@extends('layouts.app')

@section('title', 'Edit Lead')

@section('page-specific-style')
<link href="https://cdnjs.cloudflare.com/ajax/libs/bootstrap-tagsinput/0.8.0/bootstrap-tagsinput.css" rel="stylesheet"/>
<style>
    .bootstrap-tagsinput .label-info {
        background-color: cadetblue;
        padding: 0 3px;
        border-radius: 5px;
    }

    .bootstrap-tagsinput {
        display: block;
        /* line-height: 5px;
        overflow-y: scroll; */
    }

</style>
@endsection

@section('content')
<div class="container-fluid">
    <div class="row">
        <div class="col-xl-12">
            <div class="card">
                <div class="card-body">

                    <h4 class="card-title text-primary">All Leads > {{ $lead->fullName }} ({{ $lead->lead_code }})</h4>
                    @include('includes.alerts')
                    <h1 class="mt-5">
                        @if($lead->is_customer)
                            <i class="bx bx-user text-primary"></i>
                        @else
                            <i class="bx bx-user"></i>
                        @endif
                        {{ $lead->fullName }}
                    </h1>
                    <p class="card-title-desc">Customer Id {{ $lead->lead_code }}</p>

                    <form method="POST" action="{{ route('leads.update', $lead->id) }}" autocomplete="off">
                        @csrf
                        @method('PUT')

                    <div class="row mb-5">
                        <div class="col-3">
                            <select class="form-select" id="is_active" name="status">
                                @forelse ($leadStatusItems as $item)
                                <option value="{{ $item->value }}"
                                    {{ isset($lead) && $lead->status == $item->value ? 'selected' : '' }}>
                                    {{ $item->value }}
                                </option>
                                @empty
                                    <option value="">No status found!</option>
                                @endforelse
                            </select>
                        </div>
                        <div class="col-3">
                            <select class="form-select" id="assigned_to" name="assigned_to_user">
                                @forelse ($assignedToUsers as $user)
                                <option value="{{ $user->id }}"
                                    {{ isset($lead) && $lead->assigned_to_user == $user->id ? 'selected' : '' }}>
                                    {{ $user->name }}
                                </option>
                                @empty
                                    <option value="">No user found!</option>
                                @endforelse
                            </select>
                        </div>
                        <div class="col-3">
                            <input
                                type="text"
                                class="form-control"
                                id="tags"
                                name="tags[]"
                                placeholder="Tags"
                                data-role="tagsinput"
                                autocomplete="off"
                                value="{{ old('tags', $tagsString) }}"
                            >
                            @error('tags')
                                <span class="text-danger">{{ $message }}</span>
                            @enderror
                        </div>
                        <div class="col-3">
                            <select class="form-select" id="source" name="source">
                                @forelse ($sourceItems as $source)
                                    <option value="{{ $source->value }}"
                                        {{ isset($lead) && $lead->source == $source->value ? 'selected' : '' }}>
                                        {{ $source->value }} </option>
                                @empty
                                    <option value="">No source found!</option>
                                @endforelse
                            </select>
                        </div>
                    </div>

                    <!-- Nav tabs -->
                    <ul class="nav nav-tabs nav-tabs-custom nav-justified" role="tablist">
                        <li class="nav-item">
                            <a class="nav-link active" data-bs-toggle="tab" href="#contact" role="tab">
                                <span class="d-block d-sm-none"><i class="fas fa-address-book"></i></span>
                                <span class="d-none d-sm-block">Contact</span>
                            </a>
                        </li>
                        <li class="nav-item">
                            <a class="nav-link" data-bs-toggle="tab" href="#dependents" role="tab">
                                <span class="d-block d-sm-none"><i class="fas fa-users"></i></span>
                                <span class="d-none d-sm-block">Dependents</span>
                            </a>
                        </li>
                        <li class="nav-item">
                            <a class="nav-link" data-bs-toggle="tab" href="#opportunities" role="tab">
                                <span class="d-block d-sm-none"><i class="fas fa-users"></i></span>
                                <span class="d-none d-sm-block">Opporunities</span>
                            </a>
                        </li>
                        <li class="nav-item">
                            <a class="nav-link" data-bs-toggle="tab" href="#policies" role="tab">
                                <span class="d-block d-sm-none"><i class="fas fa-file-alt"></i></span>
                                <span class="d-none d-sm-block">Policies</span>
                            </a>
                        </li>
                        <li class="nav-item">
                            <a class="nav-link" data-bs-toggle="tab" href="#notes" role="tab">
                                <span class="d-block d-sm-none"><i class="fas fa-sticky-note"></i></span>
                                <span class="d-none d-sm-block">Notes</span>
                            </a>
                        </li>
                        <li class="nav-item">
                            <a class="nav-link" data-bs-toggle="tab" href="#recording" role="tab">
                                <span class="d-block d-sm-none"><i class="fas fa-microphone"></i></span>
                                <span class="d-none d-sm-block">Recording</span>
                            </a>
                        </li>
                    </ul>

                    <!-- Tab panes -->
                    <div class="tab-content p-3 text-muted">
                        <!-- Contact Tab -->
                        <div class="tab-pane active" id="contact" role="tabpanel">
                            {{-- <form method="POST" action="{{ route('leads.update', $lead->id) }}" autocomplete="off">
                                @csrf
                                @method('PUT') --}}

                                <div class="accordion" id="accordionPanelsStayOpenExample">
                                    <div class="accordion-item">
                                        <h2 class="accordion-header" id="headingOne">
                                            <button class="accordion-button fw-medium" type="button" data-bs-toggle="collapse" data-bs-target="#collapseOne" aria-expanded="true" aria-controls="collapseOne">
                                            Primary Information
                                            </button>
                                        </h2>
                                        <div id="collapseOne" class="accordion-collapse collapse show" aria-labelledby="headingOne" data-bs-parent="#accordionExample">
                                            <div class="accordion-body">
                                                <div class="row">
                                                    <div class="col-md-4 mb-3">
                                                        <label for="country" class="form-label">Country</label>
                                                        <select class="form-select" id="country" name="country" required>
                                                            @forelse ($countries as $item)
                                                                <option value="{{ $item->shortname }}"
                                                                    {{ isset($lead) && $lead->country == $item->shortname ? 'selected' : '' }}>
                                                                    {{ $item->shortname }} </option>
                                                            @empty
                                                                <option value="">Countries not found!</option>
                                                            @endforelse
                                                        </select>
                                                    </div>
                                                    <div class="col-8">
                                                        <label for="phone">Primary Phone</label>
                                                        <input type="text" class="form-control" id="phone" name="primary_phone_number" placeholder="Primary Phone" value="{{ $lead->primary_phone_number }}" autocomplete="off" required>
                                                        <div id="phone-error" class="text-default text-bold mt-2" style="display: none;"></div>
                                                        <div id="phone-loader" class="position-absolute top-50 end-0 translate-middle-y me-2" style="display: none;">
                                                            <div class="spinner-border text-primary" role="status">
                                                                <span class="visually-hidden">Loading...</span>
                                                            </div>
                                                        </div>
                                                    </div>
                                                </div>
                                                <div class="row">
                                                    <div class="col-4">
                                                        <label for="first_name" class="form-label">First Name</label>
                                                        <input type="text" class="form-control" id="first_name" name="first_name" value="{{ $lead->first_name }}" required>
                                                        @error('first_name')
                                                            <div class="text-danger">{{ $message }}</div>
                                                        @enderror
                                                    </div>
                                                    <div class="col-4">
                                                        <label for="middle_name" class="form-label">Middle Name</label>
                                                        <input type="text" class="form-control" id="middle_name" name="middle_name" value="{{ $lead->midle_name }}">
                                                        @error('middle_name')
                                                            <div class="text-danger">{{ $message }}</div>
                                                        @enderror
                                                    </div>
                                                    <div class="col-4">
                                                        <label for="last_name" class="form-label">Last Name</label>
                                                        <input type="text" class="form-control" id="last_name" name="last_name" value="{{ $lead->last_name }}" required>
                                                        @error('last_name')
                                                            <div class="text-danger">{{ $message }}</div>
                                                        @enderror
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                    </div>
                                    <div class="accordion-item">
                                        <h2 class="accordion-header" id="headingTwo">
                                            <button class="accordion-button fw-medium collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseTwo" aria-expanded="false" aria-controls="collapseTwo">
                                            Basic Information                                            </button>
                                        </h2>
                                        <div id="collapseTwo" class="accordion-collapse collapse" aria-labelledby="headingTwo" data-bs-parent="#accordionExample">
                                            <div class="accordion-body">
                                                <div class="row">
                                                    <div class="col-3">
                                                        <label for="phone_2" class="form-label">Phone2</label>
                                                        <input type="text" class="form-control" id="phone_2" name="phone_2" value="{{ $lead->information?->phone_2 }}">
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="phone_3" class="form-label">Phone3</label>
                                                        <input type="text" class="form-control" id="phone_3" name="phone_3" value="{{ $lead->information?->phone_3 }}">
                                                    </div>

                                                    <div class="col-3">
                                                        <label for="email1" class="form-label">Email 1</label>
                                                        <input type="email" class="form-control" id="email1" name="email1" value="{{ $lead->information?->email }}">
                                                        @error('email1')
                                                            <div class="text-danger">{{ $message }}</div>
                                                        @enderror
                                                    </div>

                                                    <div class="col-3">
                                                        <label for="email2" class="form-label">Email2</label>
                                                        <input type="email" class="form-control" id="email2" name="email_2" value="{{ $lead->information?->email_2 }}">
                                                        @error('email2')
                                                            <div class="text-danger">{{ $message }}</div>
                                                        @enderror
                                                    </div>

                                                </div>
                                                <div class="row mt-2">
                                                    <div class="col-12">
                                                        <label for="address" class="form-label">Address</label>
                                                        <input type="text" class="form-control" id="address" name="address" value="{{ $lead->information?->address }}">
                                                        @error('address')
                                                            <div class="text-danger">{{ $message }}</div>
                                                        @enderror
                                                    </div>
                                                </div>
                                                <div class="row mt-2">
                                                    <div class="col-3">
                                                        <label for="zip" class="form-label">Zip</label>
                                                        <input type="text" class="form-control" id="zip" name="zip" value="{{ $lead->information?->zipcode }}">
                                                        @error('zip')
                                                            <div class="text-danger">{{ $message }}</div>
                                                        @enderror
                                                    </div>

                                                    <div class="col-3">
                                                        <label for="country2" class="form-label">Country</label>
                                                        <select name="country2" class="form-select">
                                                            @forelse ($countries as $country)
                                                                <option value="{{ $country->name }}"
                                                                    {{ isset($lead) && $lead->information?->country == $country->name ? 'selected' : '' }}>
                                                                    {{ $country->name }} </option>
                                                            @empty
                                                                <option value="">Countries not found!</option>
                                                            @endforelse
                                                        </select>
                                                    </div>

