

<div class="row">
    <div class="col-xs-2 form-group form-group-sm">
        <label for="">DERECHOHABIENCIA</label>
        {!! $derechohabiencia !!}
    </div>
    <div id="seguroAfiliacionDiv" class="col-xs-2 form-group form-group-sm">
        <label for=""><span class="text-red">*</span> Folio</label>
        <div class="input-group">
            <input style="width: 250%" maxlength="13" name="folio" id="folio" type="text"
                   class="form-control col-sm-8"
                   placeholder="PÓLIZA">
            <span style="width: 40%; background-color: lightgray;"
                  class="input-group-addon"></span>
            <input maxlength="2" name="ConsecutivoDerechoHab" id="ConsecutivoDerechoHab"
                   type="text"
                   class="form-control"
                   placeholder="CONS">
            <span class="input-group-btn">
                                    <button id="openModalConsecutivos" class="btn btn-default btn-sm" type="button"><i
                                                class="fa fa-search"></i></button>
                                </span>
        </div>
    </div>
    <div id="imssAfiliacionDiv" class="hidden col-xs-2 form-group form-group-sm">
        <label for="">Folio IMSS/ISSSTE</label>
        <input name="folio_imss" id="folio_imss" type="text" class="form-control"
               placeholder="">
    </div>
    <div id="otroAfiliacionDiv" class="hidden col-xs-2 form-group form-group-sm">
        <label for="">Folio</label>
        <input maxlength="15" name="folio_otro" id="folio_otro" type="text" class="form-control"
               placeholder="">
    </div>

    <div class="col-xs-2 form-group form-group-sm">
        <label for="">Ini de Vigencia</label>
        <input name="inicio_vigencia" id="inicio_vigencia" type="text"
               class="form-control" placeholder="">
    </div>
    <div class="col-xs-2 form-group form-group-sm">
        <label for="">Fin de Vigencia</label>
        <input name="fin_vigencia" id="fin_vigencia" type="text" class="form-control"
               placeholder="">
    </div>
    <div class="col-xs-2 form-group form-group-sm">
        <label for="">Estado de Afiliación</label>
        {!! $entidad_afiliacion !!}
    </div>

</div>

<div class="row">
    <div class="col-xs-4 form-group form-group-sm">
        <label for=""><span class="text-red">*</span> Dependencia</label>
        {!! $dependencia !!}
    </div>
    <div class="col-xs-2 form-group form-group-sm">
        <label for=""><span class="text-red">*</span> Programa</label>
        {!! $programa !!}
    </div>
</div>

