<%= f.text_field :name, label: { text: "Employer Name" }, data: { logo_upload_target: "employer" }, class: "w-full" %>
<%= f.text_field :effective_date, label: { text: "Effective Date" }, class: "w-full" %>
<%= f.text_field :group_number, label: { text: "Group/Medical Number" }, class: "w-full" %>