                                                    <div class="col-3">
                                                        <label for="city" class="form-label">City</label>
                                                        <input type="text" class="form-control" id="city" name="city" value="{{ $lead->information?->city }}">
                                                        @error('city')
                                                            <div class="text-danger">{{ $message }}</div>
                                                        @enderror
                                                    </div>

                                                    <div class="col-3">
                                                        <label for="state" class="form-label">State</label>
                                                        <select name="state" class="form-select">
                                                            @forelse ($states as $state)
                                                                <option value="{{ $state->value }}"
                                                                    {{ isset($lead) && $lead->information?->state == $state->value ? 'selected' : '' }}>
                                                                    {{ $state->name }} </option>
                                                            @empty
                                                                <option value="">States not found!</option>
                                                            @endforelse
                                                        </select>
                                                    </div>
                                                </div>
                                                <div class="row">
                                                    <div class="col-3">
                                                        <label for="age" class="form-label">Age</label>
                                                        <input type="number" class="form-control" id="age" name="age" value="{{ $lead->information?->age }}">
                                                        @error('age')
                                                            <div class="text-danger">{{ $message }}</div>
                                                        @enderror
                                                    </div>

                                                    <div class="col-3">
                                                        <label for="dob" class="form-label">Date of Birth</label>
                                                        <input type="date" class="form-control" id="dob" name="dob" value="{{ $lead->information?->dob }}">
                                                        @error('dob')
                                                            <div class="text-danger">{{ $message }}</div>
                                                        @enderror
                                                    </div>

                                                    <div class="col-3">
                                                        <label for="gender" class="form-label">Gender</label>
                                                        <select name="gender" class="form-select">
                                                            @forelse ($genders as $gender)
                                                                <option value="{{ $gender->value }}"
                                                                    {{ isset($lead) && $lead->information?->gender == $gender->value ? 'selected' : '' }}>
                                                                    {{ $gender->value }} </option>
                                                            @empty
                                                                <option value="">Genders not found!</option>
                                                            @endforelse
                                                        </select>
                                                    </div>

                                                    <div class="col-3">
                                                        <label for="language" class="form-label">Language</label>
                                                        <select name="language" class="form-select">
                                                            @forelse ($languages as $language)
                                                                <option value="{{ $language->value }}"
                                                                    {{ isset($lead) && $lead->information?->language == $language->value ? 'selected' : '' }}>
                                                                    {{ $language->value }} </option>
                                                            @empty
                                                                <option value="">Languages not found!</option>
                                                            @endforelse
                                                        </select>
                                                    </div>
                                                </div>
                                                <div class="row mt-2">
                                                    <div class="col-3">
                                                        <label for="maritial_status" class="form-label">Maritial Status</label>
                                                        <select name="maritial_status" class="form-select">
                                                            @forelse ($maritialStatuses as $maritialStatus)
                                                                <option value="{{ $maritialStatus->value }}"
                                                                    {{ isset($lead) && $lead->information?->maritial_status == $maritialStatus->value ? 'selected' : '' }}>
                                                                    {{ $maritialStatus->value }} </option>
                                                            @empty
                                                                <option value="">Maritial Statuses not found!</option>
                                                            @endforelse
                                                        </select>
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="veteran" class="form-label">Veteran</label>
                                                        <select name="veteran" class="form-select" >
                                                            <option value="1" @if($lead->information?->veteran == 1) selected @endif>Yes</option>
                                                            <option value="0" @if($lead->information?->veteran == 0) selected @endif>No</option>
                                                        </select>
                                                    </div>

                                                    <div class="col-3">
                                                        <label for="contact_time" class="form-label">Contact time</label>
                                                        <input type="time" class="form-control" id="contact_time" name="contact_time">
                                                        @error('contact_time')
                                                            <div class="text-danger">{{ $message }}</div>
                                                        @enderror
                                                    </div>

                                                    <div class="col-3">
                                                        <label for="contact_method" class="form-label">Contact Method</label>
                                                        <select name="contact_method" class="form-select">
                                                            @forelse ($contactMethods as $contactMethod)
                                                                <option value="{{ $contactMethod->value }}"
                                                                    {{ isset($lead) && $lead->information?->contact_method == $contactMethod->value ? 'selected' : '' }}>
                                                                    {{ $contactMethod->value }} </option>
                                                            @empty
                                                                <option value="">Contact Methods not found!</option>
                                                            @endforelse
                                                        </select>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                    </div>
                                    <div class="accordion-item">
                                        <h2 class="accordion-header" id="headingThree">
                                            <button class="accordion-button fw-medium collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseThree" aria-expanded="false" aria-controls="collapseThree">
                                            Mailing Information and Concent
                                            </button>
                                        </h2>
                                        <div id="collapseThree" class="accordion-collapse collapse" aria-labelledby="headingThree" data-bs-parent="#accordionExample">
                                            <div class="accordion-body">
                                                <div class="row">
                                                    <div class="col-3">
                                                        <label for="mailing_zipcode" class="form-label">Mailing Zipcode</label>
                                                        <input type="text" class="form-control" id="mailing_zipcode" name="mailing_zipcode" value="{{ $lead->information?->mailing_zipcode }}">
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="mailing_city" class="form-label">Mailing City</label>
                                                        <input type="text" class="form-control" id="mailing_city" name="mailing_city" value="{{ $lead->information?->mailing_city }}">
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="mailing_state" class="form-label">Mailing State</label>
                                                        <input type="text" class="form-control" id="mailing_state" name="mailing_state" value="{{ $lead->information?->mailing_state }}">
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="mailing_address" class="form-label">Mailing Address</label>
                                                        <input type="text" class="form-control" id="mailing_address" name="mailing_address" value="{{ $lead->information?->mailing_address }}">
                                                    </div>

