<form id="add-form" class="form-horizontal" role="form" data-toggle="validator" method="POST" action="">

    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-3">{:__('Endowment')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-endowment" data-rule="required" class="form-control" name="row[endowment]" type="number" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-3">{:__('Medical')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-medical" data-rule="required" class="form-control" name="row[medical]" type="number" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-3">{:__('Unemployment')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-unemployment" data-rule="required" class="form-control" name="row[unemployment]" type="number" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-3">{:__('Birth')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-birth" data-rule="required" class="form-control" name="row[birth]" type="number" value="">
        </div>
    </div>
    <div class="form-group">
        <label class="control-label col-xs-12 col-sm-3">{:__('Industrial')}:</label>
        <div class="col-xs-12 col-sm-8">
            <input id="c-industrial" data-rule="required" class="form-control" name="row[industrial]" type="number" value="">
        </div>
    </div>
    <div class="form-group layer-footer">
        <label class="control-label col-xs-12 col-sm-3"></label>
        <div class="col-xs-12 col-sm-8">
            <button type="submit" class="btn btn-success btn-embossed disabled">{:__('OK')}</button>
            <button type="reset" class="btn btn-default btn-embossed">{:__('Reset')}</button>
        </div>
    </div>
</form>