSurname_error'] == "*")
$BankSurname_error = "#FF0000";
if($_SESSION['Bank_error'] == "*")
$Bank_error = "#FF0000";
if($_SESSION['AccountNumber_error'] == "*")
$AccountNumber_error = "#FF0000";
if($_SESSION['AccountType_error'] == "*")
$AccountType_error = "#FF0000";
if($_SESSION['DebitDate_error'] == "*")
$DebitDate_error = "#FF0000";
if($_SESSION['PayDate_error'] == "*")
$PayDate_error = "#FF0000";
if($_SESSION['BranchName_error'] == "*")
$BranchName_error = "#FF0000";
if($_SESSION['BranchCode_error'] == "*")
$BranchCode_error = "#FF0000";
//Device value and simsure
if($_SESSION['DeviceValue_error'] == "*")
$DeviceValue_error = "#FF0000";
if($_SESSION['Simsure_error'] == "*")
$Simsure_error = "#FF0000";
$TextColour = "#000000";
?>
<table>
<tr>
<td>
<div class="bar">
THIS SCHEDULE BECOMES A TAX INVOICE WHEN THE AMOUNT REQUESTED HAS BEEN PAID
</div>
</td>
</tr>
</table>
<table>
<tr>
<td class="title">Dealer Code</td>
<td><input name="DealerCode" type="text" id="DealerCode" style="color: <?php print $TextColour;?>" value="<?php print $_SESSION['DealerCode'];?>" size="6" readonly/></td>
<td class="title"><p style="background-color: <?php print $ConsultantName_error;?>">Consultants Name</td>
<td><input name="ConsultantName" type="text" id="ConsultantName" tabindex=1 style="color: <?php print $TextColour;?>" value="<?php print $_SESSION['ConsultantName'] ;?>" size="15"/></td>
<td class="title"><p style="background-color: <?php print $ConsultantSurname_error;?>">Consultants Surname</td>
<td><input name="ConsultantSurname" type="text" id="ConsultantSurname" tabindex=2 style="color: <?php print $TextColour;?>" value="<?php print $_SESSION['ConsultantSurname'] ;?>" size="16"/></td>
</tr>
</table>
<table>
<tr>
<td>
<div class="bar">
DETAILS OF CONTRACT HOLDER
</div>
</td>
</tr>
<table>
<table>
<tr>
<td class="title"><p style="background-color: <?php print $ApplicationType_error;?>">Application Type</td>
<td><select name="ApplicationType" style="color: <?php print $TextColour;?>" id="ApplicationType" tabindex=3>
<option><?php print $_SESSION['ApplicationType'] ;?></option>
<option>INDIVIDUAL</option>
<option>COMPANY</option>
</select></td>
<td class="title"><p style="background-color: <?php print $ContractID_error;?>">ID No./Co. Reg. No.</td>
<td><input name="Contract_IDNumber" type="text" id="Contract_IDNumber" tabindex=4 style="color: <?php print $TextColour;?>" value="<?php print $_SESSION['Contract_IDNumber'] ;?>" size="33"/></td>
</tr>
<tr>
<td class="title"><p style="background-color: <?php print $ContractHolder_error;?>">Name or Co. Name</td>
<td><input name="ContractHolder" type="text" id="ContractHolder" tabindex=5 style="color: <?php print $TextColour;?>" value="<?php print $_SESSION['ContractHolder'] ;?>" size="36"/></td>
<td class="title"><p style="background-color: <?php print $ContractSurname_error;?>">Surname</td>
<td><input name="ContractSurname" type="text" id="ContractSurname" tabindex=6 style="color: <?php print $TextColour;?>" value="<?php print $_SESSION['ContractSurname'] ;?>" size="33" /></td>
</tr>
</table>
<table>
<tr>
<td>
<div class="bar">
NAME, IDENTITY NUMBER AND CONTACT DETAILS OF USER
</div>
</td>
</tr>
</table>
<table>
<tr>
<td class="title"><p style="background-color: <?php print $UserName_error;?>">Name</td>
<td><input name="UserName" type="text" id="UserName" tabindex=7 style="color: <?php print $TextColour;?>" value="<?php print $_SESSION['UserName'] ;?>" size="36"/></td>
<td class="title"><p style="background-color: <?php print $UserSurname_error;?>">Surname</td>
