@extends('layouts.app')

@section('content')
    <div class="container">
        <div class="row justify-content-center">
            <div class="">
                {{ Breadcrumbs::render('amendment.change.entry',$app->application_id) }}
                <div class="shadow card">
                    <div class="shadow-sm card-header fs-3">労保連労働災害保険契約内容異動届(変更)画面</div>
                    <form id="entryForm" method="POST" action="{{ route('amendment.change.confirm',$app->application_id) }}">
                        @csrf
                        <div class="card-body">
                            @if (session('status'))
                                <div class="alert alert-success" role="alert">
                                    {{ session('status') }}
                                </div>
                            @endif
                            <ul>
                                @foreach ($errors->all() as $error)
                                    <li class="fs-6 text-danger">{{ $error }}</li>
                                @endforeach
                            </ul>
                            @php
                                $LIN = explode('-', $app->LINumber);
                                $postcode = explode('-', $ins->post_code);
                                $tels = explode('-', $ins->tel);
                                $ad = $ins->address1 . $ins->address2;
                            @endphp
                            <div class="d-flex">
                                <div class="col-4">
                                    <div class="shadow-sm input-group mb-3">
                                        <span class="input-group-text bg-secondary-subtle fs-5">変更日</span>
                                        <input type="date" value="{{ old('date') }}" id="date" name="date" class="form-control fs-5 @error('date') is-invalid @enderror">
                                    </div>
                                </div>
                            </div>
                            <div class="shadow-sm input-group mb-3">
                                <span class="input-group-text bg-secondary-subtle fs-5">労働保険番号</span>
                                <div class="form-floating">
                                    <input type="text"
                                        class="form-control fs-5 @error('LINumber') is-invalid @enderror @error('prefecture') is-invalid @enderror"
                                        name="prefecture" id="floatingInput1" maxlength="2" value="{{ old('prefecture',$LIN[0]) }}"
                                        placeholder="99" required>
                                    <label for="floatingInput1">府県</label>
                                </div>
                                <div class="form-floating" style="width: 70px;flex: none;">
                                    <input type="text" class="form-control fs-5"
                                        name="remit" id="floatingInput2" maxlength="1" value="*"
                                        placeholder="9" disabled>
                                    <label for="floatingInput2">所掌</label>
                                </div>
                                <div class="form-floating" style="width: 70px;flex: none;">
                                    <input type="text"
                                        class="form-control fs-5"
                                        name="jurisdiction" id="floatingInput3" maxlength="2"
                                        value="**" placeholder="99" disabled>
                                    <label for="floatingInput3">管轄</label>
                                </div>
                                <div class="form-floating col-2">
                                    <input type="text"
                                        class="form-control fs-5 @error('LINumber') is-invalid @enderror @error('core_number') is-invalid @enderror"
                                        name="core_number" id="floatingInput4" maxlength="6"
                                        value="{{ old('core_number',$LIN[1]) }}" placeholder="999999" required>
                                    <label for="floatingInput4">基幹番号</label>
                                </div>
                                <div class="form-floating">
                                    <input type="text"
                                        class="form-control fs-5 @error('LINumber') is-invalid @enderror @error('branch_number') is-invalid @enderror"
                                        name="branch_number" id="floatingInput5" maxlength="3"
                                        value="{{ old('branch_number',$LIN[2]) }}" placeholder="999" required>
                                    <label for="floatingInput5">枝番号</label>
                                </div>
                                <div class="form-floating" style="width: 70px;flex: none;">
                                    <input type="text"
                                        class="form-control fs-5"
                                        name="serial_number" id="floatingInput6" maxlength="2"
                                        value="{{ old('serial_number',$LIN[3]) }}" placeholder="99" required>
                                    <label for="floatingInput6">追番</label>
                                </div>
                            </div>