                                                    <div class="col-3">
                                                        <label for="taxable-household-member" class="form-label">Taxable Household Member</label>
                                                        <input type="text" class="form-control" id="taxable-household-member" name="taxable_household_members" value="{{ $lead->information?->taxable_household_members }}">
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="consent-to-search-marketplace" class="form-label">Consent to search marketplace</label>
                                                        <select name="consent_to_search_marketplace" class="form-select">
                                                            <option value="1" @if($lead->information?->consent_to_search_marketplace == 1) selected @endif>Yes</option>
                                                            <option value="0" @if($lead->information?->consent_to_search_marketplace == 0) selected @endif>No</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="consent-to-assist-with-documents" class="form-label">Consent To Assist With Documents</label>
                                                        <select name="consent_to_assist_with_documents" class="form-select">
                                                            <option value="1" @if($lead->information?->consent_to_assist_with_documents == 1) selected @endif>Yes</option>
                                                            <option value="0" @if($lead->information?->consent_to_assist_with_documents == 0) selected @endif>No</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="consent-to-call" class="form-label">Consent To Call/Text/Email</label>
                                                        <select name="consent_to_call_text_email" class="form-select">
                                                            <option value="1" @if($lead->information?->consent_to_call_text_email == 1) selected @endif>Yes</option>
                                                            <option value="0" @if($lead->information?->consent_to_call_text_email == 0) selected @endif>No</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="consent-to-submit-application" class="form-label">Consent To Submit Application</label>
                                                        <select name="consent_to_submit_application" class="form-select">
                                                            <option value="1" @if($lead->information?->consent_to_submit_application == 1) selected @endif>Yes</option>
                                                            <option value="0" @if($lead->information?->consent_to_submit_application == 0) selected @endif>No</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="consent-to-call" class="form-label">Consent To Reenroll/renew</label>
                                                        <select name="consent_to_reenroll_renew" class="form-select">
                                                            <option value="1" @if($lead->information?->consent_to_reenroll_renew == 1) selected @endif>Yes</option>
                                                            <option value="0" @if($lead->information?->consent_to_reenroll_renew == 0) selected @endif>No</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="understant-duration-of-consent" class="form-label">Understand Duration of Consent</label>
                                                        <select name="understand_duration_of_consent" class="form-select">
                                                            <option value="1" @if($lead->information?->understand_duration_of_consent == 1) selected @endif>Yes</option>
                                                            <option value="0" @if($lead->information?->understand_duration_of_consent == 0) selected @endif>No</option>
                                                        </select>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                    </div>
                                    <div class="accordion-item">
                                        <h2 class="accordion-header" id="headingFour">
                                            <button class="accordion-button fw-medium collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseFour" aria-expanded="false" aria-controls="collapseFour">
                                            Financial Information
                                            </button>
                                        </h2>
                                        <div id="collapseFour" class="accordion-collapse collapse" aria-labelledby="headingFour" data-bs-parent="#accordionExample">
                                            <div class="accordion-body">
                                                <div class="row">
                                                    <div class="col-3">
                                                        <label for="occupation" class="form-label">Occupation</label>
                                                        <input type="text" class="form-control" id="occupation" name="occupation" value="{{ $lead->information?->occupation }}">
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="budget" class="form-label">Budget</label>
                                                        <input type="number" class="form-control" id="budget" name="budget" value="{{ $lead->information?->budget }}">
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="annual_income" class="form-label">Annual Income</label>
                                                        <input type="number" class="form-control" id="annual_income" name="annual_income" value="{{ $lead->information?->annual_income }}">
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="monthly_income" class="form-label">Monthly Income</label>
                                                        <input type="number" class="form-control" id="monthly_income" name="monthly_income" value="{{ $lead->information?->monthly_income }}" readonly>
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="weekly_income" class="form-label">Weekly Income</label>
                                                        <input type="number" class="form-control" id="weekly_income" name="weekly_income" value="{{ $lead->information?->weekly_income }}" readonly>
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="household_annual_income" class="form-label">Household Annual Income</label>
                                                        <input type="number" class="form-control" id="household_annual_income" name="household_annual_income" value="{{ $lead->information?->household_annual_income }}">
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="household_monthly_income" class="form-label">Household Monthly Income</label>
                                                        <input type="number" class="form-control" id="household_monthly_income" name="household_monthly_income" value="{{ $lead->information?->household_monthly_income }}" readonly>
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="household_weekly_income" class="form-label">Household Weekly Income</label>
                                                        <input type="number" class="form-control" id="household_weekly_income" name="household_weekly_income" value="{{ $lead->information?->household_weekly_income }}" readonly>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                    </div>
                                    <div class="accordion-item">
                                        <h2 class="accordion-header" id="headingFive">
                                            <button class="accordion-button fw-medium collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseFive" aria-expanded="false" aria-controls="collapseFive">
                                            Medical Information
                                            </button>
                                        </h2>
                                        <div id="collapseFive" class="accordion-collapse collapse" aria-labelledby="headingFive" data-bs-parent="#accordionExample">
                                            <div class="accordion-body">
                                                <div class="row">
                                                    <div class="col-6">
                                                        <label for="medications" class="form-label">Medications</label>
                                                        <textarea class="form-control" id="medications" name="medications">{!! $lead->information?->medications !!}</textarea>
                                                    </div>
                                                    <div class="col-6">
                                                        <label for="conditions" class="form-label">Conditions</label>
                                                        <textarea class="form-control" id="conditions" name="conditions">{!! $lead->information?->conditions !!}</textarea>
                                                    </div>
                                                </div>
                                                <div class="row">
                                                    <div class="col-3">
                                                        <label for="is_smoker" class="for-label">Is smoker?</label>
                                                        <select name="is_smoker" class="form-select">
                                                            <option value="1" @if($lead->information?->is_smoker == 1) selected @endif>Yes</option>
                                                            <option value="0" @if($lead->information?->is_smoker == 0) selected @endif>No</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="has_diabetes" class="for-label">Has diabetes?</label>
                                                        <select name="has_diabetes" class="form-select">
                                                            <option value="1" @if($lead->information?->has_diabetes == 1) selected @endif>Yes</option>
                                                            <option value="0" @if($lead->information?->has_diabetes == 0) selected @endif>No</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="has_cancer" class="for-label">Has cancer?</label>
                                                        <select name="has_cancer" class="form-select">
                                                            <option value="1" @if($lead->information?->has_cancer == 1) selected @endif>Yes</option>
                                                            <option value="0" @if($lead->information?->has_cancer == 0) selected @endif>No</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="has_heart_disease" class="for-label">Has heart disease?</label>
                                                        <select name="has_heart_disease" class="form-select">
                                                            <option value="1" @if($lead->information?->has_heart_disease == 1) selected @endif>Yes</option>
                                                            <option value="0" @if($lead->information?->has_heart_disease == 0) selected @endif>No</option>
                                                        </select>
                                                    </div>
                                                </div>
                                                <div class="row">
                                                    <div class="col-3">
                                                        <label for="pcp_name" class="form-label">PCP Name</label>
                                                        <input type="text" class="form-control" id="pcp_name" name="pcp_name" value="{{ $lead->information?->pcp_name }}">
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="pcp_id" class="form-label">PCP ID</label>
                                                        <input type="text" class="form-control" id="pcp_id" name="pcp_id" value="{{ $lead->information?->pcp_id }}">
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="pcp_office" class="form-label">PCP Office</label>
                                                        <input type="text" class="form-control" id="pcp_office" name="pcp_office" value="{{ $lead->information?->pcp_office }}">
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="mrn" class="form-label">MRN</label>
                                                        <input type="text" class="form-control" id="mrn" name="mrn" value="{{ $lead->information?->mrn }}">
                                                    </div>
                                                    <div class="col-3">
                                                        <label for="empi" class="form-label">EMPI</label>
                                                        <input type="text" class="form-control" id="empi" name="empi" value="{{ $lead->information?->empi }}">
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                    </div>
                                    <div class="accordion-item">
                                        <h2 class="accordion-header" id="headingSix">
                                            <button class="accordion-button fw-medium collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseSix" aria-expanded="false" aria-controls="collapseSix">
                                            Medicare Information
                                            </button>
                                        </h2>
                                        <div id="collapseSix" class="accordion-collapse collapse" aria-labelledby="headingSix" data-bs-parent="#accordionExample">
                                            <div class="accordion-body">
                                                <div class="row">
                                                    <div class="col-2">
                                                        <label for="medicare_claim_number" class="form-label">Medicare claim Number</label>
                                                        <input type="text" class="form-control" id="medicare_claim_number" name="medicare_claim_number" value="{{ $lead->information?->medicare_claim_number }}">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="medicare_part_a" class="form-label">Medicare Part A</label>
                                                        <input type="text" class="form-control" id="medicare_part_a" name="medicare_part_a" value="{{ $lead->information?->medicare_part_a }}">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="medicare_part_b" class="form-label">Medicare Part B</label>
                                                        <input type="text" class="form-control" id="medicare_part_b" name="medicare_part_b" value="{{ $lead->information?->medicare_part_b }}">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="medicaid_number" class="form-label">Medicid Number</label>
                                                        <input type="text" class="form-control" id="medicaid_number" name="medicaid_number" value="{{ $lead->information?->medicaid_number }}">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="medicaid_level" class="form-label">Medicaid Level</label>
                                                        <select name="medicaid_level" class="form-select">
                                                            @forelse ($medicaidLevels as $item)
                                                                <option value="{{ $item->value }}"
                                                                    {{ isset($lead) && $lead->information?->medicaid_level == $item->value ? 'selected' : '' }}>
                                                                    {{ $item->value }} </option>
                                                            @empty
                                                                <option value="">Medicaid Levels not found!</option>
                                                            @endforelse
                                                        </select>
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="enrollment_eligibility" class="form-label">Enrollment Eligibility</label>
                                                        <select name="enrollment_eligibility" class="form-select">
                                                            @forelse ($enrollmentEligibilities as $item)
                                                                <option value="{{ $item->value }}"
                                                                    {{ isset($lead) && $lead->information?->enrollment_eligibility == $item->value ? 'selected' : '' }}>
                                                                    {{ $item->value }} </option>
                                                            @empty
                                                                <option value="">Enrollment Eligibilities not found!</option>
                                                            @endforelse
                                                        </select>
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="scope_of_appointment" class="form-label">Scope of appointment</label>
                                                        <select name="scope_of_appointment" class="form-select">
                                                            <option value="1" @if($lead->information?->scope_of_appointment == 1) selected @endif>Yes</option>
                                                            <option value="0" @if($lead->information?->scope_of_appointment == 0) selected @endif>No</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="medicaid_username" class="form-label">Medicid Username</label>
                                                        <input type="text" class="form-control" id="medicaid_username" name="medicaid_username" value="{{ $lead->information?->medicaid_username }}">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="medicaid_password" class="form-label">Medicid Password</label>
                                                        <input type="text" class="form-control" id="medicaid_password" name="medicaid_password" value="{{ $lead->information?->medicaid_password }}">
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                    </div>
                                    <div class="accordion-item">
                                        <h2 class="accordion-header" id="headingSeven">
                                            <button class="accordion-button fw-medium collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseSeven" aria-expanded="false" aria-controls="collapseSeven">
                                            Legal Information
                                            </button>
                                        </h2>
                                        <div id="collapseSeven" class="accordion-collapse collapse" aria-labelledby="headingSeven" data-bs-parent="#accordionExample">
                                            <div class="accordion-body">
                                                <div class="row">
                                                    <div class="col-2">
                                                        <label for="ssn" class="form-label">SSN</label>
                                                        <input type="text" class="form-control" id="ssn" name="ssn">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="tax_filing" class="form-label">Tax Filing</label>
                                                        <select name="tax_filing" class="form-select">
                                                            @forelse ($taxFilings as $item)
                                                                <option value="{{ $item->value }}"
                                                                    {{ isset($lead) && $lead->information?->tax_filing == $item->value ? 'selected' : '' }}>
                                                                    {{ $item->value }} </option>
                                                            @empty
                                                                <option value="">Tax Filings not found!</option>
                                                            @endforelse
                                                        </select>
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="drivers_license" class="form-label">Driver's License</label>
                                                        <input type="text" class="form-control" id="drivers_license" name="drivers_license" value="{{ $lead->information?->drivers_license }}">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="drivers_license_state" class="form-label">Driver's License State</label>
                                                        <select name="drivers_license_state" class="form-select">
                                                            @forelse ($states as $state)
                                                                <option value="{{ $state->value }}"
                                                                    {{ isset($lead) && $lead->information?->drivers_license_state == $state->value ? 'selected' : '' }}>
                                                                    {{ $state->name }} </option>
                                                            @empty
                                                                <option value="">States not found!</option>
                                                            @endforelse
                                                        </select>
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="drivers_license_exp" class="form-label">Driver's License Expiration</label>
                                                        <input type="date" class="form-control" id="drivers_license_exp" name="drivers_license_exp" value="{{ $lead->information?->drivers_license_expiration }}">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="mothers_maiden_name" class="form-label">Mother's Maiden Name</label>
                                                        <input type="text" class="form-control" id="mothers_maiden_name" name="mothers_maiden_name" value="{{ $lead->information?->mothers_maiden_name }}">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="legal_status" class="form-label">Legal Status</label>
                                                        <input type="text" class="form-control" id="legal_status" name="legal_status" value="{{ $lead->information?->legal_status }}">
                                                        {{-- <select name="legal_status" class="form-select">
                                                            <option value="1">Citizen</option>
                                                            <option value="2">Permanent Resident</option>
                                                            <option value="3">Work Visa</option>
                                                        </select> --}}
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="immegration_document" class="form-label">Immegration Document</label>
                                                        <input type="text" class="form-control" id="immegration_document" name="immegration_document" value="{{ $lead->information?->immegration_document }}">
                                                        {{-- <select name="immegration_document" class="form-select">
                                                            <option value="1">Passport</option>
                                                            <option value="2">Visa</option>
                                                            <option value="3">Green Card</option>
                                                        </select> --}}
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="alien_number" class="form-label" tooltip="USCIS Number, format is A123456789">Alien #</label>
                                                        <input type="text" class="form-control" id="alien_number" name="alien_number" value="{{ $lead->information?->alien_number }}">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="i_94_number" class="form-label" tooltip="I-94 / I-94A Arrival / Departure Record #">I-94 #</label>
                                                        <input type="text" class="form-control" id="i_94_number" name="i_94_number" value="{{ $lead->information?->i_94_number }}">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="green_card_number" class="form-label">Green Card #</label>
                                                        <input type="text" class="form-control" id="green_card_number" name="green_card_number" value="{{ $lead->information?->green_card_number }}">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="immigration_status" class="form-label">Immigration Statuses</label>
                                                        <select name="immigration_statuses" class="form-select">
                                                            @forelse ($immigrationStatuses as $item)
                                                                <option value="{{ $item->value }}"
                                                                    {{ isset($lead) && $lead->information?->immigration_statuses == $item->value ? 'selected' : '' }}>
                                                                    {{ $item->value }} </option>
                                                            @empty
                                                                <option value=""> Immigration Statuses not found!</option>
                                                            @endforelse
                                                        </select>
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="other-statuses" class="form-label">Other Statuses</label>
                                                        <select name="other_statuses" class="form-select">
                                                            @forelse ($otherStatuses as $item)
                                                                <option value="{{ $item->value }}"
                                                                    {{ isset($lead) && $lead->information?->other_statuses == $item->value ? 'selected' : '' }}>
                                                                    {{ $item->value }} </option>
                                                            @empty
                                                                <option value="">Other Statuses not found!</option>
                                                            @endforelse
                                                        </select>
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="savis_id" class="form-label">Sevis ID</label>
                                                        <input type="text" class="form-control" id="savis_id" name="sevis_id" value="{{ $lead->information?->sevis_id }}">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="passport" class="form-label">Passport</label>
                                                        <input type="text" class="form-control" id="passport" name="passport" value="{{ $lead->information?->passport }}">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="passport_country" class="form-label">Passport Country</label>
                                                        <select name="passport_country" class="form-select">
                                                            @forelse ($passportCountries as $item)
                                                                <option value="{{ $item->value }}"
                                                                    {{ isset($lead) && $lead->information?->passport_country == $item->value ? 'selected' : '' }}>
                                                                    {{ $item->value }} </option>
                                                            @empty
                                                                <option value="">Passport Countries not found!</option>
                                                            @endforelse
                                                        </select>
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="passport_expiration" class="form-label">Passport Expiration</label>
                                                        <input type="date" class="form-control" id="passport_expiration" name="passport_expiration" value="{{ $lead->information?->passport_expiration }}">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="ead_card_number" class="form-label">EAD Card Number</label>
                                                        <input type="text" class="form-control" id="ead_card_number" name="ead_card_number" value="{{ $lead->information?->ead_card_number }}">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="ead_card_code" class="form-label">EAD Card Code</label>
                                                        <input type="text" class="form-control" id="ead_card_code" name="ead_card_code" value="{{ $lead->information?->ead_card_code }}">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="ead_card_expiration" class="form-label">EAD Card Expiration</label>
                                                        <input type="date" class="form-control" id="ead_card_expiration" name="ead_card_expiration" value="{{ $lead->information?->ead_card_expiration }}">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="naturalization" class="form-label">Naturalization</label>
                                                        <input type="text" class="form-control" id="naturalization" name="naturalization" value="{{ $lead->information?->naturalization }}">
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                    </div>