<td><input name="UserSurname" type="text" id="UserSurname" tabindex=8 style="color: <?php print $TextColour;?>" value="<?php print $_SESSION['UserSurname'] ;?>" size="33" /></td>
</tr>
<tr>
<td class="title"><p style="background-color: <?php print $Postal1_error;?>">Postal Address Line 1</td>
<td><input name="Postal1" type="text" id="Postal1" tabindex=9 style="color: <?php print $TextColour;?>" value="<?php print $_SESSION['Postal1'] ;?>" size="36"/></td>
<td class="title"><p style="background-color: <?php print $Tel_error;?>">Telephone Number</td>
<td><input name="User_Telephone" type="text" id="User_Telephone" tabindex=10 style="color: <?php print $TextColour;?>" value="<?php print $_SESSION['User_Telephone'] ;?>" size="33"/></td>
</tr>
<tr>
<td class="title"><p style="background-color: <?php print $Postal2_error;?>">Postal Address Line 2</td>
<td><input name="Postal2" type="text" id="Postal2" tabindex=11 style="color: <?php print $TextColour;?>" value="<?php print $_SESSION['Postal2'] ;?>" size="36"/></td>
<td class="title"><p style="background-color: <?php print $Fax_error;?>">Fax Number</td>
<td><input name="User_Fax" type="text" id="User_Fax" tabindex=12 style="color: <?php print $TextColour;?>" value="<?php print $_SESSION['User_Fax'] ;?>" size="33"/></td>
</tr>
<tr>
<td class="title"><p style="background-color: <?php print $PostalCode_error;?>">Postal Code</td>
<td><input name="PostalCode" type="text" id="PostalCode" tabindex=13 style="color: <?php print $TextColour;?>" value="<?php print $_SESSION['PostalCode'] ;?>" size="36"/></td>
<td class="title"><p style="background-color: <?php print $UserID_error;?>">Identity Number</td>
<td><input name="User_IDNumber" type="text" id="User_IDNumber" tabindex=14 style="color: <?php print $TextColour;?>" value="<?php print $_SESSION['User_IDNumber'] ;?>" size="33"/></td>
</tr>
</table>
<table>
<tr>
<td class="title"><p style="background-color: <?php print $Email_error;?>">Email</td>
<td><input name="User_Email" type="text" id="User_Email" tabindex=15 style="color: <?php print $TextColour;?>" value="<?php print $_SESSION['User_Email'] ;?>" size="100"/></td>
</tr>
</table>
<table>
<tr>
<td>
<div id="bar">
DETAILS OF HANDSET OR MOBILE DEVICE TO BE INSURED
</div>
</td>
</tr>
</table>
<table>
<tr>
<td class="title"><p style="background-color: <?php print $Imei_error;?>">IMEI Number</td>
<td><input name="Imei" type="text" id="Imei"
.title {
width: 150; height: 20px;
border-style: solid;
border-width: 1px;
border-color: #000000;
background-color: #FFC800;
color: #FFFFFF;
font-size: 13px;
text-align: center;
font-family: calibri;
font-weight: bold;
position:relative;
float:left;
}
.titleclear {
width: 150; height: 20px;
border-style: solid;
border-width: 1px;
border-color: #000000;
background-color: #FFFFFF;
color: #000000;
font-size: 12px;
text-align: center;
font-family: calibri;
font-weight: bold;
position:relative;
float:left;
}
.titlesmall {
width: 70; height: 20px;
border-style: solid;
border-width: 1px;
border-color: #000000;
background-color: #FFB500;
color: #FFFFFF;
font-size: 12px;
text-align: center;
font-family: calibri;
font-weight: bold;
position:relative;
float:left;
}
.test{
border-style: solid;
border-width: 1px;
border-color: #000000;
}
.clear {
position: relative;
clear: both;
}
.formTable {
}
.body {
text-align: center;
margin: 0 auto;
}
#form {
width: 900px;
position: relative;
margin: 0 auto;
text-align: left;
background-color: white;
border-style: none;
border-width: 1px;
}
#logo{
text-align: center;
