<!DOCTYPE html>
<html>

<head>
    <meta charset="utf-8" />
    <title>Claim Print | Funeral Cover Application</title>
    <style>
        body {
            font-family: Arial, sans-serif;
            font-size: 12px;
            color: #333;
            line-height: 1.5;
            margin: 0;
            padding: 0;
            background-color: #f8f8f8;
        }

        .container {
            max-width: 800px;
            margin: auto;
            padding: 20px;
            border: 1px solid #ddd;
            box-shadow: 0px 0px 10px rgba(0, 0, 0, 0.1);
            background: #fff;
        }

        .header {
            text-align: center;
            margin-bottom: 20px;
        }

        .header img {
            width: 120px;
            margin-bottom: 10px;
        }

        .header h3 {
            font-size: 14px;
            margin: 0;
            color: #333;
        }

        .header p {
            font-size: 10px;
            color: #666;
        }

        table {
            width: 100%;
            border-collapse: collapse;
            margin-bottom: 15px;
        }

        th, td {
            padding: 8px;
            border: 1px solid #ddd;
            text-align: left;
            font-size: 11px;
        }

        th {
            background: #f2f2f2;
            font-weight: bold;
        }

        .section-title {
            font-size: 12px;
            font-weight: bold;
            padding: 6px;
            background-color: #f2f2f2;
            border-left: 3px solid #007bff;
            margin-top: 10px;
        }

        .footer {
            text-align: center;
            font-size: 10px;
            color: #777;
            margin-top: 10px;
        }

        .declaration {
            border: 1px solid #ddd;
            padding: 10px;
            margin-top: 20px;
            font-size: 11px;
        }

        .declaration-title {
            background: #007bff;
            color: white;
            padding: 5px;
            font-weight: bold;
            text-align: left;
        }

        .signature-box {
            margin-top: 10px;
            padding: 10px;
            border: 1px solid #ddd;
            font-size: 12px;
        }

        @media print {
            body { background: none; }
            .container { box-shadow: none; border: none; }
            .btn-print { display: none; }
        }
    </style>
</head>

<body>
    <div class="container">

    
    <div class="header">
        <img src="<?php echo e(asset('admin/assets/img/logos/logo-new.png')); ?>"
             alt="Mbabane Burial Society Logo">

        <h3>FUNERAL CLAIM FORM</h3>

        <p>
            515 Siteshi Rd, Industrial Site | P.O. Box 477, Mbabane<br>
            Tel: +268 2404 2888 / 2404 3011 | Email: info@mbbs.co.sz
        </p>

        <p>
            <strong>Claim Reference:</strong> <?php echo e($claim->reference_number); ?> |
            <strong>Date Generated:</strong> <?php echo e(now()->format('d M Y')); ?>

        </p>
    </div>

    
    <div class="section-title">A. POLICY HOLDER DETAILS</div>
    <table>
        <tr><th>Policy Holder Name</th><td><?php echo e($member->name); ?> <?php echo e($member->surname); ?></td></tr>
        <tr><th>National ID</th><td><?php echo e($member->national_id); ?></td></tr>
        <tr><th>Date of Birth</th><td><?php echo e($member->date_of_birth); ?></td></tr>
        <tr><th>Gender</th><td><?php echo e($member->gender); ?></td></tr>
        <tr><th>Nationality</th><td><?php echo e($member->nationality); ?></td></tr>
        <tr><th>Residential Address</th><td><?php echo e($member->residential_address); ?></td></tr>
        <tr><th>Contact Number</th><td><?php echo e($member->code); ?> <?php echo e($member->cell_number); ?></td></tr>
    </table>

    
    <div class="section-title">B. DECEASED DETAILS</div>
    <table>
        <tr><th>Full Name</th><td><?php echo e($claim->deceased_full_name); ?></td></tr>
        <tr><th>National ID</th><td><?php echo e($claim->deceased_national_id); ?></td></tr>
        <tr><th>Gender</th><td><?php echo e($claim->deceased_gender); ?></td></tr>
        <tr><th>Date of Birth</th><td><?php echo e($claim->deceased_date_of_birth); ?></td></tr>
        <tr><th>Deceased Category</th><td><?php echo e($claim->deceased_type); ?></td></tr>
    </table>

    
    <div class="section-title">C. CLAIM DETAILS</div>
    <table>
        <tr><th>Date of Death</th><td><?php echo e($claim->date_of_death); ?></td></tr>
        <tr><th>Cause of Death</th><td><?php echo e($claim->cause_of_death); ?></td></tr>
        <tr><th>Relationship to Policy Holder</th><td><?php echo e($claim->relationship_to_policyholder); ?></td></tr>
        <tr><th>Claim Status</th><td><?php echo e($claim->claim_status); ?></td></tr>

        <tr>
            <th>Amount Claimed</th>
            <td>
                <?php if($claim->amount_claimed): ?>
                    <?php echo e(number_format($claim->amount_claimed, 2)); ?>

                <?php else: ?>
                    Not yet determined
                <?php endif; ?>
            </td>
        </tr>

        <tr><th>Remarks</th><td><?php echo e($claim->remarks ?? 'N/A'); ?></td></tr>
    </table>

    
    <div class="section-title">D. CLAIMANT DETAILS</div>
    <table>
        <tr><th>Full Name</th><td><?php echo e($claim->claimant_full_name); ?></td></tr>
        <tr><th>National ID</th><td><?php echo e($claim->claimant_national_id ?? 'N/A'); ?></td></tr>
        <tr><th>Phone Number</th><td><?php echo e($claim->claimant_phone ?? 'N/A'); ?></td></tr>
        <tr><th>Address</th><td><?php echo e($claim->claimant_address ?? 'N/A'); ?></td></tr>
    </table>

    
    <div class="declaration">
        <div class="declaration-title">CLAIMANT DECLARATION</div>
        <p>
            I hereby declare that the information provided in this claim is true and correct to
            the best of my knowledge. I understand that any false declaration may result in the
            rejection of this claim.
        </p>

        <p><strong>Claimant Signature:</strong> _____________________________</p>
        <p><strong>Date:</strong> ____ / ____ / ______</p>
    </div>

    
    <div class="declaration">
        <div class="declaration-title">FOR OFFICIAL USE ONLY</div>

        <table>
            <tr>
                <th>Processed By</th>
                <td><?php echo e($claim->actionBy->name ?? '—'); ?></td>
            </tr>
            <tr>
                <th>Date Processed</th>
                <td><?php echo e($claim->action_at ? \Carbon\Carbon::parse($claim->action_at)->format('d M Y H:i') : '—'); ?>

</td>
            </tr>
            <tr>
                <th>Decision</th>
                <td><?php echo e($claim->claim_status); ?></td>
            </tr>
            <tr>
                <th>Comments</th>
                <td><?php echo e($claim->action_comment ?? '—'); ?></td>
            </tr>
        </table>

        <p><strong>Authorized Signature:</strong> _____________________________</p>
        <p><strong>Date:</strong> ____ / ____ / ______</p>
    </div>

    
    <div class="text-center">
        <button onclick="window.print()" class="btn-print">
            <i class="fas fa-print"></i> Print Document
        </button>
    </div>

    
    <div class="footer">
        Funeral Claim Form – Private & Confidential – Mbabane Burial Society
    </div>

</div>

</body>

</html>
<?php /**PATH C:\WORK-STATION\MBBS\Insurance-Version Controls\03-01-2026\resources\views/documents/claim.blade.php ENDPATH**/ ?>