                                    <div class="accordion-item">
                                        <h2 class="accordion-header" id="headingEight">
                                            <button class="accordion-button fw-medium collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseEight" aria-expanded="false" aria-controls="collapseEight">
                                            Insurance Information
                                            </button>
                                        </h2>
                                        <div id="collapseEight" class="accordion-collapse collapse" aria-labelledby="headingEight" data-bs-parent="#accordionExample">
                                            <div class="accordion-body">
                                                <div class="row">
                                                    <div class="col-2">
                                                        <label for="intrested_in" class="form-label">Intrested In</label>
                                                        <select name="intrested_in" class="form-select">
                                                            <option value="1">Health</option>
                                                            <option value="2">Life</option>
                                                            <option value="3">Auto</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="insured_premium" class="form-label">Insured Premium</label>
                                                        <input type="number" class="form-control" id="insured_premium" name="insured_premium">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="insured_carrier" class="form-label">Insured Carrier</label>
                                                        <input type="text" class="form-control" id="insured_carrier" name="insured_carrier">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="insured_intent" class="form-label">Insured Intent</label>
                                                        <select name="insured_intent" class="form-select">
                                                            <option value="1">Health</option>
                                                            <option value="2">Life</option>
                                                            <option value="3">Auto</option>
                                                        </select>
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="term_wanted" class="form-label">Term Wanted</label>
                                                        <input type="text" class="form-control" id="term_wanted" name="term_wanted">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="coverage_wanted" class="form-label">Coverage Wanted</label>
                                                        <input type="text" class="form-control" id="coverage_wanted" name="coverage_wanted">
                                                    </div>
                                                    <div class="col-2">
                                                        <label for="is_insured" class="form-label">Is Insured ?</label>
                                                        <select name="is_insured" class="form-select">
                                                            <option value="1" @if($lead->information?->is_insured == 1) selected @endif>Yes</option>
                                                            <option value="0" @if($lead->information?->is_insured == 0) selected @endif>No</option>
                                                        </select>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                    </div>

                                    <div class="accordion-item">
                                        <h2 class="accordion-header" id="headingNine">
                                            <button class="accordion-button fw-medium collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseNine" aria-expanded="false" aria-controls="collapseNine">
                                            Marketing Information
                                            </button>
                                        </h2>
                                        <div id="collapseNine" class="accordion-collapse collapse" aria-labelledby="headingNine" data-bs-parent="#accordionExample">
                                            <div class="accordion-body">
                                            </div>
                                        </div>
                                    </div>
                                </div>
                                <div class="row mt-3">
                                    <div class="col-12">
                                        <button type="submit" class="btn btn-primary">Submit</button>
                                    </div>
                                </div>

                            </form>
                        </div>

                        <!-- Dependents Tab -->
                        <div class="tab-pane" id="dependents" role="tabpanel">
                            <form action="{{ route('leads.updateDependent', $lead->id) }}" method="POST" autocomplete="off">
                                @csrf
                                @method('PUT')

                                @forelse ($dependents as $key => $leadDependent)
                                    <input type="hidden" name="dependent[{{$key}}][id]" value="{{ $leadDependent->id }}">

                                    <div class="accordion" id="accordionPanelsStayOpenExample">
                                        <div class="accordion-item">
                                            <h2 class="accordion-header" id="headingOne">
                                                <button class="accordion-button fw-medium" type="button" data-bs-toggle="collapse" data-bs-target="#collapseOne" aria-expanded="true" aria-controls="collapseOne">
                                                Primary Information
                                                </button>
                                            </h2>
                                            <div id="collapseOne" class="accordion-collapse collapse show" aria-labelledby="headingOne" data-bs-parent="#accordionExample">
                                                <div class="accordion-body">
                                                    <div class="row">
                                                        <div class="col-4">
                                                            <label for="d_first_name" class="form-label">First Name</label>
                                                            <input type="text" class="form-control" id="d_first_name" name="dependent[{{ $key }}][first_name]" value="{{ $leadDependent->first_name }}" required>
                                                            @error('first_name')
                                                                <div class="text-danger">{{ $message }}</div>
                                                            @enderror
                                                        </div>
                                                        <div class="col-4">
                                                            <label for="middle_name" class="form-label">Middle Name</label>
                                                            <input type="text" class="form-control" id="middle_name_d" name="dependent[{{ $key }}][middle_name]" value="{{ $leadDependent->midle_name }}">
                                                            @error('middle_name')
                                                                <div class="text-danger">{{ $message }}</div>
                                                            @enderror
                                                        </div>
                                                        <div class="col-4">
                                                            <label for="last_name" class="form-label">Last Name</label>
                                                            <input type="text" class="form-control" id="last_name_d" name="dependent[{{ $key }}][last_name]" value="{{ $leadDependent->last_name }}" required>
                                                            @error('last_name')
                                                                <div class="text-danger">{{ $message }}</div>
                                                            @enderror
                                                        </div>
                                                    </div>
                                                    <div class="row">
                                                        <div class="col-4">
                                                            <label for="relationship" class="form-label">relationship</label>
                                                            <select class="form-select" id="relationship" name="dependent[{{ $key }}][relationship]" required>
                                                                @forelse ($relationships as $item)
                                                                    <option value="{{ $item->value }}"
                                                                        {{ isset($lead) && $leadDependent->relationship == $item->value ? 'selected' : '' }}>
                                                                        {{ $item->value }} </option>
                                                                @empty
                                                                    <option value="">Relationships not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>
                                                        <div class="col-4">
                                                            <label for="gender" class="form-label">Gender</label>
                                                            <select class="form-select" id="gender_d" name="dependent[{{ $key }}][gender]">
                                                                @forelse ($genders as $item)
                                                                    <option value="{{ $item->value }}"
                                                                        {{ isset($lead) && $leadDependent->gender == $item->value ? 'selected' : '' }}>
                                                                        {{ $item->value }} </option>
                                                                @empty
                                                                    <option value="">Gender not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>
                                                        <div class="col-4">
                                                            <label for="phone">Primary Phone</label>
                                                            <input type="text" class="form-control" id="phone_d" name="dependent[{{ $key }}][primary_phone_number]" placeholder="Primary Phone" value="{{ $leadDependent->primary_phone_number }}" autocomplete="off" required>
                                                            <div id="phone-error" class="text-default text-bold mt-2" style="display: none;"></div>
                                                            <div id="phone-loader" class="position-absolute top-50 end-0 translate-middle-y me-2" style="display: none;">
                                                                <div class="spinner-border text-primary" role="status">
                                                                    <span class="visually-hidden">Loading...</span>
                                                                </div>
                                                            </div>
                                                        </div>
                                                    </div>

                                                </div>
                                            </div>
                                        </div>
                                        <div class="accordion-item">
                                            <h2 class="accordion-header" id="headingTwo">
                                                <button class="accordion-button fw-medium collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseTwo" aria-expanded="false" aria-controls="collapseTwo">
                                                Basic Information                                            </button>
                                            </h2>
                                            <div id="collapseTwo" class="accordion-collapse collapse" aria-labelledby="headingTwo" data-bs-parent="#accordionExample">
                                                <div class="accordion-body">
                                                    <div class="row">
                                                        <div class="col-3">
                                                            <label for="phone_2" class="form-label">Phone2</label>
                                                            <input type="text" class="form-control" id="phone_2" name="dependent[{{ $key }}][phone_2]" value="{{ $leadDependent->phone_2 }}">
                                                        </div>

                                                        <div class="col-3">
                                                            <label for="dob" class="form-label">Date of Birth</label>
                                                            <input type="date" class="form-control" id="dob_dependent" name="dependent[{{ $key }}][dob]" value="{{ $leadDependent->dob }}">
                                                            @error('dob')
                                                                <div class="text-danger">{{ $message }}</div>
                                                            @enderror
                                                        </div>

                                                        <div class="col-3">
                                                            <label for="age" class="form-label">Age</label>
                                                            <input type="number" class="form-control" id="age_dependent" name="dependent[{{ $key }}][age]" value="{{ $leadDependent->age }}">
                                                            @error('age')
                                                                <div class="text-danger">{{ $message }}</div>
                                                            @enderror
                                                        </div>

                                                        <div class="col-3">
                                                            <label for="height" class="form-label">Height</label>
                                                            <input type="text" class="form-control" id="height" name="dependent[{{ $key }}][height]" value="{{ $leadDependent->height }}">
                                                        </div>

                                                        <div class="col-3">
                                                            <label for="weight" class="form-label">Weight</label>
                                                            <input type="text" class="form-control" id="weight" name="dependent[{{ $key }}][weight]" value="{{ $leadDependent->weight }}">
                                                        </div>

