@isset($vars['claimData']->claimResponse)
    <div class="box-header ">
        <h3 class="box-title text-green pull-right">{{$vars['claimData']->claimResponse->TiraStatusCode}} <i
                    class="text-blue">{{$vars['claimData']->claimResponse->TiraStatusDesc}}</i></h3>
    </div>
@endisset
<form class="prevent-resubmit-form" id="create_claim_discharge_voucher_form" method="post" action="/discharge_vouchers"
      enctype="multipart/form-data">
    @csrf
    <div class="box-body">
        <input type="hidden" name="officer_id" value="{{auth()->user()->id}}">

        <input type="hidden" name="id" @isset($vars['claimData'])value="{{$vars['claimData']->id}}"@endisset >
        <input type="hidden" name="officer_id" value="{{auth()->user()->id}}">
        <div class="row">
            <div class="form-group col-md-4">
                <label for="license_plate">Discharge Voucher Number</label>
                <input type="text" class="form-control text-uppercase pull-right"
                       @isset($vars['claimData'])value="{{$vars['claimData']->discharge_voucher_number}}"
                       @endisset name="discharge_voucher_number" id="discharge_voucher_number"
                       placeholder="Discharge Voucher Number" required>
            </div>


            <div class="form-group  col-md-4">
                <label for="license_plate">Discharge Voucher Date</label>
                <div class="input-group">
                    <div class="input-group-prepend">
                        <span class="input-group-text"><i class="far fa-calendar-alt"></i></span>
                    </div>
                    <input type="datetime-local" class="form-control text-uppercase  pull-right"
                           @isset($vars['claimData']) value="{{\Carbon\Carbon::parse($vars['claimData']->discharge_voucher_date)->format('Y-m-d\TH:i')}}"
                           @endisset  name="discharge_voucher_date" id="discharge_voucher_date" required>
                </div>
                <!-- /.input group -->
            </div>

            <div class="form-group  col-md-4">
                <label for="license_plate">Claim Offer Communication Date</label>
                <div class="input-group">
                    <div class="input-group-prepend">
                        <span class="input-group-text"><i class="far fa-calendar-alt"></i></span>
                    </div>
                    <input type="datetime-local" class="form-control text-uppercase  pull-right"
                           @isset($vars['claimData']) value="{{\Carbon\Carbon::parse($vars['claimData']->claim_offer_communication_date)->format('Y-m-d\TH:i')}}"
                           @endisset name="claim_offer_communication_date" id="claim_offer_communication_date" required>
                </div>
                <!-- /.input group -->
            </div>

        </div>
        <div class="row">


            <div class="form-group col-md-4">
                <label for="license_plate">Claim Offer Amount</label>
                <div class="input-group">
                    <div class="input-group-prepend">
                        <span class="input-group-text"><i class="">Tsh</i></span>
                    </div>
                <input type="number" step="any" class="form-control text-uppercase pull-right"
                       @isset($vars['claimData'])value="{{$vars['claimData']->claim_offer_amount}}"
                       @endisset name="claim_offer_amount" id="claim_offer_amount" placeholder="Claim Offer Amount"
                       required>
                </div>
            </div>

            <div class="form-group col-md-4">
                <label for="license_plate">Claimant Response Date</label>
                <div class="input-group">
                    <div class="input-group-prepend">
                        <span class="input-group-text"><i class="far fa-calendar-alt"></i></span>
                    </div>
                    <input type="datetime-local" class="form-control text-uppercase  pull-right"
                           @isset($vars['claimData'])value="{{Carbon\Carbon::parse($vars['claimData']->claimant_response_date)->format('Y-m-d\TH:i')}}"
                           @endisset name="claimant_response_date" id="claimant_response_date" required>
                </div>
            </div>

            <div class="form-group col-md-4">
                <label for="license_plate">Claim Received Date</label>
                <div class="input-group">
                    <div class="input-group-prepend">
                        <span class="input-group-text"><i class="far fa-calendar-alt"></i></span>
                    </div>
                    <input type="datetime-local" class="form-control text-uppercase  pull-right"
                           @isset($vars['claimData']) value="{{Carbon\Carbon::parse($vars['claimData']->assessment_received_date)->format('Y-m-d\TH:i')}}"
                           @endisset name="assessment_received_date" id="assessment_received_date" required>
                </div>
            </div>
        </div>
        <div class="row">

            <div class="form-group col-md-4">
                <label for="license_plate">Adjustment Date </label>
                <div class="input-group">
                    <div class="input-group-prepend">
                        <span class="input-group-text"><i class="far fa-calendar-alt"></i></span>
                    </div>
                    <input type="datetime-local" class="form-control text-uppercase  pull-right"
                           @isset($vars['claimData']) value="{{Carbon\Carbon::parse($vars['claimData']->adjustment_date)->format('Y-m-d\TH:i')}}"
                           @endisset
                           name="adjustment_date" >
                </div>
            </div>

            <div class="form-group col-md-4">
                <label for="license_plate">Adjustment Amount</label>
                <div class="input-group">
                    <div class="input-group-prepend">
                        <span class="input-group-text"><i class="">Tsh</i></span>
                    </div>
                    <input type="number" step="any" class="form-control text-uppercase pull-right"
                           @isset($vars['claimData'])value="{{$vars['claimData']->adjustment_amount}}"
                           @endisset name="adjustment_amount" id="adjustment_amount" placeholder="Adjustment Amount"
                           required>
                </div>
            </div>


            <div class="form-group col-md-4">
                <label for="license_plate">Adjustment Reason</label>
                <input type="text" class="form-control text-uppercase pull-right"
                       @isset($vars['claimData'])value="{{$vars['claimData']->adjustment_reason}}"
                       @endisset name="adjustment_reason" id="adjustment_reason" placeholder="Adjustment Reason"
                       required>
            </div>

            <div class="form-group col-md-4">
                <label for="license_plate">Reconciled Date</label>
                <div class="input-group">
                    <div class="input-group-prepend">
                        <span class="input-group-text"><i class="far fa-calendar-alt"></i></span>
                    </div>
                    <input type="datetime-local" class="form-control text-uppercase  pull-right"
                           @isset($vars['claimData']) value="{{Carbon\Carbon::parse($vars['claimData']->reconciliation_date)->format('Y-m-d\TH:i')}}" @endisset
                            name="reconciliation_date" id="reconciliation_date">
                </div>
            </div>

            <div class="form-group col-md-4">
                <label for="license_plate">Reconciled Amount</label>
                <div class="input-group">
                    <div class="input-group-prepend">
                        <span class="input-group-text"><i class="">Tsh</i></span>
                    </div>
                    <input type="number" step="any" class="form-control text-uppercase pull-right"
                           @isset($vars['claimData'])value="{{$vars['claimData']->reconciled_amount}}"
                           @endisset name="reconciled_amount" id="reconciled_amount" placeholder="Reconciled Amount"
                           required>
                </div>
            </div>


            <div class="form-group col-md-4">
                <label for="license_plate">Reconciled Summary</label>
                <input type="text" class="form-control text-uppercase pull-right"
                       @isset($vars['claimData'])value="{{$vars['claimData']->reconciliation_summary}}"
                       @endisset name="reconciliation_summary" id="reconciliation_summary"
                       placeholder="Reconciled Summary" required>
            </div>


        </div>
    </div>
    <div class="modal-footer">
        @if(isset($vars['claimData']) && $vars['claimData']->status !== 'Success')
            <button type="submit" class="btn btn-primary "> Submit and Proceed</button>
        @endif
    </div>
</form>
<div class="policy_details_data">

</div>