<?php
$howdenAPIURL = 'https://id.howdensolutions.com/howdenAPIService/api/compliance/complaint/v1/';
?>
<!DOCTYPE html>
<html>
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<meta http-equiv="X-UA-Compatible" content="IE=edge">
<meta name="csrf-token" content="{{ csrf_token() }}" />
<title>Personal Information Details | Howden Indonesia - Official Working Website</title>
<link rel="icon" href="{{ URL::asset('resources/assets/images/favicon.png') }}">
<link href="{{ URL::asset('resources/assets/css/bootstrap.min.css') }}" rel="stylesheet">
<link href="{{ URL::asset('resources/assets/font-awesome/css/font-awesome.css') }}" rel="stylesheet">
<link href="{{ URL::asset('resources/assets/css/plugins/toastr/toastr.min.css') }}" rel="stylesheet">
<link href="{{ URL::asset('resources/assets/js/plugins/gritter/jquery.gritter.css') }}" rel="stylesheet">
<link href="{{ URL::asset('resources/assets/css/plugins/iCheck/custom.css') }}" rel="stylesheet">
<link href="{{ URL::asset('resources/assets/css/plugins/select2/select2.min.css') }}" rel="stylesheet">
<link href="{{ URL::asset('resources/assets/css/plugins/select2/select2-bootstrap4.min.css') }}" rel="stylesheet">
<link href="{{ URL::asset('resources/assets/css/animate.css') }}" rel="stylesheet">
<link href="{{ URL::asset('resources/assets/css/style.css') }}" rel="stylesheet">
<style>
.customer-complaint-form {
margin-top:50px;
}
.requiredFillMark{
color:red;
}
.carousel-item {
max-height: 470px;
min-width: auto;
}
</style>
</head>
<body style="background-color:#FFFFFF">
<div class="container">
<!-- Form -->
<div class="row customer-complaint-form">
<div class="col-lg-12">
<div class="ibox" id="iboxPersonalInformationDetails">
<div class="ibox-title">
<h5>Personal Information Details</h5>
<div class="ibox-tools">
<a class="collapse-link">
<i class="fa fa-chevron-up"></i>
</a>
<ul class="dropdown-menu dropdown-user">
<li><a href="#" class="dropdown-item">Config option 1</a>
</li>
<li><a href="#" class="dropdown-item">Config option 2</a>
</li>
</ul>
</div>
</div>
<div class="ibox-content">
<div class="sk-spinner sk-spinner-three-bounce">
<div class="sk-bounce1"></div>
<div class="sk-bounce2"></div>
<div class="sk-bounce3"></div>
</div>
<form id="personalInformationDetailsForm" method="POST" action="{{ $howdenAPIURL.'submit-personal-information-details' }}" enctype="multipart/form-data">
<div class="form-group" style="padding:25px; 0">
<img class="float-right" src="{{ URL::asset('resources/assets/images/howden_logo.png') }}" alt="Howden" height="30">
</div>
<input type="hidden" name="generateTicketNo" value="{{ $generateTicketNo }}">
<div class="form-group">
<label class="col-sm-12 col-form-label">Name <span class="requiredFillMark">*</span></label>
<div class="col-sm-12">
<input type="text" class="form-control requiredFill" name="name" placeholder="e.g : John Doe">
</div>
</div>
<div class="hr-line-dashed"></div>
<div class="form-group">
<label class="col-sm-12 col-form-label">Phone Number <span class="requiredFillMark">*</span></label>
<div class="col-sm-12">
<input type="text" class="form-control requiredFill" name="phone_no" placeholder="e.g : 081XXXXXXXXX">
</div>
</div>
<div class="hr-line-dashed"></div>
<div class="form-group">
<label class="col-sm-12 col-form-label">E-mail <span class="requiredFillMark">*</span></label>
<div class="col-sm-12">
<input type="email" class="form-control requiredFill" name="email" placeholder="e.g : john.doe@mail.com">
</div>
</div>
<div class="hr-line-dashed"></div>
<div class="form-group">
<label class="col-sm-12 col-form-label">Bank Name <span class="requiredFillMark">*</span></label>
<div class="col-sm-12">