                                                        <div class="col-3">
                                                            <label for="email" class="form-label">Email</label>
                                                            <input type="email" class="form-control" id="email_dependent" name="dependent[{{ $key }}][email]" value="{{ $leadDependent->email }}">
                                                            @error('email1')
                                                                <div class="text-danger">{{ $message }}</div>
                                                            @enderror
                                                        </div>

                                                        <div class="col-3">
                                                            <label for="language" class="form-label">Language</label>
                                                            <select name="dependent[{{ $key }}][language]" class="form-select">
                                                                @forelse ($languages as $language)
                                                                    <option value="{{ $language->value }}"
                                                                        {{ isset($lead) && $leadDependent->language == $language->value ? 'selected' : '' }}>
                                                                        {{ $language->value }} </option>
                                                                @empty
                                                                    <option value="">Languages not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>

                                                        <div class="col-3">
                                                            <label for="annual_income" class="form-label">Annual Income</label>
                                                            <input type="number" class="form-control" id="annual_income_dependent" name="dependent[{{ $key }}][annual_income]" value="{{ $leadDependent->annual_income }}">
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="occupation" class="form-label">Occupation</label>
                                                            <input type="text" class="form-control" id="occupation_dependent" name="dependent[{{ $key }}][occupation]" value="{{ $leadDependent->occupation }}">
                                                        </div>

                                                        <div class="col-3">
                                                            <label for="ssn" class="form-label">SSN</label>
                                                            <input type="text" class="form-control" id="ssn_dependents" name="dependent[{{ $key }}][ssn]" value="{{ $leadDependent->ssn }}">
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="address_same_as_contact" class="form-label">Address is same as contact</label>
                                                            <select name="dependent[{{ $key }}][address_same_as_contact]" class="form-select">
                                                                <option value="1" @if($leadDependent->address_same_as_contact == 1) selected @endif>Yes</option>
                                                                <option value="0" @if($leadDependent->address_same_as_contact == 0) selected @endif>No</option>
                                                            </select>
                                                        </div>

                                                    </div>
                                                </div>
                                            </div>
                                        </div>

                                        <div class="accordion-item">
                                            <h2 class="accordion-header" id="headingThree">
                                                <button class="accordion-button fw-medium collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseThree" aria-expanded="false" aria-controls="collapseThree">
                                                Address Information
                                                </button>
                                            </h2>
                                            <div id="collapseThree" class="accordion-collapse collapse" aria-labelledby="headingThree" data-bs-parent="#accordionExample">
                                                <div class="accordion-body">
                                                    <div class="row">
                                                        <div class="col-3">
                                                            <label for="address" class="form-label">Address</label>
                                                            <input type="text" class="form-control" id="address" name="dependent[{{ $key }}][address]" value="{{ $leadDependent->address }}">
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="city" class="form-label">City</label>
                                                            <input type="text" class="form-control" id="city" name="dependent[{{ $key }}][city]" value="{{ $leadDependent->city }}">
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="zipcode" class="form-label">Zipcode</label>
                                                            <input type="text" class="form-control" id="zipcode" name="dependent[{{ $key }}][zipcode]" value="{{ $leadDependent->zipcode }}">
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="state" class="form-label">State</label>
                                                            <select name="dependent[{{ $key }}][state]" class="form-select">
                                                                @forelse ($states as $state)
                                                                    <option value="{{ $state->value }}"
                                                                        {{ isset($lead) && $leadDependent->state == $state->value ? 'selected' : '' }}>
                                                                        {{ $state->name }} </option>
                                                                @empty
                                                                    <option value="">States not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="country" class="form-label">Country</label>
                                                            <select name="dependent[{{ $key }}][country]" class="form-select">
                                                                @forelse ($countries as $country)
                                                                    <option value="{{ $country->value }}"
                                                                        {{ isset($lead) && $leadDependent->country == $country->value ? 'selected' : '' }}>
                                                                        {{ $country->name }} </option>
                                                                @empty
                                                                    <option value="">Countries not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>

                                        <div class="accordion-item">
                                            <h2 class="accordion-header" id="headingFive">
                                                <button class="accordion-button fw-medium collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseFive" aria-expanded="false" aria-controls="collapseFive">
                                                Medical Information
                                                </button>
                                            </h2>
                                            <div id="collapseFive" class="accordion-collapse collapse" aria-labelledby="headingFive" data-bs-parent="#accordionExample">
                                                <div class="accordion-body">
                                                    <div class="row">
                                                        <div class="col-6">
                                                            <label for="medications" class="form-label">Medications</label>
                                                            <textarea class="form-control" id="medications_dependent" name="dependent[{{ $key }}][medications]">{!! $leadDependent->medications !!}</textarea>
                                                        </div>
                                                        <div class="col-6">
                                                            <label for="conditions" class="form-label">Conditions</label>
                                                            <textarea class="form-control" id="conditions_dependent" name="dependent[{{ $key }}][conditions]">{!! $leadDependent->conditions !!}</textarea>
                                                        </div>
                                                    </div>
                                                    <div class="row">
                                                        <div class="col-3">
                                                            <label for="is_smoker" class="for-label">Is smoker?</label>
                                                            <select name="dependent[{{ $key }}][is_smoker]" class="form-select">
                                                                <option value="1" @if($leadDependent->is_smoker == 1) selected @endif>Yes</option>
                                                                <option value="0" @if($leadDependent->is_smoker == 0) selected @endif>No</option>
                                                            </select>
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="has_diabetes" class="for-label">Has diabetes?</label>
                                                            <select name="dependent[{{ $key }}][has_diabetes]" class="form-select">
                                                                <option value="1" @if($leadDependent->has_diabetes == 1) selected @endif>Yes</option>
                                                                <option value="0" @if($leadDependent->has_diabetes == 0) selected @endif>No</option>
                                                            </select>
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="has_cancer" class="for-label">Has cancer?</label>
                                                            <select name="dependent[{{ $key }}][has_cancer]" class="form-select">
                                                                <option value="1" @if($leadDependent->has_cancer == 1) selected @endif>Yes</option>
                                                                <option value="0" @if($leadDependent->has_cancer == 0) selected @endif>No</option>
                                                            </select>
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="has_heart_disease" class="for-label">Has heart disease?</label>
                                                            <select name="dependent[{{ $key }}][has_heart_disease]" class="form-select">
                                                                <option value="1" @if($leadDependent->has_heart_disease == 1) selected @endif>Yes</option>
                                                                <option value="0" @if($leadDependent->has_heart_disease == 0) selected @endif>No</option>
                                                            </select>
                                                        </div>
                                                    </div>
                                                    <div class="row">
                                                        <div class="col-3">
                                                            <label for="pcp_name" class="form-label">PCP Name</label>
                                                            <input type="text" class="form-control" id="pcp_name_dependent" name="dependent[{{ $key }}][pcp_name]" value="{{ $leadDependent->pcp_name }}">
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="pcp_id" class="form-label">PCP ID</label>
                                                            <input type="text" class="form-control" id="pcp_id_dependent" name="dependent[{{ $key }}][pcp_id]" value="{{ $leadDependent->pcp_id }}">
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="pcp_office" class="form-label">PCP Office</label>
                                                            <input type="text" class="form-control" id="pcp_office_dependent" name="dependent[{{ $key }}][pcp_office]" value="{{ $leadDependent->pcp_office }}">
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="mrn" class="form-label">MRN</label>
                                                            <input type="text" class="form-control" id="mrn_dependent" name="dependent[{{ $key }}][mrn]" value="{{ $leadDependent->mrn }}">
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="empi" class="form-label">EMPI</label>
                                                            <input type="text" class="form-control" id="empi_dependent" name="dependent[{{ $key }}][empi]" value="{{ $leadDependent->empi }}">
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="accordion-item">
                                            <h2 class="accordion-header" id="headingSix">
                                                <button class="accordion-button fw-medium collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseSix" aria-expanded="false" aria-controls="collapseSix">
                                                Medicare Information
                                                </button>
                                            </h2>
                                            <div id="collapseSix" class="accordion-collapse collapse" aria-labelledby="headingSix" data-bs-parent="#accordionExample">
                                                <div class="accordion-body">
                                                    <div class="row">
                                                        <div class="col-2">
                                                            <label for="medicare_claim_number_dependent" class="form-label">Medicare claim Number</label>
                                                            <input type="text" class="form-control" id="medicare_claim_number_dependent" name="dependent[{{ $key }}][medicare_claim_number]" value="{{ $leadDependent->medicare_claim_number }}">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="medicare_part_a" class="form-label">Medicare Part A</label>
                                                            <input type="text" class="form-control" id="medicare_part_a_dependent" name="dependent[{{ $key }}][medicare_part_a]" value="{{ $leadDependent->medicare_part_a }}">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="medicare_part_b" class="form-label">Medicare Part B</label>
                                                            <input type="text" class="form-control" id="medicare_part_b_dependent" name="dependent[{{ $key }}][medicare_part_b]" value="{{ $leadDependent->medicare_part_b }}">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="medicaid_number" class="form-label">Medicid Number</label>
                                                            <input type="text" class="form-control" id="medicaid_number_dependent" name="dependent[{{ $key }}][medicaid_number]" value="{{ $leadDependent->medicaid_number }}">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="medicaid_level_dependent" class="form-label">Medicaid Level</label>
                                                            <select name="dependent[{{ $key }}][medicaid_level]" class="form-select">
                                                                @forelse ($medicaidLevels as $item)
                                                                    <option value="{{ $item->value }}"
                                                                        {{ isset($lead) && $leadDependent->medicaid_level == $item->value ? 'selected' : '' }}>
                                                                        {{ $item->value }} </option>
                                                                @empty
                                                                    <option value="">Medicaid Levels not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="enrollment_eligibility_dependent" class="form-label">Enrollment Eligibility</label>
                                                            <select name="dependent[{{ $key }}][enrollment_eligibility]" class="form-select">
                                                                @forelse ($enrollmentEligibilities as $item)
                                                                    <option value="{{ $item->value }}"
                                                                        {{ isset($lead) && $leadDependent->enrollment_eligibility == $item->value ? 'selected' : '' }}>
                                                                        {{ $item->value }} </option>
                                                                @empty
                                                                    <option value="">Enrollment Eligibilities not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="scope_of_appointment" class="form-label">Scope of appointment</label>
                                                            <select name="dependent[{{ $key }}][scope_of_appointment]" class="form-select">
                                                                <option value="1" @if($leadDependent->scope_of_appointment == 1) selected @endif>Yes</option>
                                                                <option value="0" @if($leadDependent->scope_of_appointment == 0) selected @endif>No</option>
                                                            </select>
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="medicaid_username" class="form-label">Medicid Username</label>
                                                            <input type="text" class="form-control" id="medicaid_username_dependent" name="dependent[{{ $key }}][medicaid_username]" value="{{ $leadDependent->medicaid_username }}">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="medicaid_password" class="form-label">Medicid Password</label>
                                                            <input type="text" class="form-control" id="medicaid_password_dependent" name="dependent[{{ $key }}][medicaid_password]" value="{{ $leadDependent->medicaid_password }}">
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                        <div class="accordion-item">
                                            <h2 class="accordion-header" id="headingSeven">
                                                <button class="accordion-button fw-medium collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseSeven" aria-expanded="false" aria-controls="collapseSeven">
                                                Legal Information
                                                </button>
                                            </h2>
                                            <div id="collapseSeven" class="accordion-collapse collapse" aria-labelledby="headingSeven" data-bs-parent="#accordionExample">
                                                <div class="accordion-body">
                                                    <div class="row">
                                                        <div class="col-2">
                                                            <label for="legal_status" class="form-label">Legal Status</label>
                                                            <input type="text" class="form-control" id="legal_status" name="dependent[{{ $key }}][legal_status]" value="{{ $leadDependent->legal_status }}">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="immigration_document" class="form-label">Immigration Document</label>
                                                            <input type="text" class="form-control" id="immigration_document_dependent" name="dependent[{{ $key }}][immigration_document]" value="{{ $leadDependent->immigration_document}}">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="alien_number" class="form-label" tooltip="USCIS Number, format is A123456789">Alien #</label>
                                                            <input type="text" class="form-control" id="alien_number_dependent" name="dependent[{{ $key }}][alien_number]" value="{{ $leadDependent->alien_number }}">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="i_94_number" class="form-label" tooltip="I-94 / I-94A Arrival / Departure Record #">I-94 #</label>
                                                            <input type="text" class="form-control" id="i_94_number_dependent" name="dependent[{{ $key }}][i_94_number]" value="{{ $leadDependent->i_94_number }}">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="green_card_number" class="form-label">Green Card #</label>
                                                            <input type="text" class="form-control" id="green_card_number_dependent" name="dependent[{{ $key }}][green_card_number]" value="{{ $leadDependent->green_card_number }}">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="immigration_status" class="form-label">Immigration Statuses</label>
                                                            <select name="dependent[{{ $key }}][immigration_statuses]" class="form-select">
                                                                @forelse ($immigrationStatuses as $item)
                                                                    <option value="{{ $item->value }}"
                                                                        {{ isset($lead) && $leadDependent->immigration_statuses == $item->value ? 'selected' : '' }}>
                                                                        {{ $item->value }} </option>
                                                                @empty
                                                                    <option value=""> Immigration Statuses not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="other-statuses" class="form-label">Other Statuses</label>
                                                            <select name="dependent[{{ $key }}][other_statuses]" class="form-select">
                                                                @forelse ($otherStatuses as $item)
                                                                    <option value="{{ $item->value }}"
                                                                        {{ isset($lead) && $leadDependent->other_statuses == $item->value ? 'selected' : '' }}>
                                                                        {{ $item->value }} </option>
                                                                @empty
                                                                    <option value="">Other Statuses not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="savis_id" class="form-label">Sevis ID</label>
                                                            <input type="text" class="form-control" id="savis_id_dependent" name="dependent[{{ $key }}][sevis_id]" value="{{ $leadDependent->sevis_id }}">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="passport" class="form-label">Passport</label>
                                                            <input type="text" class="form-control" id="passport_dependent" name="dependent[{{ $key }}][passport]" value="{{ $leadDependent->passport }}">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="passport_country" class="form-label">Passport Country</label>
                                                            <select name="dependent[{{ $key }}][passport_country]" class="form-select">
                                                                @forelse ($passportCountries as $item)
                                                                    <option value="{{ $item->value }}"
                                                                        {{ isset($lead) && $leadDependent->passport_country == $item->value ? 'selected' : '' }}>
                                                                        {{ $item->value }} </option>
                                                                @empty
                                                                    <option value="">Passport Countries not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="passport_expiration" class="form-label">Passport Expiration</label>
                                                            <input type="date" class="form-control" id="passport_expiration_dependent" name="dependent[{{ $key }}][passport_expiration]" value="{{ $leadDependent->passport_expiration }}">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="ead_card_number" class="form-label">EAD Card Number</label>
                                                            <input type="text" class="form-control" id="ead_card_number_dependent" name="dependent[{{ $key }}][ead_card_number]" value="{{ $leadDependent->ead_card_number }}">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="ead_card_code" class="form-label">EAD Card Code</label>
                                                            <input type="text" class="form-control" id="ead_card_code_dependent" name="dependent[{{ $key }}][ead_card_code]" value="{{ $leadDependent->ead_card_code }}">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="ead_card_expiration" class="form-label">EAD Card Expiration</label>
                                                            <input type="date" class="form-control" id="ead_card_expiration_dependent" name="dependent[{{ $key }}][ead_card_expiration]" value="{{ $leadDependent->ead_card_expiration }}">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="naturalization" class="form-label">Naturalization</label>
                                                            <input type="text" class="form-control" id="naturalization_dependent" name="dependent[{{ $key }}][naturalization]" value="{{ $leadDependent->naturalization }}">
                                                        </div>

