<!DOCTYPE html>
<html>

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

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

        .invoice-box table {
            width: 100%;
            border-collapse: collapse;
            margin-bottom: 10px;
        }

        .invoice-box table th,
        .invoice-box table td {
            padding: 6px;
            border: 1px solid #ddd;
            text-align: left;
            font-size: 10px;
        }

        .invoice-box table th {
            background: #f2f2f2;
            font-weight: bold;
        }

        .header {
            text-align: center;
            margin-bottom: 10px;
        }

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

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

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

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

        .signature {
            margin-top: 15px;
            font-size: 12px;
        }

        .footer {
            text-align: center;
            font-size: 10px;
            color: #777;
            margin-top: 10px;
        }
    </style>
</head>

<body>
    <div class="invoice-box">
        <!-- Header -->
        <div class="header">
            <img src="<?php echo e(asset('admin/assets/img/logos/logo-new.png')); ?>" alt="Mbabane Burial Society Logo">
            <h3>Funeral Cover Application 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>Date:</strong> <?php echo date('l, F jS, Y '); ?> | <strong>Document No:</strong> <?php echo mt_rand(10000000, 99999999); ?></p>
        </div>

        <!-- Policy Holder Details -->
        <div class="section-title">A. POLICY HOLDER DETAILS</div>
        <table>
            <tr><th>Policy No</th><td><?php echo e($member->national_id); ?></td></tr>
            <tr><th>Name</th><td><?php echo e($member->name); ?> <?php echo e($member->surname); ?></td></tr>
            <tr><th>Date of Birth</th><td><?php echo e($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($member->residential_address); ?></td></tr>
            <tr><th>Cell Number</th><td><?php echo e($member->code); ?> <?php echo e($member->cell_number); ?></td></tr>
        </table>

        <!-- Dependants Details -->
        <div class="section-title">B. DEPENDANTS DETAILS</div>
        <table>
            <tr><th>Surname</th><th>Name</th><th>National ID</th><th>Gender</th><th>Date of Birth</th><th>Relationship</th></tr>
            <?php $__currentLoopData = $dependants; $__env->addLoop($__currentLoopData); foreach($__currentLoopData as $dependant): $__env->incrementLoopIndices(); $loop = $__env->getLastLoop(); ?>
            <tr>
                <td><?php echo e($dependant->surname); ?></td><td><?php echo e($dependant->name); ?></td>
                <td><?php echo e($dependant->national_id); ?></td><td><?php echo e($dependant->gender); ?></td>
                <td><?php echo e($dependant->dob); ?></td><td><?php echo e($dependant->relationship); ?></td>
            </tr>
            <?php endforeach; $__env->popLoop(); $loop = $__env->getLastLoop(); ?>
        </table>

        <!-- Beneficiaries Details -->
        <div class="section-title">C. BENEFICIARIES DETAILS</div>
        <table>
            <tr><th>Surname</th><th>Name</th><th>National ID</th><th>Cell Number</th><th>Date of Birth</th><th>Relationship</th></tr>
            <?php $__currentLoopData = $beneficiaries; $__env->addLoop($__currentLoopData); foreach($__currentLoopData as $beneficiary): $__env->incrementLoopIndices(); $loop = $__env->getLastLoop(); ?>
            <tr>
                <td><?php echo e($beneficiary->surname); ?></td><td><?php echo e($beneficiary->name); ?></td>
                <td><?php echo e($beneficiary->national_id); ?></td><td><?php echo e($beneficiary->cell); ?></td>
                <td><?php echo e($beneficiary->dob); ?></td><td><?php echo e($beneficiary->relationship); ?></td>
            </tr>
            <?php endforeach; $__env->popLoop(); $loop = $__env->getLastLoop(); ?>
        </table>

        <!-- Funeral Premium Details -->
        <div class="section-title">D. FUNERAL PREMIUM DETAILS</div>
        <table>
            <tr><th>Cover Name</th><th>Amount</th><th>Monthly Premium</th><th>Waiting Period</th></tr>
            <?php $__currentLoopData = $premia; $__env->addLoop($__currentLoopData); foreach($__currentLoopData as $premium): $__env->incrementLoopIndices(); $loop = $__env->getLastLoop(); ?>
            <tr>
                <td><?php echo e($premium->cover->name); ?></td>
                <td>E <?php echo e($premium->cover->sum_assured); ?></td>
                <td>E <?php echo e($monthly_payment); ?></td>
                <td><?php echo e($premium->cover->waiting_period); ?></td>
            </tr>
            <?php endforeach; $__env->popLoop(); $loop = $__env->getLastLoop(); ?>


            <tr>
                <td colspan="2">
                <br><strong> Policy: <?php echo e($premium->cover->monthly_pay); ?></strong><br>
                        <br> Total Dependents: <?php echo e($totaldependents); ?> 
                        <br> Total Children: <?php echo e($totalchildren); ?> 
                        <br> Total Spouses: <?php echo e($totalspouses); ?> <br>
                <strong>Additional Benefits</strong>
                        <br> Airtime: <?php echo e($benefits->airtime); ?> 
                        <br> Cow: <?php echo e($benefits->cow); ?> 
                        <br> Grocery: <?php echo e($benefits->grocery); ?> <br>
                </td>
            </tr>
        </table>

        <!-- Terms and Conditions -->
        <div class="section-title">D. TERMS & CONDITIONS</div>
        <p class="terms">
            <strong>Extent of Cover:</strong> Cover applies to the member, spouse(s), and up to five children under 21.
            Children aged 21-25 are covered if they provide proof of full-time study. <br>
            <strong>Waiting Period:</strong> Individual policies have a 6-month waiting period. Group scheme waiting periods
            will be discussed with Mbabane Burial. Only accidental deaths are covered during this period. <br>
            <strong>Continuity Option:</strong> If the policyholder passes away, the surviving spouse may continue the policy
            under certain terms & conditions. <br>
            <strong>Policy Lapse:</strong> If unpaid for 3 months, a 3-month waiting period applies after arrears are cleared.
            If unpaid for 12 consecutive months, the policy will be canceled. <br>
            <strong>Payment Methods:</strong> Payments can be made via Cash, Debit Order, Bank Deposit (Nedbank),
            MTN Mobile Money (*007*1*2# - Retail Code: 151353), Government Payroll (CDAS), or Salary Deduction at the bank. <br>
            <strong>Mbabane Burial Society reserves the right to modify terms and conditions.</strong>
        </p>

        <!-- Declaration -->
        <div class="section-title">E. DECLARATION</div>
        <p>I, the undersigned, confirm that the information provided is correct to the best of my knowledge. I acknowledge that the broker and authorized representative are not responsible for inaccuracies in the information provided.</p>
        <p><strong>Consultant:</strong> <?php echo e($user->name); ?> <?php echo e($user->surname); ?> | <strong>Signature:</strong> ____________________________</p>
        <p><strong>Policyholder Signature:</strong> ____________________________</p>

        <!-- Footer -->
        <div class="footer">
            Funeral Cover Application Form – Private & Confidential – Mbabane Burial Society
        </div>
    </div>
</body>

</html>
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