<input type="text" class="form-control requiredFill" name="bank_name" placeholder="e.g : BCA">
</div>
</div>
<div class="hr-line-dashed"></div>
<div class="form-group">
<label class="col-sm-12 col-form-label">Account Number <span class="requiredFillMark">*</span></label>
<div class="col-sm-12">
<input type="text" class="form-control requiredFill" name="account_number" placeholder="e.g : 123456789">
</div>
</div>
<div class="hr-line-dashed"></div>
<div class="form-group">
<label class="col-sm-12 col-form-label">Account Name <span class="requiredFillMark">*</span></label>
<div class="col-sm-12">
<input type="text" class="form-control requiredFill" name="account_name" placeholder="e.g : JOHN DOE">
</div>
</div>
<div class="hr-line-dashed"></div>
<!-- Agreement -->
<div class="form-group">
<div class="col-sm-12">
<div class="i-checks"><label><input id="agreementCheck" type="checkbox" value=""> <b>Disclaimer :</b><br/><br/><ul><li><i>The information filled in form is true and valid. PT Howden Insurance Brokers Indonesia is not liable to any lawful obligations arising from any false or invalid information in this application form whatsoever, all the false or invalid information will not be processed.</i></li><li><i>The client hereby agree to render PT Howden Insurance Brokers Indonesia a right to handle complaint including but not limited to grab data from records, emails, documents, confidential data, and others, liaise with relatable Parties e.g. (Insurer, Adjuster, Legal Advisor, etc) to settled complaint.</i></li><li><i>The client hereby released PT Howden Insurance Brokers Indonesia from any material or immaterial damages if eventually, there is no evidence of damages caused by PT Howden Insurance Brokers Indonesia.</i></li><ul> </label></div>
</div>
</div>
<div class="form-group">
<label class="col-sm-12 col-form-label"><span class="requiredFillMark">*</span> <i>is required</i></label>
</div>
<!-- End of Agreement -->
<div class="form-group row" style="margin-top:30px;">
<div class="col-sm-4 col-sm-offset-2">
<button type="button" id="btnClearComplaintForm" class="btn btn-danger">Clear</button>
<button type="button" id="btnSubmitPersonalInformationDetailsForm" class="btn btn-success">Submit</button>
</div>
</div>
</form>
</div>
</div>
</div>
</div>
<!-- End of Form -->
<p style="font-weight:8px;text-align: center;">
Copyright © <?= date('Y') ?> PT. Howden Insurance Brokers Indonesia. All rights reserved.<br/>
Authorised and regulated by Otoritas Jasa Keuangan (OJK).<br/>
Member of The Association of Indonesian Insurance & Reinsurance Brokers (APPARINDO).
</p>
</div>
<!-- Mainly scripts -->
{{-- <script src="{{ URL::asset('resources/assets/js/jquery-3.1.1.min.js') }}"></script> --}}
<script src="https://code.jquery.com/jquery-3.7.1.min.js"></script>
<script src="https://code.jquery.com/jquery-migrate-3.4.1.min.js"></script>
<script src="{{ URL::asset('resources/assets/js/popper.min.js') }}"></script>
<script src="{{ URL::asset('resources/assets/js/bootstrap.js') }}"></script>
<script src="{{ URL::asset('resources/assets/js/plugins/metisMenu/jquery.metisMenu.js') }}"></script>
<script src="{{ URL::asset('resources/assets/js/plugins/slimscroll/jquery.slimscroll.min.js') }}"></script>
<!-- Custom and plugin javascript -->
<script src="{{ URL::asset('resources/assets/js/inspinia.js') }}"></script>
<script src="{{ URL::asset('resources/assets/js/plugins/pace/pace.min.js') }}"></script>
<script src="{{ URL::asset('resources/assets/js/plugins/toastr/toastr.min.js') }}"></script>
<script src="{{ URL::asset('resources/assets/js/plugins/iCheck/icheck.min.js') }}"></script>
<script src="{{ URL::asset('resources/assets/js/plugins/select2/select2.full.min.js') }}"></script>