                                                        <div class="col-2">
                                                            <label for="exclude-from-policies" class="form-label">Exclude from Policies ?</label>
                                                            <select name="dependent[{{ $key }}][exclude_from_policies]" class="form-select">
                                                                <option value="1" @if($leadDependent->excluded_from_policies == 1) selected @endif>Yes</option>
                                                                <option value="0" @if($leadDependent->excluded_from_policies == 0) selected @endif>No</option>
                                                            </select>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                    </div>
                                @empty
                                    <div class="accordion" id="accordionPanelsStayOpenExample">
                                        <div class="accordion-item">
                                            <h2 class="accordion-header" id="headingOne">
                                                <button class="accordion-button fw-medium" type="button" data-bs-toggle="collapse" data-bs-target="#collapseOne" aria-expanded="true" aria-controls="collapseOne">
                                                Primary Information
                                                </button>
                                            </h2>
                                            <div id="collapseOne" class="accordion-collapse collapse show" aria-labelledby="headingOne" data-bs-parent="#accordionExample">
                                                <div class="accordion-body">
                                                    <div class="row">
                                                        <div class="col-4">
                                                            <label for="d_first_name" class="form-label">First Name</label>
                                                            <input type="text" class="form-control" id="d_first_name" name="dependent[1][first_name]" required>
                                                            @error('first_name')
                                                                <div class="text-danger">{{ $message }}</div>
                                                            @enderror
                                                        </div>
                                                        <div class="col-4">
                                                            <label for="middle_name" class="form-label">Middle Name</label>
                                                            <input type="text" class="form-control" id="middle_name_d" name="dependent[1][middle_name]">
                                                            @error('middle_name')
                                                                <div class="text-danger">{{ $message }}</div>
                                                            @enderror
                                                        </div>
                                                        <div class="col-4">
                                                            <label for="last_name" class="form-label">Last Name</label>
                                                            <input type="text" class="form-control" id="last_name_d" name="dependent[1][last_name]" required>
                                                            @error('last_name')
                                                                <div class="text-danger">{{ $message }}</div>
                                                            @enderror
                                                        </div>
                                                    </div>
                                                    <div class="row">
                                                        <div class="col-4">
                                                            <label for="relationship" class="form-label">relationship</label>
                                                            <select class="form-select" id="relationship" name="dependent[1][relationship]" required>
                                                                @forelse ($relationships as $item)
                                                                    <option value="{{ $item->value }}">
                                                                        {{ $item->value }} </option>
                                                                @empty
                                                                    <option value="">Relationships not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>
                                                        <div class="col-4">
                                                            <label for="gender" class="form-label">Gender</label>
                                                            <select class="form-select" id="gender_d" name="dependent[1][gender]">
                                                                @forelse ($genders as $item)
                                                                    <option value="{{ $item->value }}">
                                                                        {{ $item->value }} </option>
                                                                @empty
                                                                    <option value="">Gender not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>
                                                        <div class="col-4">
                                                            <label for="phone">Primary Phone</label>
                                                            <input type="text" class="form-control" id="phone_d" name="dependent[1][primary_phone_number]" placeholder="Primary Phone" autocomplete="off" required>
                                                            <div id="phone-error" class="text-default text-bold mt-2" style="display: none;"></div>
                                                            <div id="phone-loader" class="position-absolute top-50 end-0 translate-middle-y me-2" style="display: none;">
                                                                <div class="spinner-border text-primary" role="status">
                                                                    <span class="visually-hidden">Loading...</span>
                                                                </div>
                                                            </div>
                                                        </div>
                                                    </div>

                                                </div>
                                            </div>
                                        </div>
                                        <div class="accordion-item">
                                            <h2 class="accordion-header" id="headingTwo">
                                                <button class="accordion-button fw-medium collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseTwo" aria-expanded="false" aria-controls="collapseTwo">
                                                Basic Information                                            </button>
                                            </h2>
                                            <div id="collapseTwo" class="accordion-collapse collapse" aria-labelledby="headingTwo" data-bs-parent="#accordionExample">
                                                <div class="accordion-body">
                                                    <div class="row">
                                                        <div class="col-3">
                                                            <label for="phone_2" class="form-label">Phone2</label>
                                                            <input type="text" class="form-control" id="phone_2" name="dependent[1][phone_2]">
                                                        </div>

                                                        <div class="col-3">
                                                            <label for="dob" class="form-label">Date of Birth</label>
                                                            <input type="date" class="form-control" id="dob_dependent" name="dependent[1][dob]">
                                                            @error('dob')
                                                                <div class="text-danger">{{ $message }}</div>
                                                            @enderror
                                                        </div>

                                                        <div class="col-3">
                                                            <label for="age" class="form-label">Age</label>
                                                            <input type="number" class="form-control" id="age_dependent" name="dependent[1][age]">
                                                            @error('age')
                                                                <div class="text-danger">{{ $message }}</div>
                                                            @enderror
                                                        </div>

                                                        <div class="col-3">
                                                            <label for="height" class="form-label">Height</label>
                                                            <input type="text" class="form-control" id="height" name="dependent[1][height]">
                                                        </div>

                                                        <div class="col-3">
                                                            <label for="weight" class="form-label">Weight</label>
                                                            <input type="text" class="form-control" id="weight" name="dependent[1][weight]">
                                                        </div>

                                                        <div class="col-3">
                                                            <label for="email" class="form-label">Email</label>
                                                            <input type="email" class="form-control" id="email_dependent" name="dependent[1][email]">
                                                            @error('email1')
                                                                <div class="text-danger">{{ $message }}</div>
                                                            @enderror
                                                        </div>

