Diyadio WebForms :: Webform Designer

Form name:

<div class="rounderCornerMiddle">
    <div id="wrapper">
        <div class="headerText">
            BOAT CLAIM FORM
            <p>
                Issuance of this form is not to be taken as an admission of liability
            </p>
        </div>
        <fieldset>
            <legend>YOUR DETAILS </legend>
            <div class="itemField">
                <div class="listDiv">
                    Full name:
                </div>
                <div class="listDiv">
                    <input type="text" name="txbFullName" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Your address:
                </div>
                <div class="listDiv">
                    <input type="text" name="txbYourAddress" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Occupation:
                </div>
                <div class="listDiv">
                    <input type="text" name="txbOccupation" /></div>
            </div>
            <div class="itemField">
                <span class="blueBolderText">Contact details:</span>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    <p>
                        Address:
                    </p>
                </div>
                <div class="listDiv">
                    <textarea name="txbPostalAddress" rows="4" cols="22"></textarea>
                </div>
            </div>
            <div class="itemField">
                <span class="blueBolderText">Telephone</span>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Work:
                </div>
                <div class="listDiv">
                    <input type="text" name="txbWork" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Home:
                </div>
                <div class="listDiv">
                    <input type="text" name="txbHome" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Mobile:
                </div>
                <div class="listDiv">
                    <input type="text" name="txbMobile" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Email:
                </div>
                <div class="listDiv">
                    <input type="text" name="txbEmail" />
                </div>
            </div>
        </fieldset>
        <fieldset>
            <legend>CLAIM DETAILS </legend>
            <div class="itemField">
                <div class="listDiv">
                    Date/time of accident
                </div>
                <div class="listDiv">
                    <input type="text" name="txbDateTime" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Please describe location and cause of loss (please give details)
                </div>
                <div class="listDiv">
                    <textarea name="txbLocationAndCause" rows="4" cols="45"></textarea>
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    If necessary, continue on a separate sheet and attach.
                </div>
                <div class="listDiv">
                    <input type="file" name="fuAttachments" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Who caused loss? Please advise owner's and/or skipper's report on circumstances of loss and/or damage
                </div>
                <div class="listDiv">
                    <textarea name="txbCausedLoss" rows="4" cols="45"></textarea>
                </div>
            </div>
            <div class="itemField">
                <label>
                    Was the boat being raced at the time of damage?</label>
                <div class="checkboxItemField">
                    <input type="radio" name="rbtnRace" value="Yes" />
                    <input type="radio" name="rbtnRace" value="No" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    If yes, has a protest been made? Please advise details.
                </div>
                <div class="listDiv">
                    <textarea name="txbProtest" rows="4" cols="45"></textarea>
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Please advise weather conditions at the time of the loss and/or damage
                </div>
                <div class="listDiv">
                    <textarea name="txbAdviseWeather" rows="4" cols="45"></textarea>
                </div>
            </div>
            <div class="itemField">
                <label>
                    Was the boat on an approved mooring and in a site authorized for its use?
               </label>
                <div class="checkboxItemField">
                    <input type="radio" name="rbtnBoatApproved" value="Yes" />
                    <input type="radio" name="rbtnBoatApproved" value="No" />
                </div>
                <div class="listDiv">
                    <div class="listDiv">
                        If yes please describe
                    </div>
                    <div class="listDiv">
                        <textarea name="txbBoatApproved" rows="4" cols="45"></textarea>
                    </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Please advice date mooring was last inspected.
                </div>
                <div class="listDiv">
                    <textarea name="txbDateMooring" rows="4" cols="45"></textarea>
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Please give details of damage and/or items lost.
                </div>
                <div class="listDiv">
                    <textarea name="txbDamageDetails" rows="4" cols="45"></textarea>
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    If incident has been reported to Police, please advise date reported/station/police file number.
                </div>
                <div class="listDiv">
                    <textarea name="txbIncident" rows="4" cols="45"></textarea>
                </div>
            </div>
            <div class="itemField">
                <label>
                    Were any other boats involved in the loss?
                </label>
                <div class="checkboxItemField">
                    <input type="radio" name="rbtnBoatsInvolved" value="Yes" />
                    <input type="radio" name="rbtnBoatsInvolved" value="No" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    If yes, please describe:
                </div>
                <div class="listDiv">
                    <textarea name="txbBoatsInvolved" rows="4" cols="45"></textarea>
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Other party's name
                </div>
                <div class="listDiv">
                    <input type="text" name="txbPartysName" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Other party's address
                </div>
                <div class="listDiv">
                    <textarea name="txbPartysAddress" rows="4" cols="22"></textarea>
                    </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Type of boat
                </div>
                <div class="listDiv">
                    <input type="text" name="txbBoatType" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Name of other party's boat
                </div>
                <div class="listDiv">
                    <input type="text" name="txbOtherPartyBoatName" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    If insured, by whom
                </div>
                <div class="listDiv">
                    <input type="text" name="txbByWhom" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    If applicable, please describe details of damage to other boat
                </div>
                <div class="listDiv">
                    <textarea name="txbDamage" rows="4" cols="45"></textarea>
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv">
                    Were any witnesses present (including crew, passengers and independent witnesses)?
                    Please list name, address and location of witnesses.
                </div>
                <div class="listDiv">
                    <textarea name="txbWitnesses" rows="4" cols="45"></textarea>
                </div>
            </div>
        </fieldset>
        <fieldset>
            <legend>YOUR PRIVACY </legend>
            <div class="itemField">
                We collect and receive your personal information in this claim form to consider your claim. We hold it. You have rights to access it, and correct it under the Privacy Act 1993.<br />
                You must provide your relevant personal information to us to comply with the Claims Conditions of this policy. If you fail to do so, we may decline your claim.<br />
                We obtain your authority below to transfer your relevant personal information to other members of the insurance industry (including Insurance Claims Register Limited), financially interested parties noted on your policy, and repairers<br />
            </div>
        </fieldset>
        <fieldset>
            <legend>YOUR PRIVACY </legend>
            <div class="itemField">
                <span class="blueBolderText">I declare that: </span><br />
                <ul>
                    <ol>
                        1 All information given to New India in connection with the claim is true. </ol>
                    <ol>
                        2 No information relevant to the claim has been omitted. </ol>
                    <ol>
                        3 I authorize: </ol>
                    <ol>
                        <ul>
                            <ol>
                                3.1 New India to disclose this information to: </ol>
                            <ol>
                                <ul>
                                    <ol>
                                        3.1.1 Other members of the insurance industry (including Insurance Claims Register Limited), and</ol>
                                    <ol>
                                        3.1.2 Financially interested parties noted on the policy, and</ol>
                                    <ol>
                                        3.1.3 Parties repairing or replacing your property. </ol>
                                </ul>
                            </ol>
                            <ol>
                                3.2 The disclosure of my personal information held by any other parties to New India for the purpose of considering and administering the claim. </ol>
                        </ul>
                    </ol>
                </ul>
            </div>
        </fieldset>
    </div>
</div>