{config_load file="$path_language/$access.html" section="request_form"}
<script language="JavaScript" src="{$dir_ws_js}sendform.js"></script>

<script language="JavaScript" type="text/javascript">
	function submit_button(form_name)
	{ldelim}	
		var form=document.insurance_claimForm;
		var error_arr=new Array();
		
		var fullname_empty=validate("customer", "customer_error", "customer_style");
		var country_empty=validate("country_id", "country_error", "country_style");
		var tel_work_empty=validate("tel_work", "tel_work_error", "tel_work_style");
		var email_empty=validate("email", "email_error", "email_style");
		var declaration_of_insured_items_empty=validate("declaration_of_insured_items", "declaration_of_insured_items_error", "declaration_of_insured_items_style");
		var value_insured_empty=validate("value_insured", "value_insured_error", "value_insured_style");
		
		
		if (fullname_empty!=true)
		{ldelim}
			error_arr=error_arr.concat(fullname_empty);
		{rdelim}//end if
		
		if (country_empty!=true)
		{ldelim}
			error_arr=error_arr.concat(country_empty);
		{rdelim}//end if
		
		if (tel_work_empty!=true)
		{ldelim}
			error_arr=error_arr.concat(tel_work_empty);
		{rdelim}else{ldelim}
			var tel_work_invalid=validate_phone("tel_work", "tel_work_invalid", "tel_work_style");
			if (tel_work_invalid!=true)
			{ldelim}
				error_arr=error_arr.concat(tel_work_invalid);
			{rdelim}//end if
		{rdelim}//end if
		
		if (form.tel_home.value!="")
		{ldelim}
			var tel_home_invalid=validate_phone("tel_home", "tel_home_invalid", "tel_home_style");
			if (tel_home_invalid!=true)
			{ldelim}
				error_arr=error_arr.concat(tel_home_invalid);
			{rdelim}//end if
		{rdelim}//end if
		else
		{ldelim}
			document.getElementById("tel_home_style").style.color = '#333333';
			document.getElementById("tel_home").style.background = '#FFFFFF';
		{rdelim}//end if
		
		
		if (form.mobile.value!="")
		{ldelim}
			var mobile_invalid=validate_phone("mobile", "mobile_invalid", "mobile_style");
			if (mobile_invalid!=true)
			{ldelim}
				error_arr=error_arr.concat(mobile_invalid);
			{rdelim}//end if
		{rdelim}//end if
		else
		{ldelim}
			document.getElementById("mobile_style").style.color = '#333333';
			document.getElementById("mobile").style.background = '#FFFFFF';
		{rdelim}//end if
		
		if (email_empty!=true)
		{ldelim}
			error_arr=error_arr.concat(email_empty);
		{rdelim}else{ldelim}
			var email_invalid=validate_email("email", "email_invalid", "email_style");
			if (email_invalid!=true)
			{ldelim}
				error_arr=error_arr.concat(email_invalid);
			{rdelim}//end if
		{rdelim}//end if
		
		if (declaration_of_insured_items_empty!=true)
		{ldelim}
			error_arr=error_arr.concat(declaration_of_insured_items_empty);
		{rdelim}//end if
		
		if (value_insured_empty!=true)
		{ldelim}
			error_arr=error_arr.concat(value_insured_empty);
		{rdelim}//end if
		