                                                        <div class="col-3">
                                                            <label for="language" class="form-label">Language</label>
                                                            <select name="dependent[1][language]" class="form-select">
                                                                @forelse ($languages as $language)
                                                                    <option value="{{ $language->value }}">
                                                                        {{ $language->value }} </option>
                                                                @empty
                                                                    <option value="">Languages not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>

                                                        <div class="col-3">
                                                            <label for="annual_income" class="form-label">Annual Income</label>
                                                            <input type="number" class="form-control" id="annual_income_dependent" name="dependent[1][annual_income]">
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="occupation" class="form-label">Occupation</label>
                                                            <input type="text" class="form-control" id="occupation_dependent" name="dependent[1][occupation]">
                                                        </div>

                                                        <div class="col-3">
                                                            <label for="ssn" class="form-label">SSN</label>
                                                            <input type="text" class="form-control" id="ssn_dependents" name="dependent[1][ssn]">
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="address_same_as_contact" class="form-label">Address is same as contact</label>
                                                            <select name="dependent[1][address_same_as_contact]" class="form-select">
                                                                <option value="1">Yes</option>
                                                                <option value="0">No</option>
                                                            </select>
                                                        </div>

                                                    </div>
                                                </div>
                                            </div>
                                        </div>

                                        <div class="accordion-item">
                                            <h2 class="accordion-header" id="headingThree">
                                                <button class="accordion-button fw-medium collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseThree" aria-expanded="false" aria-controls="collapseThree">
                                                Address Information
                                                </button>
                                            </h2>
                                            <div id="collapseThree" class="accordion-collapse collapse" aria-labelledby="headingThree" data-bs-parent="#accordionExample">
                                                <div class="accordion-body">
                                                    <div class="row">
                                                        <div class="col-3">
                                                            <label for="address" class="form-label">Address</label>
                                                            <input type="text" class="form-control" id="address" name="dependent[1][address]">
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="city" class="form-label">City</label>
                                                            <input type="text" class="form-control" id="city" name="dependent[1][city]">
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="zipcode" class="form-label">Zipcode</label>
                                                            <input type="text" class="form-control" id="zipcode" name="dependent[1][zipcode]">
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="state" class="form-label">State</label>
                                                            <select name="dependent[1][state]" class="form-select">
                                                                @forelse ($states as $state)
                                                                    <option value="{{ $state->value }}">
                                                                        {{ $state->name }} </option>
                                                                @empty
                                                                    <option value="">States not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="country" class="form-label">Country</label>
                                                            <select name="dependent[1][country]" class="form-select">
                                                                @forelse ($countries as $country)
                                                                    <option value="{{ $country->value }}">
                                                                        {{ $country->name }} </option>
                                                                @empty
                                                                    <option value="">Countries not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>

                                        <div class="accordion-item">
                                            <h2 class="accordion-header" id="headingFive">
                                                <button class="accordion-button fw-medium collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseFive" aria-expanded="false" aria-controls="collapseFive">
                                                Medical Information
                                                </button>
                                            </h2>
                                            <div id="collapseFive" class="accordion-collapse collapse" aria-labelledby="headingFive" data-bs-parent="#accordionExample">
                                                <div class="accordion-body">
                                                    <div class="row">
                                                        <div class="col-6">
                                                            <label for="medications" class="form-label">Medications</label>
                                                            <textarea class="form-control" id="medications_dependent" name="dependent[1][medications]"></textarea>
                                                        </div>
                                                        <div class="col-6">
                                                            <label for="conditions" class="form-label">Conditions</label>
                                                            <textarea class="form-control" id="conditions_dependent" name="dependent[1][conditions]"></textarea>
                                                        </div>
                                                    </div>
                                                    <div class="row">
                                                        <div class="col-3">
                                                            <label for="is_smoker" class="for-label">Is smoker?</label>
                                                            <select name="dependent[1][is_smoker]" class="form-select">
                                                                <option value="1">Yes</option>
                                                                <option value="0">No</option>
                                                            </select>
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="has_diabetes" class="for-label">Has diabetes?</label>
                                                            <select name="dependent[1][has_diabetes]" class="form-select">
                                                                <option value="1">Yes</option>
                                                                <option value="0">No</option>
                                                            </select>
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="has_cancer" class="for-label">Has cancer?</label>
                                                            <select name="dependent[1][has_cancer]" class="form-select">
                                                                <option value="1">Yes</option>
                                                                <option value="0">No</option>
                                                            </select>
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="has_heart_disease" class="for-label">Has heart disease?</label>
                                                            <select name="dependent[1][has_heart_disease]" class="form-select">
                                                                <option value="1">Yes</option>
                                                                <option value="0">No</option>
                                                            </select>
                                                        </div>
                                                    </div>
                                                    <div class="row">
                                                        <div class="col-3">
                                                            <label for="pcp_name" class="form-label">PCP Name</label>
                                                            <input type="text" class="form-control" id="pcp_name_dependent" name="dependent[1][pcp_name]">
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="pcp_id" class="form-label">PCP ID</label>
                                                            <input type="text" class="form-control" id="pcp_id_dependent" name="dependent[1][pcp_id]">
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="pcp_office" class="form-label">PCP Office</label>
                                                            <input type="text" class="form-control" id="pcp_office_dependent" name="dependent[1][pcp_office]">
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="mrn" class="form-label">MRN</label>
                                                            <input type="text" class="form-control" id="mrn_dependent" name="dependent[1][mrn]">
                                                        </div>
                                                        <div class="col-3">
                                                            <label for="empi" class="form-label">EMPI</label>
                                                            <input type="text" class="form-control" id="empi_dependent" name="dependent[1][empi]">
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>

                                        <div class="accordion-item">
                                            <h2 class="accordion-header" id="headingSix">
                                                <button class="accordion-button fw-medium collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseSix" aria-expanded="false" aria-controls="collapseSix">
                                                Medicare Information
                                                </button>
                                            </h2>
                                            <div id="collapseSix" class="accordion-collapse collapse" aria-labelledby="headingSix" data-bs-parent="#accordionExample">
                                                <div class="accordion-body">
                                                    <div class="row">
                                                        <div class="col-2">
                                                            <label for="medicare_claim_number_dependent" class="form-label">Medicare claim Number</label>
                                                            <input type="text" class="form-control" id="medicare_claim_number_dependent" name="dependent[1][medicare_claim_number]">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="medicare_part_a" class="form-label">Medicare Part A</label>
                                                            <input type="text" class="form-control" id="medicare_part_a_dependent" name="dependent[1][medicare_part_a]">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="medicare_part_b" class="form-label">Medicare Part B</label>
                                                            <input type="text" class="form-control" id="medicare_part_b_dependent" name="dependent[1][medicare_part_b]">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="medicaid_number" class="form-label">Medicid Number</label>
                                                            <input type="text" class="form-control" id="medicaid_number_dependent" name="dependent[1][medicaid_number]">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="medicaid_level_dependent" class="form-label">Medicaid Level</label>
                                                            <select name="dependent[1][medicaid_level]" class="form-select">
                                                                @forelse ($medicaidLevels as $item)
                                                                    <option value="{{ $item->value }}">
                                                                        {{ $item->value }} </option>
                                                                @empty
                                                                    <option value="">Medicaid Levels not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="enrollment_eligibility_dependent" class="form-label">Enrollment Eligibility</label>
                                                            <select name="dependent[1][enrollment_eligibility]" class="form-select">
                                                                @forelse ($enrollmentEligibilities as $item)
                                                                    <option value="{{ $item->value }}">
                                                                        {{ $item->value }} </option>
                                                                @empty
                                                                    <option value="">Enrollment Eligibilities not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="scope_of_appointment" class="form-label">Scope of appointment</label>
                                                            <select name="dependent[1][scope_of_appointment]" class="form-select">
                                                                <option value="1">Yes</option>
                                                                <option value="0">No</option>
                                                            </select>
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="medicaid_username" class="form-label">Medicid Username</label>
                                                            <input type="text" class="form-control" id="medicaid_username_dependent" name="dependent[1][medicaid_username]">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="medicaid_password" class="form-label">Medicid Password</label>
                                                            <input type="text" class="form-control" id="medicaid_password_dependent" name="dependent[1][medicaid_password]">
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>

                                        <div class="accordion-item">
                                            <h2 class="accordion-header" id="headingSeven">
                                                <button class="accordion-button fw-medium collapsed" type="button" data-bs-toggle="collapse" data-bs-target="#collapseSeven" aria-expanded="false" aria-controls="collapseSeven">
                                                Legal Information
                                                </button>
                                            </h2>
                                            <div id="collapseSeven" class="accordion-collapse collapse" aria-labelledby="headingSeven" data-bs-parent="#accordionExample">
                                                <div class="accordion-body">
                                                    <div class="row">
                                                        <div class="col-2">
                                                            <label for="legal_status" class="form-label">Legal Status</label>
                                                            <input type="text" class="form-control" id="legal_status" name="dependent[1][legal_status]">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="immigration_document" class="form-label">Immigration Document</label>
                                                            <input type="text" class="form-control" id="immigration_document_dependent" name="dependent[1][immigration_document]">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="alien_number" class="form-label" tooltip="USCIS Number, format is A123456789">Alien #</label>
                                                            <input type="text" class="form-control" id="alien_number_dependent" name="dependent[1][alien_number]">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="i_94_number" class="form-label" tooltip="I-94 / I-94A Arrival / Departure Record #">I-94 #</label>
                                                            <input type="text" class="form-control" id="i_94_number_dependent" name="dependent[1][i_94_number]">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="green_card_number" class="form-label">Green Card #</label>
                                                            <input type="text" class="form-control" id="green_card_number_dependent" name="dependent[1][green_card_number]">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="immigration_status" class="form-label">Immigration Statuses</label>
                                                            <select name="dependent[1][immigration_statuses]" class="form-select">
                                                                @forelse ($immigrationStatuses as $item)
                                                                    <option value="{{ $item->value }}">
                                                                        {{ $item->value }} </option>
                                                                @empty
                                                                    <option value=""> Immigration Statuses not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="other-statuses" class="form-label">Other Statuses</label>
                                                            <select name="dependent[1][other_statuses]" class="form-select">
                                                                @forelse ($otherStatuses as $item)
                                                                    <option value="{{ $item->value }}">
                                                                        {{ $item->value }} </option>
                                                                @empty
                                                                    <option value="">Other Statuses not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="savis_id" class="form-label">Sevis ID</label>
                                                            <input type="text" class="form-control" id="savis_id_dependent" name="dependent[1][sevis_id]">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="passport" class="form-label">Passport</label>
                                                            <input type="text" class="form-control" id="passport_dependent" name="dependent[1][passport]">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="passport_country" class="form-label">Passport Country</label>
                                                            <select name="dependent[1][passport_country]" class="form-select">
                                                                @forelse ($passportCountries as $item)
                                                                    <option value="{{ $item->value }}">
                                                                        {{ $item->value }} </option>
                                                                @empty
                                                                    <option value="">Passport Countries not found!</option>
                                                                @endforelse
                                                            </select>
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="passport_expiration" class="form-label">Passport Expiration</label>
                                                            <input type="date" class="form-control" id="passport_expiration_dependent" name="dependent[1][passport_expiration]">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="ead_card_number" class="form-label">EAD Card Number</label>
                                                            <input type="text" class="form-control" id="ead_card_number_dependent" name="dependent[1][ead_card_number]">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="ead_card_code" class="form-label">EAD Card Code</label>
                                                            <input type="text" class="form-control" id="ead_card_code_dependent" name="dependent[1][ead_card_code]">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="ead_card_expiration" class="form-label">EAD Card Expiration</label>
                                                            <input type="date" class="form-control" id="ead_card_expiration_dependent" name="dependent[1][ead_card_expiration]">
                                                        </div>
                                                        <div class="col-2">
                                                            <label for="naturalization" class="form-label">Naturalization</label>
                                                            <input type="text" class="form-control" id="naturalization_dependent" name="dependent[1][naturalization]">
                                                        </div>

