File: /var/www/html/taxicamera/applicationold/views/admin/setting/pdf.php
<!doctype html>
<html>
<head>
<meta charset="utf-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta name="viewport" content="width=device-width, initial-scale=1">
<title>EC Legal Claim Form</title>
</head>
<body>
<div class="body_wrapper" style="border: 1px solid #ccc;padding: 20px;width:750px;margin: 40px auto;">
<form>
<div style="width: 100%;display: inline-block;">
<div style="width: 60%;float: left;"><a href="#">
<img style="max-width: 100%;display: block;" src="<?= base_url('./images/logo.jpg') ?>" alt="" />
</a></div>
<div style="40%;float: right;text-align: right;">
<p style="color:#000;font-size: 12px;font-weight: normal;margin: 0 0 2px;">E C Legal Pty Ltd ABN 20 050 271 684</p>
<p style="color:#000;font-size: 12px;font-weight: normal;margin: 0 0 2px;">Level 9, 461 Bourke Street, Melbourne VIC 3000</p>
<p style="color:#000;font-size: 12px;font-weight: normal;margin: 0 0 2px;">Tel: 03 8611 2699 | Email: info@eclegal.com.au</p>
<a href="www.eclegal.com.au" style="color:#6aaab8;text-decoration: none;font-size: 11px;font-weight: normal;margin: 0;">www.eclegal.com.au</a>
</div>
</div>
<h2 style="color:#000;font-size: 28px;font-weight: normal;margin: 20px 0 20px;text-align: center;">Motor Vehicle Claim Instructions</h2>
<div style="width: 100%;display: inline-block;">
<div style="width:49%;float: left;">
<label style="width: 17%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Repairer:</label>
<div style="width: 83%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" readonly/>
</div>
</div>
<div style="width:49%;float: right;">
<label style="width: 17%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Phone:</label>
<div style="width: 83%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" readonly/>
</div>
</div>
</div>
<?php if(isset($owner_vehicle) && $owner_vehicle):?>
<div style="background: #eeeeef;padding: 15px;width: 100%;display: inline-block;margin: 30px 0 0;box-sizing: border-box;">
<h2 style="color:#6aaab8;font-size: 21px;font-weight: normal;margin: 0 0 20px;">Your Vehicle Details:</h2>
<div style="width: 100%;display: inline-block;">
<div style="width:49%;float: left;">
<label style="width: 36%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Make, Model & Year:</label>
<div style="width: 64%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" value="<?= $owner_vehicle['company_make'];?>" readonly/>
</div>
</div>
<div style="width:49%;float: right;">
<label style="width: 17%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Rego:</label>
<div style="width: 83%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" value="<?= $owner_vehicle['company_rego'];?>" readonly/>
</div>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<label style="width: 7%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Insured:</label>
<div style="width:17%;float: left;position: relative;top: 4px;">
<input type="checkbox" name="" value=""> Yes
<input type="checkbox" name="" value=""> No
</div>
<label style="width: 40%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">If Yes, name of Insurer & Claim/Policy number:</label>
<div style="width: 36%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" readonly/>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<label style="width: 17%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Owner Name:</label>
<div style="width: 83%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="MR/MRS/MS" value="<?= $owner_vehicle['company_name'];?>" readonly/>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<label style="width: 17%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Owner Address:</label>
<div style="width: 83%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" value="<?= $owner_vehicle['companyaddress'];?>" readonly/>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<div style="width:49%;float: left;">
<label style="width: 35%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Owner Contact:</label>
<div style="width: 65%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="Home/Work" value="<?= $owner_vehicle['company_landline'];?>" readonly/>
</div>
</div>
<div style="width:49%;float: right;">
<div style="width: 100%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="Mobile" value="<?= $owner_vehicle['company_mobile'];?>" readonly/>
</div>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<div style="width:49%;float: left;">
<label style="width: 35%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Email:</label>
<div style="width: 65%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="Home/Work" value="<?= $owner_vehicle['company_email'];?>" readonly/>
</div>
</div>
<div style="width:49%;float: right;">
