radiantrh/Vue/Nouveaufraisfuneraire/index.php

<?php 
    $this->titre = "INTER-SANTE - Nouvelle Demande Frais Funéraires"; 
?>

<div id="div_adherent" class="container-fluid py-1 animate__animated animate__fadeIn">

    <form id="frmderogation" name="frmderogation" method="post" class="needs-validation">
        
        <h1 class="text-primary"><i class="fas fa-file-signature me-2"></i><?= _('Fiche de demande de Frais Funéraires') ?></h1>

        <div class="card-header d-flex justify-content-between align-items-center py-1">
            <h5 class="mb-0 fw-bold">
                <?= _("POLICE") ?> : <span class="text-secondary"><?= $this->nettoyer($_SESSION['numeroPolice_C']) ?></span>
                <span class="ms-3 badge bg-primary text-light small fw-normal">ID: <?= $this->nettoyer($_SESSION['idPolice_C']) ?></span>
            </h5>
        </div>

        <input type="hidden" id="fraisReel" name="fraisReel" value="<?= $montant_fraisfuneraire ?>">
        <input type="hidden" id="montantApayer" name="montantApayer" value="<?= $montant_fraisfuneraire ?>">

        <div class="card shadow-sm border-0" style="border-radius: 15px;">
            <div class="card-body p-4">
                
                <h6 class="text-primary text-uppercase small fw-bold mb-4 border-bottom pb-2">
                    <i class="fas fa-info-circle me-2"></i><?= _("Détails du sinistre") ?>
                </h6>

                <div class="row g-3 mb-4">
                    <div class="col-md-6">
                        <label class="form-label fw-bold small text-uppercase"><?= _("Demandeur (Nom & Prénoms)") ?> <span class="text-danger">*</span></label>
                        <input class="form-control fw-bold border-primary" type="text" id="demandeur" name="demandeur" required autofocus>
                    </div>
                    <div class="col-md-6">
                        <label class="form-label fw-bold small text-uppercase"><?= _("Lien Parenté Demandeur") ?> <span class="text-danger">*</span></label>
                        <select class="form-select fw-bold" id="codeLienDemandeur" name="codeLienDemandeur" required>
                            <?php liste_options($liendemandeur,""); ?>                      
                        </select>
                    </div>
                    <div class="col-md-8">
                        <label class="form-label fw-bold small text-uppercase"><?= _("Cause du décès") ?> <span class="text-danger">*</span></label>
                        <input class="form-control" type="text" id="causeDeces" name="causeDeces" required>
                    </div>
                    <div class="col-md-4">
                        <label class="form-label fw-bold small text-uppercase"><?= _("Date du décès") ?> <span class="text-danger">*</span></label>
                        <div class="input-group">
                            <span class="input-group-text bg-white"><i class="fas fa-calendar-times text-danger"></i></span>
                            <input class="form-control datepicker fw-bold" type="text" id="dateDeces" name="dateDeces" required>
                        </div>
                    </div>
                </div>

                <h6 class="text-primary text-uppercase small fw-bold mb-4 border-bottom pb-2">
                    <i class="fas fa-user-check me-2"></i><?= _("Bénéficiaire du règlement") ?>
                </h6>

                <div class="row g-3 mb-4">
                    <div class="col-md-6">
                        <label class="form-label fw-bold small text-uppercase"><?= _("Nom du bénéficiaire au règlement") ?> <span class="text-danger">*</span></label>
                        <input class="form-control fw-bold border-primary text-uppercase" type="text" id="beneficiaireReglement" name="beneficiaireReglement" required>
                    </div>
                    <div class="col-md-6">
                        <label class="form-label fw-bold small text-uppercase"><?= _("Lien Parenté Bénéficiaire") ?> <span class="text-danger">*</span></label>
                        <select class="form-select fw-bold" id="codeLienBeneficiaire" name="codeLienBeneficiaire" required>
                            <?php liste_options($lienbeneficiaire,""); ?>                       
                        </select>
                    </div>
                    <div class="col-md-12">
                        <label class="form-label fw-bold small text-uppercase"><?= _("Observations") ?></label>
                        <textarea class="form-control" id="observations" name="observations" rows="2"></textarea>
                    </div>
                </div>

                <!--
                <div class="row g-3 mb-4 bg-light p-3 rounded-3 border">
                    <div class="col-md-6 text-center">
                        <label class="form-label small text-muted text-uppercase fw-bold"><?= _("Frais prévus") ?></label>
                        <div class="h4 mb-0 text-secondary opacity-50"><?= format_N($montant_fraisfuneraire) ?></div>
                    </div>
                    <div class="col-md-6 text-center border-start">
                        <label class="form-label small text-muted text-uppercase fw-bold text-primary"><?= _("Montant Retenu") ?></label>
                        <div class="h4 mb-0 text-primary fw-bold"><?= format_N($montant_fraisfuneraire) ?></div>
                        <input type="hidden" id="montantApayer" name="montantApayer" value="<?= $montant_fraisfuneraire ?>">
                    </div>
                </div>
                -->

                <h6 class="text-white text-uppercase small fw-bold mb-4 p-2 rounded bg-success d-flex align-items-center">
                    <i class="fas fa-university me-2 ms-2"></i><?= _("Informations sur le paiement") ?>
                </h6>

                <div class="row g-3">
                    <div class="col-md-4">
                        <label class="form-label fw-bold small text-uppercase"><?= _("Mode de Paiement") ?> <span class="text-danger">*</span></label>
                        <select class="form-select border-success" id="codeModePaiementDemande" name="codeModePaiementDemande" required>
                            <?php liste_options($modepaiement,""); ?>                       
                        </select> 
                    </div>
                    <div class="col-md-4">
                        <label class="form-label fw-bold small text-uppercase"><?= _("Banque du Bénéficiaire") ?> <span class="text-danger">*</span></label>
                        <select class="form-select border-success" id="codeBanqueBeneficiaire" name="codeBanqueBeneficiaire" required>
                            <?php liste_options($banque, ""); ?>        
                        </select>
                    </div>
                    <div class="col-md-4">
                        <label class="form-label fw-bold small text-uppercase"><?= _("N° Compte (RIB/IBAN)") ?> <span class="text-danger">*</span></label>
                        <div class="input-group">
                            <span class="input-group-text bg-success text-white"><i class="fas fa-credit-card"></i></span>
                            <input class="form-control border-success fw-bold" type="text" id="numeroCompteBeneficiaire" name="numeroCompteBeneficiaire" required>
                        </div>
                    </div>
                </div>
                
                <div class="row mt-5">
                    <div class="col-12 text-end">
                        <hr class="opacity-25">
                        <button type="button" class="btn btn-primary btn-lg px-5 shadow-sm fw-bold" id="btn_enreg" onclick="enregistrerdemandefraisfuneraire();">
                            <i class="fas fa-save me-2"></i><?= _("Enregistrer la demande") ?>
                        </button>
                    </div>
                </div>

            </div>
        </div>

        <?php if (isset($msgErreur)): ?>
            <div id="msgErreur" class="alert alert-danger mt-3 shadow-sm border-0 animate__animated animate__shakeX">
                <i class="fas fa-exclamation-circle me-2"></i> <?= $msgErreur ?>
            </div>  
        <?php endif; ?>
    </form> 
</div>

<div id="div_test"></div>

<style>
    .form-control:focus, .form-select:focus {
        border-color: #0d6efd;
        box-shadow: 0 0 0 0.25rem rgba(13, 110, 253, 0.1);
    }
    textarea.form-control { min-height: 80px; }
    .bg-success { background-color: #28a745 !important; }
</style>