                                                        <div class="col-2">
                                                            <label for="exclude-from-policies" class="form-label">Exclude from Policies ?</label>
                                                            <select name="dependent[1][exclude_from_policies]" class="form-select">
                                                                <option value="1">Yes</option>
                                                                <option value="0">No</option>
                                                            </select>
                                                        </div>
                                                    </div>
                                                </div>
                                            </div>
                                        </div>
                                    </div>
                                @endforelse

                                <div class="row mt-3">
                                    <div class="col-12">
                                        <button type="submit" class="btn btn-primary">Submit</button>
                                    </div>
                                </div>
                            </form>
                        </div>

                        {{-- Opporunities Tab --}}
                        <div class="tab-pane" id="opportunities" role="tabpanel">
                            <form action="" method="POST">
                                @csrf
                                <div class="row">
                                    <div class="col-6">
                                        <label for="carrier" class="form-label">Carrier</label>
                                        <select name="carrier" class="form-select">
                                            <option value="1">Carrier 1</option>
                                            <option value="2">Carrier 2</option>
                                            <option value="3">Carrier 3</option>
                                        </select>
                                    </div>
                                    <div class="col-6">
                                        <label for="product" class="form-label">Product</label>
                                        <select name="product" class="form-select">
                                            <option value="1">Product 1</option>
                                            <option value="2">Product 2</option>
                                            <option value="3">Product 3</option>
                                        </select>
                                    </div>
                                </div>
                                <div class="row">
                                    <div class="col-2">
                                        <label for="application-number" class="form-label">Application Number</label>
                                        <input type="text" class="form-control" id="application-number" name="application-number">
                                    </div>
                                    <div class="col-2">
                                        <label for="policy-number" class="form-label">Policy Number</label>
                                        <input type="text" class="form-control" id="policy-number" name="policy-number">
                                    </div>
                                    <div class="col-2">
                                        <label for="member-id" class="form-label">Member ID</label>
                                        <input type="text" class="form-control" id="member-id" name="member-id">
                                    </div>
                                    <div class="col-2">
                                        <label for="policy-name" class="form-label">Policy Name</label>
                                        <input type="text" class="form-control" id="policy-name" name="policy-name">
                                    </div>
                                    <div class="col-2">
                                        <label for="policy-code" class="form-label">Policy Code</label>
                                        <input type="text" class="form-control" id="policy-code" name="policy-code">
                                    </div>
                                    <div class="col-2">
                                        <label for="primary-policy" class="form-label">Primary Policy</label>
                                        <select name="primary-policy" class="form-select">
                                            <option value="yes">Yes</option>
                                            <option value="no">No</option>
                                        </select>
                                    </div>
                                    <div class="col-2">
                                        <label for="premium" class="form-label">Premium</label>
                                        <input type="number" class="form-control" id="premium" name="premium">
                                    </div>
                                    <div class="col-2">
                                        <label for="enrollment-fee" class="form-label">Enrollment Fee</label>
                                        <input type="number" class="form-control" id="enrollment-fee" name="enrollment-fee">
                                    </div>
                                    <div class="col-2">
                                        <label for="admin-fee" class="form-label">Admin Fee</label>
                                        <input type="number" class="form-control" id="admin-fee" name="admin-fee">
                                    </div>
                                    <div class="col-2">
                                        <label for="deposit" class="form-label">Deposit</label>
                                        <input type="number" class="form-control" id="deposit" name="deposit">
                                    </div>
                                </div>
                            </form>
                        </div>

                        <!-- Policies Tab -->
                        <div class="tab-pane" id="policies" role="tabpanel">
                            <form action="" method="POST">
                                @csrf
                                <!-- Policies Form Fields -->
                                <div id="policies-container">
                                    <div class="input-group mb-2">
                                        <input type="text" class="form-control" name="policies[]" placeholder="Enter policy name" required>
                                        <button type="button" class="btn btn-outline-secondary add-policy"><i class="fas fa-plus"></i></button>
                                        <button type="button" class="btn btn-outline-danger remove-policy d-none"><i class="fas fa-minus"></i></button>
                                    </div>
                                </div>
                                <div class="input-group mb-2 template d-none">
                                    <input type="text" class="form-control" name="policies[]" placeholder="Enter policy name" required>
                                    <button type="button" class="btn btn-outline-secondary add-policy"><i class="fas fa-plus"></i></button>
                                    <button type="button" class="btn btn-outline-danger remove-policy"><i class="fas fa-minus"></i></button>
                                </div>
                                <button type="submit" class="btn btn-primary">Add Policies</button>
                            </form>
                        </div>

                        <!-- Notes Tab -->
                        <div class="tab-pane" id="notes" role="tabpanel">
                            <form action="" method="POST">
                                @csrf
                                <!-- Notes Form Fields -->
                                <div id="notes-container">
                                    <div class="input-group mb-2">
                                        <textarea class="form-control" name="notes[]" placeholder="Enter note" required></textarea>
                                        <button type="button" class="btn btn-outline-secondary add-note"><i class="fas fa-plus"></i></button>
                                        <button type="button" class="btn btn-outline-danger remove-note d-none"><i class="fas fa-minus"></i></button>
                                    </div>
                                </div>
                                <div class="input-group mb-2 template d-none">
                                    <textarea class="form-control" name="notes[]" placeholder="Enter note" required></textarea>
                                    <button type="button" class="btn btn-outline-secondary add-note"><i class="fas fa-plus"></i></button>
                                    <button type="button" class="btn btn-outline-danger remove-note"><i class="fas fa-minus"></i></button>
                                </div>
                                <button type="submit" class="btn btn-primary">Add Notes</button>
                            </form>
                        </div>

                        <!-- Recording Tab -->
                        <div class="tab-pane" id="recording" role="tabpanel">
                            <form action="" method="POST" enctype="multipart/form-data">
                                @csrf
                                <!-- Recording Form Fields -->
                                <div class="mb-3">
                                    <label for="recording_file" class="form-label">Upload Recording</label>
                                    <input type="file" class="form-control" id="recording_file" name="recording_file">
                                    @error('recording_file')
                                        <div class="text-danger">{{ $message }}</div>
                                    @enderror
                                </div>
                                <button type="submit" class="btn btn-primary">Upload Recording</button>
                            </form>
                        </div>
                    </div>

                </div>
            </div>
        </div>
    </div>
</div>
@endsection

@section('page-specific-script')
<script src="https://cdnjs.cloudflare.com/ajax/libs/bootstrap-tagsinput/0.8.0/bootstrap-tagsinput.min.js"></script>
<script>
    document.addEventListener('DOMContentLoaded', function () {
        $('#tags').tagsinput({
            trimValue: true,
            allowDuplicates: false
        });

        const containers = {
            dependents: document.getElementById('dependents-container'),
            policies: document.getElementById('policies-container'),
            notes: document.getElementById('notes-container')
        };

        // Add and Remove functionality for dependents, policies, and notes
        function handleTabAction(containerId, addClass, removeClass) {
            const container = containers[containerId];

            container.addEventListener('click', function (e) {
                if (e.target.classList.contains(addClass)) {
                    e.preventDefault();
                    const template = document.querySelector(`.${containerId}-container .template`).cloneNode(true);
                    template.classList.remove('template', 'd-none');
                    container.appendChild(template);
                }

                if (e.target.classList.contains(removeClass)) {
                    e.preventDefault();
                    e.target.closest('.input-group').remove();
                    updateRemoveButtonVisibility(containerId);
                }
            });

            function updateRemoveButtonVisibility(id) {
                const inputGroups = containers[id].querySelectorAll('.input-group');
                const removeButtons = containers[id].querySelectorAll(`.${removeClass}`);
                removeButtons.forEach(button => button.classList.toggle('d-none', inputGroups.length <= 1));
            }

            // Initialize remove button visibility
            updateRemoveButtonVisibility(containerId);
        }

        // Initialize handlers for dependents, policies, and notes
        handleTabAction('dependents', 'add-dependent', 'remove-dependent');
        handleTabAction('policies', 'add-policy', 'remove-policy');
        handleTabAction('notes', 'add-note', 'remove-note');
    });

    $(document).ready(function() {
        // Function to update income fields
        function updateIncomeFields() {
            // Get values from inputs
            const annualIncome = parseFloat($('#annual_income').val()) || 0;
            const householdAnnualIncome = parseFloat($('#household_annual_income').val()) || 0;

            // Calculate monthly and weekly income
            const monthlyIncome = annualIncome / 12;
            const weeklyIncome = annualIncome / 52;

            const householdMonthlyIncome = householdAnnualIncome / 12;
            const householdWeeklyIncome = householdAnnualIncome / 52;

            // Update fields
            $('#monthly_income').val(monthlyIncome.toFixed(2));
            $('#weekly_income').val(weeklyIncome.toFixed(2));

            $('#household_monthly_income').val(householdMonthlyIncome.toFixed(2));
            $('#household_weekly_income').val(householdWeeklyIncome.toFixed(2));
        }

        // Attach event listeners to annual income fields using jQuery
        $(document).on('input', '#annual_income', updateIncomeFields);
        $(document).on('input', '#household_annual_income', updateIncomeFields);

        // Initial update
        updateIncomeFields();
    });
</script>
@endsection