<div style="width:40%;float: left;position: relative;top: 4px;">
<label>GST:</label>
<input type="checkbox" name="" value=""> Yes
<input type="checkbox" name="" value=""> No
</div>
<label style="width: 11%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">ABN:</label>
<div style="width: 48%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" value="<?= $owner_vehicle['company_abn'];?>" readonly/>
</div>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<label style="width: 17%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Driver Name:</label>
<div style="width: 83%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="MR/MRS/MS" value="<?= $owner_vehicle['drivername'];?>" readonly/>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<label style="width: 17%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Driver Address:</label>
<div style="width: 83%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" value="<?= $owner_vehicle['driveraddress'];?>" readonly/>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<div style="width:49%;float: left;">
<label style="width: 23%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Date of Birth:</label>
<div style="width: 65%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" value="<?= $owner_vehicle['driverdob'];?>" readonly/>
</div>
</div>
<div style="width:49%;float: right;">
<label style="width: 39%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">License & Expiry Date:</label>
<div style="width: 59%;float: right">
<?php //$date=$owner_vehicle['driver_dr_licence_expiry'];
$old_date = $owner_vehicle['driver_dr_licence_expiry'];
$date = new DateTime($old_date);
$new_date= $date->format('d/m/Y');
?>
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder=""
value="<?php echo $new_date;?>" readonly />
</div>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<div style="width:49%;float: left;">
<label style="width: 35%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Driver Contact:</label>
<div style="width: 65%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="Home/Work" value="<?= $owner_vehicle['driverlandline'];?>" readonly/>
</div>
</div>
<div style="width:49%;float: right;">
<div style="width: 100%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="Mobile" value="<?= $owner_vehicle['drivermobile'];?>" readonly/>
</div>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<label style="width: 17%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Email:</label>
<div style="width: 83%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" value="<?= $owner_vehicle['driveremail'];?>" readonly/>
</div>
</div>
</div>
<?php endif?>
<div style="background: #eeeeef;padding: 15px;width: 100%;display: inline-block;margin: 10px 0 0;box-sizing: border-box;">
<h2 style="color:#6aaab8;font-size: 21px;font-weight: normal;margin: 0 0 20px;">Offending Vehicle Details:</h2>
<div style="width: 100%;display: inline-block;">
<div style="width:49%;float: left;">
<label style="width: 36%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">No. Of cars involved in accident:</label>
<div style="width: 64%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" value="<?php echo $no_of_car;?>" readonly/>
</div>
</div>
</div>
<?php if(isset($singl_accidents) && $singl_accidents):?>
<?php $i=1;?>
<?php foreach($singl_accidents as $key =>$singl_accident):?>
<?php if($no_of_car>1){?>
<h4 class="form-section">Car No:<?php echo $i;?></h4>
<?php } ?>
<div style="width: 100%;display: inline-block;">
<div style="width:49%;float: left;">
<label style="width: 36%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Make, Model & Year:</label>
<div style="width: 64%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" value="<?= $singl_accident['make'];?>" readonly/>
</div>
</div>
<div style="width:49%;float: right;">
<label style="width: 17%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Rego:</label>
<div style="width: 83%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" value="<?= $singl_accident['rego'];?>" readonly/>
</div>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<label style="width: 7%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Insured:</label>
<div style="width:17%;float: left;position: relative;top: 4px;">
<input type="checkbox" name="" value="1" <?php if($singl_accident['is_insured']==1){ echo "checked";}?>> Yes
<input type="checkbox" name="" value="2" <?php if($singl_accident['is_insured']==2){ echo"checked";}?>> No
</div>
<label style="width: 40%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">If Yes, name of Insurer & Claim/Policy number:</label>
<div style="width: 36%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" value="<?= $singl_accident['insurance_company'];?>" readonly/>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<label style="width: 17%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Owner Name:</label>
