[one_half][text* nam placeholder "Your Name"][/one_half] [one_half_last][text* add placeholder "Full Address"][/one_half_last]

[one_half][text* inv placeholder "Invoice Number"][/one_half] [one_half_last][date* date placeholder "Dispatch Date"][/one_half_last]

[one_half][email* email placeholder "Email Address"][/one_half] [one_half_last][tel* tel placeholder "Contact Number"][/one_half_last]

[one_half][file file-904][/one_half] [one_half_last][select* menu-590 multiple "Reason for Claim" "Building Damage" "Electronic Damage" "Furniture Damage" "Missing Items" "Other"][/one_half_last]

[one_half][text textarea-6 placeholder "Additional Information"][/one_half] [one_half_last] [/one_half_last]

[acceptance acceptance-87] I have read and agree with the claim filing instructions given below. [/acceptance]

[submit "Submit"]