		if (error_arr.length>0)
		{ldelim}
			show_erros(error_arr, '{#lbl_warning#}', '90%', '{$dir_ws_theme}');
		{rdelim}else{ldelim}
			submit_action_form(form_name);
		{rdelim}//end if
	{rdelim}
</script>
<table width="780" border="0" cellspacing="0" cellpadding="0">
  <tr>
    <td width="210" valign="top" align="right">
	<table width="100%" border="0" cellspacing="0" cellpadding="0">
	  <tr>
		<td align="right" class="title_left">{$request_from}</td>
	  </tr>
	  <tr>
		<td align="right" class="title_request_form">{$form_name}</td>
	  </tr>
	</table>
	</td>
    <td width="1" valign="top" class="bg_grey2"><img src="{$dir_ws_theme}images/trans.gif" width="1" height="1"></td>
    <td valign="top" class="space10px_left">
	 <table width="90%" border="0" align="center" cellpadding="0" cellspacing="0" bgcolor="#F2F2F2">
        <tr>
          <td width="10" height="10"><img src="{$dir_ws_theme}images/box1.gif" width="10" height="11"></td>
          <td height="10" background="{$dir_ws_theme}images/box2.gif"><img src="{$dir_ws_theme}images/trans.gif" width="1" height="1"></td>
          <td width="10" height="10"><img src="{$dir_ws_theme}images/box3.gif" width="10" height="11"></td>
        </tr>
        <tr>
          <td width="10" background="{$dir_ws_theme}images/box4.gif"><img src="{$dir_ws_theme}images/trans.gif" width="1" height="1"></td>
          <td>
		  <div id="errors"></div>
		  <form name="insurance_claimForm" id="insurance_claimForm" method="post" action="?module=request.form&form=insurance.claim" enctype="multipart/form-data">
		  <table width="70%" border="0" align="center" cellpadding="0" cellspacing="1">
	  <tr>
        <td align="right"  class="bold">{#lbl_required#}</td>
      </tr>
	  <tr>
		<td><table width="100%" border="0" cellspacing="0" cellpadding="0">
          <tr>
            <td width="60%" id="customer_style">
			{#lbl_your_name#} <span class="required">*</span><br />
			<input name="customer" type="text" class="inputbox" id="customer" value="{$customer.customer}" size="20">
            <input name="customer_error" type="hidden" id="customer_error" value="{#str_fullname_empty#}">			</td>
            <td id="country_style">{#lbl_country#} <span class="required">*</span><br />
			{$country}
          <input name="country_error" type="hidden" id="country_error" value="{#str_country_empty#}">			</td>
          </tr>
        </table></td>
	  </tr>
	  <tr>
	    <td id="company_style">{#lbl_company#} <br />
		<input name="company" type="text" id="company" size="88" class="inputbox">
          <input name="company_error" type="hidden" id="company_error" value="{#str_company_empty#}">		</td>
	    </tr>
	  <tr>
	    <td>{#lbl_address#}<br />
		<input name="address" type="text" id="address" size="88" class="inputbox">		</td>
	    </tr>
	  <tr>
	    <td><input name="address2" type="text" id="address2" size="88" class="inputbox"></td>
	    </tr>
	  <tr>
	    <td><table width="100%" border="0" cellspacing="0" cellpadding="0">
          <tr>
            <td width="34%" valign="bottom" id="tel_work_style">{#lbl_tel_work#} <span class="required">*</span><br />
			<input name="tel_work" type="text" id="tel_work" size="20" class="inputbox">
            <input name="tel_work_error" type="hidden" id="tel_work_error" value="{#str_tel_work_empty#}">
            <input name="tel_work_invalid" type="hidden" id="tel_work_invalid" value="{#str_tel_work_invalid#}">			</td>
            <td width="34%" valign="bottom" id="tel_home_style">{#lbl_tel_home#}<br />
			<input name="tel_home" type="text" id="tel_home" size="20" class="inputbox">
			<input name="tel_home_invalid" type="hidden" id="tel_home_invalid" value="{#str_tel_home_invalid#}">			</td>
			<td valign="bottom" id="mobile_style">{#lbl_mobile#}<br />
			<input name="mobile" type="text" id="mobile" size="25" class="inputbox">
			<input name="mobile_invalid" type="hidden" id="mobile_invalid" value="{#str_mobile_invalid#}">			</td>
          </tr>
        </table></td>
	    </tr>
	  <tr>
	    <td><table width="100%" border="0" cellspacing="0" cellpadding="0">
          <tr>
            <td width="40%" valign="bottom">{#lbl_vat#}<br />
              <input name="vat" type="text" id="vat" size="20" class="inputbox"></td>
            <td valign="bottom" id="email_style">{#lbl_email#} <span class="required">*</span><br />
              <input name="email" type="text" class="inputbox" id="email" size="52">
              <input name="email_error" type="hidden" id="email_error" value="{#str_email_empty#}">
              <input name="email_invalid" type="hidden" id="email_invalid" value="{#str_email_invalid#}"></td>
          </tr>
        </table></td>
	    </tr>
	  <tr>
	    <td><table width="100%" border="0" cellspacing="0" cellpadding="0">
          <tr>
            <td width="50%" valign="top"><table width="100%" border="0" cellspacing="0" cellpadding="0">
              <tr>
                <td id="declaration_of_insured_items_style">{#lbl_declaration_of_insured_items#} <span class="required">*</span><br><input type="file" name="declaration_of_insured_items" id="declaration_of_insured_items" style="width:250" /><br />

				  <span style="color:#000000; height:30px;">(.pdf, .doc, .txt,  .xls, .zip, .rar)</span>
                  <input name="declaration_of_insured_items_error" type="hidden" id="declaration_of_insured_items_error" value="{#str_declaration_of_insured_items_empty#}"></td>
              </tr>
			
			  <!-- <tr>
				<td align="left" valign="top" style="font-weight:bold; padding-right:5px">{#lbl_file#}</td>
				<td><input type="file" name="attach" style="width:300" /><br />

				  <span style="color:#000000; height:30px;">(.pdf, .doc, .txt,  .xls, .zip, .rar)</span></td>
			  </tr>-->
			  
              <tr>
                <td id="value_insured_style">{#lbl_value_insured#} <span class="required">*</span><br>
                  <input name="value_insured" type="text" id="value_insured" size="35" class="inputbox">
                  <input name="value_insured_error" type="hidden" id="value_insured_error" value="{#str_value_insured_empty#}"></td>
              </tr>
            </table></td>
            <td valign="bottom" class="space10px_left">{#lbl_other_infomation#}<br>
              <textarea name="other_infomation" style="width:208" rows="4" wrap="virtual" id="other_infomation" class="textarea"></textarea></td>
          </tr>
        </table></td>
	  </tr>
	  <tr>
	    <td align="center"><br /><br /><input type="button" name="send" value="{#lbl_send#}" class="button" onClick="submit_button('insurance_claimForm');" /> <input type="reset" name="Reset" value="{#lbl_reset#}" class="button" />
	      <input name="action" type="hidden" id="action" value="save"></td>
	    </tr>
	</table>
		  </form>
		  </td>
          <td width="10" background="{$dir_ws_theme}images/box5.gif"><img src="./images/trans.gif" width="1" height="1"></td>
        </tr>
        <tr>
          <td width="10" height="10"><img src="{$dir_ws_theme}images/box6.gif" width="10" height="10"></td>
          <td height="10" background="{$dir_ws_theme}images/box7.gif"><img src="./images/trans.gif" width="1" height="1"></td>
          <td width="10" height="10"><img src="{$dir_ws_theme}images/box8.gif" width="10" height="10"></td>
        </tr>
</table>
	</td>
  </tr>
</table>