<div style="width: 83%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="MR/MRS/MS" value="<?= $singl_accident['owner_name'];?>" readonly />
</div>
</div>
<div style="width: 100%;display: inline-block;">
<label style="width: 17%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Owner Address:</label>
<div style="width: 83%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" value="<?= $singl_accident['owner_address'];?>" readonly/>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<div style="width:49%;float: left;">
<label style="width: 35%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Owner Contact:</label>
<div style="width: 65%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="Home/Work" readonly/>
</div>
</div>
<div style="width:49%;float: right;">
<div style="width: 100%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="Mobile" value="<?= $singl_accident['owner_contact_no'];?>" readonly/>
</div>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<div style="width:49%;float: left;">
<label style="width: 35%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Email:</label>
<div style="width: 65%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="Home/Work" value="<?= $singl_accident['owner_email'];?>" readonly/>
</div>
</div>
<div style="width:49%;float: right;">
<div style="width:40%;float: left;position: relative;top: 4px;">
<label>GST:</label>
<input type="checkbox" name="" value=""> Yes
<input type="checkbox" name="" value=""> No
</div>
<!-- <label style="width: 11%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">ABN:</label>
<div style="width: 48%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" value="<?= $singl_accident['abn'];?>" readonly/>
</div> -->
</div>
</div>
<div style="width: 100%;display: inline-block;">
<label style="width: 17%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Driver Name:</label>
<div style="width: 83%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="MR/MRS/MS"
value="<?= $singl_accident['driver_name'];?>" readonly/>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<label style="width: 17%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Driver Address:</label>
<div style="width: 83%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" value="<?= $singl_accident['driver_address'];?>" readonly/>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<div style="width:49%;float: left;">
<label style="width: 23%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Date of Birth:</label>
<div style="width: 65%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" readonly/>
</div>
</div>
<div style="width:49%;float: right;">
<label style="width: 39%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">License & Expiry Date:</label>
<div style="width: 59%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" readonly/>
</div>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<div style="width:49%;float: left;">
<label style="width: 35%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Driver Contact:</label>
<div style="width: 65%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="Home/Work" readonly/>
</div>
</div>
<div style="width:49%;float: right;">
<div style="width: 100%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="Mobile" value="<?= $singl_accident['driver_contact_no'];?>" readonly/>
</div>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<label style="width: 17%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Email:</label>
<div style="width: 83%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" value="<?= $singl_accident['driver_email'];?>" readonly/>
</div>
</div>
<?php $i++; ?>
<?php endforeach ?>
<?php endif ?>
</div>
<div style="background: #eeeeef;padding: 15px;width: 100%;display: inline-block;margin: 10px 0 0;box-sizing: border-box;">
<h2 style="color:#6aaab8;font-size: 21px;font-weight: normal;margin: 0 0 20px;">Witness Details:</h2>
<div style="width: 100%;display: inline-block;">
<label style="width: 17%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Name:</label>
<div style="width: 83%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="MR/MRS/MS" value="<?= $singl_accident['witness_name'];?>" readonly/>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<label style="width: 17%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Address:</label>
<div style="width: 83%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="" value="<?= $singl_accident['witness_address'];?>" readonly/>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<div style="width:49%;float: left;">
<label style="width: 35%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Contact:</label>