<script src="https://www.google.com/recaptcha/api.js?render=6LcGFdgUAAAAACpxpHjWtpJvN94_ZIJCN1C69DUu"></script>
<script>
$(document).ready(function() {
$.ajaxSetup({
headers: {
'X-CSRF-TOKEN': $('meta[name="csrf-token"]').attr('content')
}
});
function getRecaptcha() {
$('input[name="g-recaptcha-response"]').remove();
grecaptcha.ready(function() {
grecaptcha.execute('6LcGFdgUAAAAACpxpHjWtpJvN94_ZIJCN1C69DUu', {action: 'homepage'}).then(function(token) {
$('#personalInformationDetailsForm').prepend('<input type="hidden" name="g-recaptcha-response" value="' + token + '">');
});
});
}
function resetForm() {
$('input[name="name"]').val('');
$('input[name="phone_no"]').val('');
$('input[name="email"]').val('');
$('input[name="bank_name"]').val('');
$('input[name="account_number"]').val('');
$('input[name="account_name"]').val('');
$('.i-checks').iCheck('uncheck');
}
$(document).on('click', '#btnSubmitPersonalInformationDetailsForm', function(e) {
e.preventDefault();
var isSubmit = true;
$('.requiredFill').each(function(){
// Required Check
if ( $(this).val() == "" ) {
toastr.error('This is required.', 'Error :');
$(this).focus();
isSubmit = false;
return false;
}
});
if ( isSubmit ) {
if ( $('.i-checks').iCheck('update')[0].checked == false ) {
toastr.error('Please check Disclaimer if you want to proceed.', 'Error :');
$('.i-checks').focus();
isSubmit = false;
return false;
}
var form_data = new FormData();
var other_data = $('#personalInformationDetailsForm').serializeArray();
var totalfiles = $('.attachment').length;
$.each(other_data,function(key,input){
form_data.append(input.name, input.value);
});
$('#iboxPersonalInformationDetails').children('.ibox-content').toggleClass('sk-loading');
$.ajax({
url: $("#personalInformationDetailsForm").attr('action'),
type: 'post',
data: form_data,
dataType: 'json',
contentType: false,
processData: false,
success: function(response){
$('#iboxPersonalInformationDetails').children('.ibox-content').toggleClass('sk-loading');
resetForm();
if ( response.status == 'invalid_token' ) {
toastr.error('Invalid token!');
} else if ( response.status == 'expired' ) {
toastr.warning('Your Form was expired!');
} else if ( response.status == 'success' ) {
toastr.success('Your Form was sent successfully!');
} else {
toastr.error('Failed to sent your form, please try later or contact our administrator by other way.');
}
getRecaptcha();
},
error : function($xhr, textStatus,errorThrown){
$('#iboxPersonalInformationDetails').children('.ibox-content').toggleClass('sk-loading');
toastr.error('Failed to sent your form, please try later or contact our administrator by other way.', 'Error :');
}
});
}
});
$(document).on('click', '#btnClearComplaintForm', function(e) {
$('input[name="name"]').val('');
$('input[name="phone_no"]').val('');
$('input[name="email"]').val('');
$('input[name="bank_name"]').val('');
$('input[name="account_number"]').val('');
$('input[name="account_name"]').val('');
getRecaptcha();
});
let toast = $('.toast');
setTimeout(function() {
toast.toast({
delay: 5000,
animation: true
});
toast.toast('show');
}, 2200);
toastr.options.progressBar = true;
toastr.options.closeButton = true;
$('.i-checks').iCheck({
checkboxClass: 'icheckbox_square-green',
radioClass: 'iradio_square-green',
});
getRecaptcha();
setInterval(function(){
getRecaptcha();
}, 90 * 1000);
$('.requiredFill').attr('autocomplete','off');
});
</script>
</body>
</html>
Copyright © 2026 PT. Howden Insurance Brokers Indonesia. All rights reserved.
Authorised and regulated by Otoritas Jasa Keuangan (OJK).
Member of The Association of Indonesian Insurance & Reinsurance Brokers (APPARINDO).