Diyadio WebForms :: Webform Designer

Form name:

<div class="rounderCornerMiddle">
    <div id="wrapper">
        <div class="itemField">
            <div class="headerText">
                MARINE CLAIM FORM
                <br />
                <br />
                <hr />
            </div>
        </div>
        <fieldset>
            <div class="itemField">
                <div class="listDiv2">
                    Name &amp; Address of the consignors<span class="redText">*</span>
                </div>
                <div class="listDiv">
                    <textarea name="nameAndAddressOfConsignors" cols="22" rows="3"></textarea></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Name &amp; Address of the consignees</div>
                <div class="listDiv">
                    <textarea name="nameAndAddressOfconsignees" cols="22" rows="3"></textarea></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Nature of goods</div>
                <div class="listDiv">
                    <input type="text" name="natureOfGoods" /></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Number and date of the carrier's receipt</div>
                <div class="listDiv">
                    <input type="text" name="numberAndDate" /></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Place of dispatch</div>
                <div class="listDiv">
                    <input type="text" name="placeOfDispatch" /></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Place of destination</div>
                <div class="listDiv">
                    <input type="text" name="placeOfDestination" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Date of arrival of the consignment at destination if by streamer, dates of landing
                    and clearance</div>
                <div class="listDiv">
                    <input type="text" name="dateOfArrival" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Date of dispatch to interior destination, if any</div>
                <div class="listDiv">
                    <input type="text" name="dateOfDispatch" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Date of taking delivery at the final destination</div>
                <div class="listDiv">
                    <input type="text" name="dateOfTakingDelivery" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Reason for delay for taking delivery at final destination, if any
                </div>
                <div class="listDiv">
                    <input type="text" name="reasonForDelay" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Date when loss or damaged noted
                </div>
                <div class="listDiv">
                    <input type="text" name="dateWhenLossOrDamaged" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Total number of cases and/or packages dispatched with marks if any
                </div>
                <div class="listDiv">
                    <input type="text" name="totalNumberOfCases" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Number taken delivery of
                </div>
                <div class="listDiv">
                    <input type="text" name="numberTakenDelivery" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Number not delivered by the Carriers (Steamer agents or land carriers)
                </div>
                <div class="listDiv">
                    <input type="text" name="numberNotDelivered" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Full details of the condition of the cases and/or Packages taken delivery of
                </div>
                <div class="listDiv">
                    <input type="text" name="fullDetailsOfCondition" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    If damaged in transit, was steamer survey held or open delivery taken? If so, attach
                    certificates from the carriers
                </div>
                <div class="listDiv">
                    <input type="file" name="attachCertificates" />
                </div>
            </div>
            <div class="checkboxItemField">
                <label>
                    Has claim been made against carriers</label>
                <input type="radio" value="Yes" name="claimMade" />
                <input type="radio" value="No" name="claimMade" />
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    If claim has not been lodged, state the reason for the same
                </div>
                <div class="listDiv">
                    <textarea name="stateTheReason" cols="22" rows="3"></textarea>
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Sound market value of goods on date of arrival
                </div>
                <div class="listDiv">
                    <input type="text" name="soundMarketValue" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Duty payable on sound goods
                </div>
                <div class="listDiv">
                    <input type="text" name="dutyPayable" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Further remarks
                </div>
                <div class="listDiv">
                    <textarea name="furtherRemarks" cols="22" rows="3"></textarea>
                </div>
            </div>
        </fieldset>
        <fieldset>
            <legend>Documents</legend>
            <div class="itemField">
                <div class="listDiv2">
                    Original Insurance Policy and/ or Certificate duly endorsed
                </div>
                <div class="listDiv">
                    <input type="file" name="originalInsurencePolicy" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Complete invoices together with supplementary
                </div>
                <div class="listDiv">
                    <input type="file" name="completeInVoices" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Copy of the Bill of Lading
                </div>
                <div class="listDiv">
                    <input type="file" name="copyOfBill" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Copies of correspondence exchanged with the carriers Port Trust together with their
                    replies in original
                </div>
                <div class="listDiv">
                    <input type="file" name="correspondenceExchanged" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Steamers survey report
                </div>
                <div class="listDiv">
                    <input type="file" name="streamersSurveyReport" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Carriers Certificate (Rail, Lorry, Post and/or Air)
                </div>
                <div class="listDiv">
                    <input type="file" name="carriersCertificate" />
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Address
                </div>
                <div class="listDiv">
                    <textarea name="addressDocuments" rows="4" cols="22"></textarea>
                </div>
            </div>
        </fieldset>
        <fieldset>
            <legend>DETAILS OF DAMAGES</legend>
            <div class="itemField">
                <div class="listDiv2">
                    Particulars of goods
                </div>
                <div class="listDiv">
                    <textarea name="particulerOfGoods" rows="4" cols="22"></textarea>
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Nature of loss
                </div>
                <div class="listDiv">
                    <textarea name="natureOfLoss" rows="4" cols="22"></textarea>
                </div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Estimate of repairs and/or replacements
                </div>
                <div class="listDiv">
                    <textarea name="estimateOfRepairs" rows="4" cols="22"></textarea>
                </div>
            </div>
        </fieldset>
    </div>
</div>