<div style="width: 65%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="Home/Work" value="<?= $singl_accident['witness_mobile'];?>" readonly/>
</div>
</div>
<div style="width:49%;float: right;">
<div style="width: 100%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="Mobile" value="<?= $singl_accident['make'];?>" readonly/>
</div>
</div>
</div>
</div>
<div style="background: #eeeeef;padding: 15px;width: 100%;display: inline-block;margin: 10px 0 0;box-sizing: border-box;">
<h2 style="color:#6aaab8;font-size: 21px;font-weight: normal;margin: 0 0 20px;">Accident Details:</h2>
<div style="width: 100%;display: inline-block;">
<?php
$fulldata_time = $singl_accident['accident_datetime'];
$date_time=(explode(" ",$fulldata_time));
?>
<label style="width: 5%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Date:</label>
<div style="width: 20%;float: left;margin-right: 6px;">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="MR/MRS/MS" value="<?php echo $date_time[0];?>" readonly/>
</div>
<label style="width: 5%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Time:</label>
<div style="width: 20%;float: left;margin-right: 6px;">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="MR/MRS/MS" value="<?php echo $date_time[1];?>" readonly/>
</div>
<label style="width: 5%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Place:</label>
<div style="width: 43%;float: left">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="MR/MRS/MS" value="<?= $singl_accident['witness_address'];?>" readonly/>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<label style="width: 17%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Description:</label>
<div style="width: 83%;float: right">
<textarea style="box-sizing: border-box;width: 100%;height: 90px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;resize: none;"><?= $singl_accident['description'];?></textarea>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<div style="width: 100%;display: inline-block;">
<label style="width: 32%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Police: Was matter reported to police?:</label>
<div style="width:17%;float: left;position: relative;top: 4px;">
<input type="checkbox" name="" value="1" <?php if($singl_accident['is_police_attended']==1){ echo "checked"; }?> > Yes
<input type="checkbox" name="" value="2" <?php if($singl_accident['is_police_attended']==2){ echo "checked"; }?>> No
</div>
</div>
</div>
<div style="width: 100%;display: inline-block;">
<div style="width:49%;float: left;">
<label style="width: 24%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Police Station:</label>
<div style="width: 75%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="Home/Work" value="<?= $singl_accident['police_station'];?>" readonly/>
</div>
</div>
<div style="width:49%;float: right;">
<label style="width: 39%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Name of Police Officer:</label>
<div style="width: 60%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="Mobile" value="<?= $singl_accident['officer_name'];?>" readonly/>
</div>
</div>
</div>
</div>
<div style="background: #eeeeef;padding: 15px;width: 100%;display: inline-block;margin: 10px 0 0;box-sizing: border-box;">
<h2 style="color:#6aaab8;font-size: 21px;font-weight: normal;margin: 0 0 20px;">Diagram of Accident:</h2>
<div style="width: 15%;float: left;">
<div style="width: 100%;float: left;margin: 0 0 20px;">
<img src="<?= base_url('./images/diagram1.jpg') ?>" alt="" />
<p style="margin: 0;">Your Vehicle</p>
</div>
<div style="width: 100%;float: left;margin: 0 0 20px;">
<img src="<?= base_url('./images/diagram2.jpg') ?>" alt="" />
<p style="margin: 0;">Other Vehicle</p>
</div>
<div style="width: 100%;float: left;margin: 0 0 20px;">
<img src="<?= base_url('./images/diagram3.jpg') ?>" alt="" />
<p style="margin: 0;">Stop Sign</p>
</div>
<div style="width: 100%;float: left;">
<img src="<?= base_url('./images/diagram4.jpg') ?>" alt="" />
<p style="margin: 0;">Give Way Sign</p>
</div>
</div>
<div style="width: 50%;float: left;background: #fff;border:1px solid #000;height: 400px;"></div>
<div style="width: 31%;float: left;margin-left: 20px;">
<img style="max-width: 100%;display: block;" src="<?= base_url('./images/diagram-right.jpg') ?>" alt="" />
<p style="margin: 0;">Shade damaged areas of your vehicle</p>
</div>
</div>
<div style="border-bottom: 1px dotted #000;width: 100%;display: inline-block; margin: 20px 0;"></div>
<div style="width: 100%;display: inline-block;">
<h2 style="text-align: center;text-transform: uppercase;color:#000;font-size: 18px;margin: 0 0 20px;">WHAT YOU SHOULD DO</h2>
<p>1. Before you sign this form, read the information on our website at www.eclegal.com.au especially the Client Information Section under Motor Vehicle Collision
