Insurance claim form
Register a claim. Send the facts of what happened, not documents you do not need for the first notice.
This form is not an insurance contract or a legal record of a claim. Send only what is needed to quote or register the request. Health details are special-category data under the GDPR — leave them out unless the request cannot be handled without them.
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<!doctype html>
<html lang="en">
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1">
<title>Insurance claim form</title>
<style>
body { font-family: "Segoe UI", sans-serif; color: #12263a; margin: 0; background: #fff; }
main { max-width: 640px; margin: 0 auto; padding: 32px 20px 64px; }
h1 { font-size: 28px; font-weight: 650; letter-spacing: -0.02em; line-height: 1.2; }
h2 { font-size: 18px; margin: 18px 0 0; }
p { line-height: 1.5; }
form { display: grid; gap: 14px; position: relative; }
.field { display: grid; gap: 6px; }
label span, .check span { font-size: 14px; }
input, select, textarea { font: inherit; color: inherit; padding: 10px 12px; border: 1px solid #b4bdce; border-radius: 8px; width: 100%; box-sizing: border-box; background: #fff; }
textarea { min-height: 96px; }
.check { display: flex; gap: 8px; align-items: flex-start; }
.check input { width: auto; margin-top: 4px; }
button { background: #3c4ad8; color: #fff; border: 0; border-radius: 8px; padding: 12px 18px; font: inherit; cursor: pointer; }
.note { background: #fff6eb; padding: 12px 14px; border-radius: 8px; }
form [data-show-if] { display: none; }
form:has(select[name="police_report"] option[value="yes"]:checked) [data-show-if="police_report"][data-show-equals="yes"] { display: grid; }
</style>
</head>
<body>
<main>
<h1 data-i18n="title">Insurance claim form</h1>
<p data-i18n="lede">Register a claim. Send the facts of what happened, not documents you do not need for the first notice.</p>
<p class="note" data-i18n="disclaimer">This form is not an insurance contract or a legal record of a claim. Send only what is needed to quote or register the request. Health details are special-category data under the GDPR — leave them out unless the request cannot be handled without them.</p>
<form id="fg-form" action="https://formgong.com/submit" method="POST" enctype="multipart/form-data" data-sitekey="">
<input type="hidden" name="access_key" value="fk_your_access_key">
<div aria-hidden="true" style="position:absolute;left:-10000px;width:1px;height:1px;overflow:hidden"><label>Leave this field empty<input name="botcheck" tabindex="-1" autocomplete="off"></label></div>
<section><h2 data-i18n="section.policy">Policy</h2>
<div class="field"><label for="fg-policy_number"><span data-i18n="policy_number">Policy number</span></label><input id="fg-policy_number" name="policy_number" type="text" required maxlength="40"></div>
<div class="field"><label for="fg-cover_type"><span data-i18n="cover_type">Cover</span></label><select id="fg-cover_type" name="cover_type" required><option value="">—</option><option value="auto" data-i18n="cover_type.auto">Car</option><option value="home" data-i18n="cover_type.home">Home</option><option value="travel" data-i18n="cover_type.travel">Travel</option><option value="other" data-i18n="cover_type.other">Other</option></select></div>
<div class="field"><label for="fg-incident_date"><span data-i18n="incident_date">Date of the incident</span></label><input id="fg-incident_date" name="incident_date" type="date" required></div></section>
<section><h2 data-i18n="section.incident">What happened</h2>
<div class="field"><label for="fg-city"><span data-i18n="city">City</span></label><input id="fg-city" name="city" type="text" required maxlength="80" autocomplete="address-level2"></div>
<div class="field"><label for="fg-description"><span data-i18n="description">What happened?</span></label><textarea id="fg-description" name="description" required maxlength="1000"></textarea></div>
<div class="field"><label for="fg-police_report"><span data-i18n="police_report">Was a police report filed?</span></label><select id="fg-police_report" name="police_report" required><option value="">—</option><option value="yes" data-i18n="police_report.yes">Yes</option><option value="no" data-i18n="police_report.no">No</option></select></div>