                            <div class="shadow-sm input-group mb-3">
                                <span class="input-group-text bg-secondary-subtle fs-5">事業場の名称</span>
                                <input type="text" class="form-control fs-5 @error('workplacename') is-invalid @enderror"
                                    name="workplacename" value="{{ old('workplacename',$ins->workspace) }}" required>
                            </div>
                            <div class="d-flex">
                                <div class="col-6">
                                    <div class="shadow-sm input-group mb-3">
                                        <span class="input-group-text bg-secondary-subtle fs-5">事業主の氏名</span>
                                        <input type="text" class="form-control fs-5 @error('name') is-invalid @enderror"
                                            name="name" value="{{ old('name',$ins->name) }}" required>
                                    </div>
                                </div>
                            </div>
                            <div class="shadow-sm input-group mb-3">
                                <span class="input-group-text bg-secondary-subtle fs-5">メールアドレス</span>
                                <input type="email"
                                    class="form-control fs-5 @error('email') is-invalid @enderror" name="email"
                                    value="{{ old('email',$ins->email) }}">
                            </div>
                            <div class="d-flex">
                                <div class="col-4">
                                    <div class="shadow-sm input-group mb-3">
                                        <span class="input-group-text bg-secondary-subtle fs-5">郵便番号</span>
                                        <input type="text"
                                            class="form-control fs-5 @error('post_number_1') is-invalid @enderror"
                                            maxlength="3" name="post_number_1" value="{{ old('post_number_1',$postcode[0]) }}" required>
                                        <span class="input-group-text bg-secondary-subtle">―</span>
                                        <input type="text"
                                            class="form-control fs-5 @error('post_number_2') is-invalid @enderror"
                                            maxlength="4" name="post_number_2" value="{{ old('post_number_2',$postcode[1]) }}" required>
                                    </div>
                                </div>
                                <div class="col-6">
                                    <div class="shadow-sm input-group mb-3 ms-1">
                                        <span class="input-group-text bg-secondary-subtle fs-5">電話番号</span>
                                        <input type="tel1"
                                            class="form-control fs-5 @error('tel') is-invalid @enderror" name="tel1"
                                            value="{{ old('tel1',$tels[0]) }}" required>
                                        <span class="input-group-text bg-secondary-subtle">―</span>
                                        <input type="tel2"
                                            class="form-control fs-5 @error('tel') is-invalid @enderror" name="tel2"
                                            value="{{ old('tel2',$tels[1]) }}" required>
                                        <span class="input-group-text bg-secondary-subtle">―</span>
                                        <input type="tel3"
                                            class="form-control fs-5 @error('tel') is-invalid @enderror" name="tel3"
                                            value="{{ old('tel3',$tels[2]) }}" required>
                                    </div>
                                </div>
                            </div>
                            <div class="shadow-sm input-group mb-3">
                                <span class="input-group-text bg-secondary-subtle fs-5">事業場の所在地</span>
                                <input type="text" class="form-control fs-5 @error('address') is-invalid @enderror"
                                    name="address" value="{{ old('address',$ad) }}" required>
                            </div>
                            <div class="d-flex">
                                <a href="{{ route('home') }}" class="fs-5 btn btn-secondary shadow-sm">一覧に戻る</a>
                                <button type="button" class="fs-5 btn btn-secondary shadow-sm"  onClick="submitAfterValidate();"
                                    style="margin:auto 0px auto auto">確認する</button>
                            </div>
                        </div>
                    </form>
                </div>
            </div>
        </div>
    </div>
    </div>
    <style>
        label:has(input[type="radio"]:checked) {
            background: #86b7fe;
        }
        span.bg-gray{
            background-color: var(--bs-secondary-bg);
        }
    </style>
    <script>
        function submitAfterValidate() {
            const form = document.getElementById('entryForm');
            form.submit();
        }
        window.addEventListener('pageshow', function (e) {
            if (e.persisted) {
                requestAnimationFrame(() => window.scrollTo({ top: 0, left: 0, behavior: 'auto' }));
            }
        });
    </script>
@endsection