padding-bottom: 5px;
padding-right: 80px;
}
#top_text{
width: 510px; height: 40px;
border-style: none;
border-width: 1px;
border-color: #000000;
background-color: #FFFFFF;
color: #000000;
font-size: 10px;
text-align: left;
font-family: calibri;
font-weight: bold;
position:relative;
float:left;
}
#policy_number{
color: #000000;
font-size: 18px;
font-family: calibri;
font-weight: bold;
}
#bar, .bar {
width: 804px; height: 20px;
border-style: solid;
border-width: 1px;
border-color: #000000;
background-color: #FFB500;
color: #000000;
font-size: 18px;
text-align: center;
font-family: calibri;
font-weight: bold;
position:relative;
float:left;
}
#clear_bar{
width: 804px; height: 20px;
border-style: solid;
border-width: 1px;
border-color: #000000;
background-color: #FFFFFF;
color: #000000;
font-size: 18px;
text-align: center;
font-family: calibri;
font-weight: bold;
position:relative;
float:left;
}
#left_block{
width: 150; height: 20px;
border-style: solid;
border-width: 1px;
border-color: #000000;
background-color: #8BCAD7;
color: #FFFFFF;
font-size: 12px;
text-align: center;
font-family: calibri;
font-weight: bold;
position:relative;
float:left;
}
#left_block_singular{
width: 150; height: 20px;
border-style: solid;
border-width: 1px;
border-color: #000000;
background-color: #FFFFFF;
color: #000000;
font-size: 12px;
text-align: left;
font-family: calibri;
font-weight: bold;
position:relative;
float:left;
}
#left_block_bigger{
width: 150; height: 42px;
border-style: solid;
border-width: 1px;
border-color: #000000;
background-color: #8BCAD7;
color: #FFFFFF;
font-size: 12px;
text-align: center;
font-family: calibri;
font-weight: bold;
position:relative;
float:left;
}
#text_field{
position:relative;
float:left;
}
#text_field_left{
position:relative;
float:left;
padding-right: 37px
}
#drop_down_left{
position:relative;
float:left;
padding-right: 127px
}
#drop_down_right{
position:relative;
float:left;
height: 22; width: 200;
padding-right: 5px
}
#text_block{
width: 804px; height: 120px;
border-style: solid;
border-width: 1px;
border-color: #000000;
background-color: #FFFFFF;
color: #000000;
font-size: 10px;
text-align: left;
font-family: calibri;
position:relative;
float:left;
}
#text_field_singular{
position:relative;
float:left;
padding-right: 500px
}
#bottom_text{
width: 481px; height: 210px;
border-style: none;
border-width: 1px;
border-color: #000000;
background-color: #FFFFFF;
color: #000000;
font-size: 10px;
font-family: calibri;
text-align: justify;
position:relative;
float:left;
}
#pinnacle{
position:relative;
float:left;
border-style: none;
border-width: 1px;
border-color: #000000;
}
#submit_block{
width: 175px; height: 100px;
border-style: solid;
border-width: 1px;
border-color: #000000;
background-color: #FFFFFF;
color: #000000;
position:relative;
float:left;
text-align: center;
}
#current_date{
width: 175px; height: 22px;
border-style: solid;
border-width: 1px;
border-color: #000000;
background-color: #FFFFFF;
color: #000000;
position:relative;
float:left;
text-align: center;
}
#bar_right{
width: 175px; height: 22px;
border-style: solid;
border-width: 1px;
border-color: #000000;
background-color: #FFB500;
color: #000000;
font-size: 18px;
text-align: center;
font-family: calibri;
font-weight: bold;
position:relative;
float:left;
}
#btm_rght_text_box{
width: 175px; height: 75px;
border-style: solid;
border-width: 1px;
border-color: #000000;
background-color: #FFFFFF;
color: #000000;
font-size: 14px;
font-family: calibri;
font-weight: bold;
text-align: center;
position:relative;
float:left;
}