Jason Jordan
56 lines
2.6 KiB
Plaintext
56 lines
2.6 KiB
Plaintext
<div class="bg-deepcove min-h-screen w-full flex flex-col">
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<h1 class="font-bold text-4xl text-platinum">New Employer Setup</h1>
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<h3 class="font-bold text-2xl text-bluemana">General Information</h3>
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<%= form_with model: @form, url: employer_setup_index_path, local: true do |f| %>
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<div class="flex flex-col my-8 space-y-6">
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<div class="flex space-x-10">
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<div class="w-1/5">
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<%= f.text_field :name, label: { text: "Employer Name" }, class: "w-full" %>
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</div>
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<div class="w-1/5">
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<%= f.text_field :group_number, label: { text: "Group/Medical Number" }, class: "w-full" %>
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</div>
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<div>
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<%= f.check_box :dental %>
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</div>
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</div>
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<div class="flex space-x-10">
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<div class="w-1/5">
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<%= f.text_field :pl_plan_key, label: { text: "Pl Plan Key" }, class: "w-full" %>
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</div>
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<div class="w-1/5">
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<%= f.text_field :effect_date, label: { text: "Effective Date" }, class: "w-full" %>
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</div>
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</div>
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<div class="flex space-x-10">
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<div class="w-1/5">
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<%= f.select :number_of_plans, options_for_select((1..6).to_a), label: { text: "Number of Plans" }, class: "w-1/3" %>
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</div>
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<div class="w-1/5">
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<%= f.select :network, options_for_select([["Cigna", "cig"], ["Cigna+Regional", "cig+"], ["Medcost", "med"]]), label: { text: "Provider Network" }, data: { controller: "form-toggle", action: "change->form-toggle#toggleDivs" }, class: "w-full" %>
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</div>
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<div id="div-a" class="w-1/5" data-form-toggle-target="divA">
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<%= f.select :number_of_additional_network_logos, options_for_select((0..6).to_a), label: { text: "Number of Additional Network Logos" }, class: "w-1/3" %>
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</div>
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</div>
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<div class="flex space-x-5 items-center mt-4">
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<label for="file_upload_input" class="cursor-pointer bg-atmosphere hover:bg-bluetang text-platinum font-bold py-2 px-4 rounded border border-platinum">
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Choose Employer Logo File
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</label>
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<span id="file_name_display" class="ml-2 text-bluemana font-semibold">No file chosen</span>
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<%= f.file_field :employer_logo, class: "hidden", id: "file_upload_input" %>
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</div>
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<div class="pt-8">
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<%= f.submit "Continue to Plans" %>
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</div>
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</div>
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<% end %>
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</div>
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<script>
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document.getElementById('file_upload_input').addEventListener('change', function(e) {
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var fileName = e.target.files[0] ? e.target.files[0].name : 'No file chosen';
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document.getElementById('file_name_display').textContent = fileName;
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});
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</script> |