[text* nam placeholder "Your Name"]

[text* add placeholder "Full Address"]

[text* inv placeholder "Invoice Number"]

[date* date placeholder "Dispatch Date"]

[email* email placeholder "Email Address"]

[tel* tel placeholder "Contact Number"]

[one_third]Reason for Claim[/one_third] [one_half_last]  [/one_half_last]

[checkbox* checkbox-26 "Building Damage" "Electronic Damage" "Furniture Damage" "Missing Items" "Other"]


[one_third] . [/one_third] [one_half_last][file file-904][/one_half_last]

[text textarea-6 placeholder "Additional Information"]

[acceptance acceptance-436 optional] I have read and agree with the claim filing instructions given below. [/acceptance]

[submit "Submit"]