Recovery. Contact us if you have any questions;</p>
<p>2. Complete the details on this form fully and truthfully. Provide as much information as possible;</p>
<p>3. Sign and return the form to us. Our address is on the first page;</p>
<p>4. Be prepared to provide us with a copy of the vehicle registration certificate and any other information about the collision</p>
<p>5. If you are comprehensively insured, lodge a claim form with your insurer marked “Report Only”. This will protect your rights and will not affect your no claim
bonus if a claim is not made;</p>
<p>6. Refer any communications from the offending party or their insurers to us. Do not communicate directly with these people.</p>
</div>
<div style="width: 100%;display: inline-block;">
<h2 style="text-align: center;text-transform: uppercase;color:#000;font-size: 18px;margin: 0 0 20px;">WHAT WE WILL DO</h2>
<p>1. Ensure that your vehicle is assessed by qualified assessors. There is no need for you to obtain any further quotes;</p>
<p>2. Make a claim on the offending party or their insurers. Upon recovery of funds, we will pay the repairer directly for the repair cost;</p>
<p>3. All costs and charges will be paid by the offending party or their insurance company. The repairer will also contribute to these costs and charges. <strong>There will be
no cost to you except in circumstances set out on www.eclegal.com.au</strong> – these include unless you deal directly with the offending party or their insurance
company; withdraw your claim after 7 days of us contacting you to confirm these instructions or decide not to authorise the repairer to repair the vehicle.</p>
</div>
<div style="width: 100%;display: inline-block;">
<h2 style="color:#fff;text-align: center;line-height: 35px;font-size: 18px;margin: 0 0 20px;background: #6aa8ba">Repairer Confirmation</h2>
<div style="width: 47%;float: left;margin-right: 12px;">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="">
<p style="margin: 0;">(name of panel shop)</p>
</div>
<label style="width: 50%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 18px;">confirms that this matter is referred to E C Legal on the basis set out on our website at <strong>www.eclegal.com.au</strong> under Motor Vehicle Collision Recovery – Repairer Information.</label>
</div>
<div style="width: 100%;display: inline-block; margin-top: 20px;">
<div style="width:30%;float: left;">
<label style="width: 21%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Dated:</label>
<div style="width: 78%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="Home/Work">
</div>
</div>
<div style="width:68%;float: right;">
<label style="width: 27%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Signature of Repairer:</label>
<div style="width: 73%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="Mobile">
</div>
</div>
<div style="width: 100%;display: inline-block; margin-top: 20px;text-align: center;"><img src="images/pdf-foter-logo.jpg" alt="" /></div>
</div>
<div style="width: 100%;display: inline-block;margin-top: 15px;">
<h2 style="color:#fff;text-align: center;line-height: 35px;font-size: 18px;margin: 0 0 20px;background: #6aa8ba">Authority To Act</h2>
<p>I / We instruct E C Legal to act on my / our behalf to recover the losses arising from the collision as set out on this form.</p>
<p>I / We authorise E C Legal to:</p>
<ul style="margin: 0;padding: 0 0 20px 15px;">
<li>do all things necessary for the conduct of the recovery action including settling the claim provided that the settlement covers all the costs arising from the collision and I have no further liability to any person;</li>
<li>negotiate an agreeable cost of repairs directly with my referring repairer to enable a settlement to occur;</li>
<li>commence legal proceedings (following any necessary advice from E C Legal) provided that my referring repairer and E C Legal are responsible for all costs incurred;</li>
<li>pay your referring repairer and any other service providers (e.g. assessor, rental vehicle provider) directly for any expenses properly incurred</li>
</ul>
<div style="width:30%;float: left;">
<label style="width: 21%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Dated:</label>
<div style="width: 78%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="Home/Work">
</div>
</div>
<div style="width:68%;float: right;">
<label style="width: 27%;float: left;color:#000;font-size: 14px;font-weight: normal;line-height: 30px;">Signature of Repairer:</label>
<div style="width: 73%;float: right">
<input style="box-sizing: border-box;width: 100%;height: 30px;border:1px solid #ccc;background: none;padding: 0 0 0 12px;color:#000;font-size: 13px;font-weight: normal;" type="text" placeholder="Mobile">
</div>
</div>
</div>
</form>
</div>
</body>
</html>