<div class="field" data-show-if="police_report" data-show-equals="yes"><label for="fg-police_ref"><span data-i18n="police_ref">Report number</span></label><input id="fg-police_ref" name="police_ref" type="text" maxlength="40"></div></section>
<section><h2 data-i18n="section.contact">Contact</h2>
<div class="field"><label for="fg-name"><span data-i18n="name">Name</span></label><input id="fg-name" name="name" type="text" required maxlength="80" autocomplete="name"></div>
<div class="field"><label for="fg-email"><span data-i18n="email">Email</span></label><input id="fg-email" name="email" type="email" required maxlength="120" autocomplete="email"></div>
<div class="field"><label for="fg-phone"><span data-i18n="phone">Phone</span></label><input id="fg-phone" name="phone" type="tel" required maxlength="40" autocomplete="tel"></div></section>
<section><h2 data-i18n="section.evidence">Photos</h2>
<div class="field"><label for="fg-photo"><span data-i18n="photo">One photo, up to 5 MiB</span></label><input id="fg-photo" name="photo" type="file" accept=".jpg,.jpeg,.png"></div>
<div class="field"><label for="fg-photo_url"><span data-i18n="photo_url">Or a link to photos</span></label><input id="fg-photo_url" name="photo_url" type="url" maxlength="300"></div></section>
<section><h2 data-i18n="section.consent">Consent</h2>
<div class="field"><label class="check"><input id="fg-consent_contact" name="consent_contact" type="checkbox" value="yes" required><span data-i18n="consent_contact">I agree to be contacted about this request.</span></label></div>
<div class="field"><label class="check"><input id="fg-consent_privacy" name="consent_privacy" type="checkbox" value="yes" required><span data-i18n="consent_privacy">I agree that these answers are stored so the request can be handled.</span></label></div></section>
<!-- Set data-sitekey on this form to YOUR_TURNSTILE_SITE_KEY. Required for attachments. -->
<div data-turnstile></div>
<button type="submit" data-i18n="submit">Send</button>
<p data-status role="status"></p>
</form>
</main>
<script type="application/json" id="fg-labels">{"uk":{"title":"Форма заяви про страховий випадок","lede":"Реєстрація випадку. Опишіть, що сталося, без документів, які не потрібні для першого повідомлення.","submit":"Надіслати","thanks":"Надіслано. Дякуємо.","file_too_big":"До 3 файлів, по 5 MiB, разом до 10 MiB.","disclaimer":"Ця форма не є договором страхування і не є юридичним записом про випадок. Надсилайте лише те, що потрібно для розрахунку чи реєстрації заявки. Дані про здоров'я — особлива категорія за GDPR: не додавайте їх, якщо без них заявку можна обробити.","section.policy":"Поліс","policy_number":"Номер поліса","cover_type":"Покриття","cover_type.auto":"Авто","cover_type.home":"Житло","cover_type.travel":"Подорож","cover_type.other":"Інше","incident_date":"Дата випадку","section.incident":"Що сталося","city":"Місто","description":"Що сталося?","police_report":"Чи є заява в поліцію?","police_report.yes":"Так","police_report.no":"Ні","police_ref":"Номер заяви","section.contact":"Контакт","name":"Ім'я","email":"Електронна пошта","phone":"Телефон","section.evidence":"Фото","photo":"Одне фото, до 5 MiB","photo_url":"Або посилання на фото","section.consent":"Згода","consent_contact":"Погоджуюсь, щоб зі мною зв'язалися щодо цієї заявки.","consent_privacy":"Погоджуюсь, що ці відповіді зберігаються, щоб заявку можна було обробити."},"en":{"title":"Insurance claim form","lede":"Register a claim. Send the facts of what happened, not documents you do not need for the first notice.","submit":"Send","thanks":"Sent. Thank you.","file_too_big":"Up to 3 files, 5 MiB each and 10 MiB combined.","disclaimer":"This form is not an insurance contract or a legal record of a claim. Send only what is needed to quote or register the request. Health details are special-category data under the GDPR — leave them out unless the request cannot be handled without them.","section.policy":"Policy","policy_number":"Policy number","cover_type":"Cover","cover_type.auto":"Car","cover_type.home":"Home","cover_type.travel":"Travel","cover_type.other":"Other","incident_date":"Date of the incident","section.incident":"What happened","city":"City","description":"What happened?","police_report":"Was a police report filed?","police_report.yes":"Yes","police_report.no":"No","police_ref":"Report number","section.contact":"Contact","name":"Name","email":"Email","phone":"Phone","section.evidence":"Photos","photo":"One photo, up to 5 MiB","photo_url":"Or a link to photos","section.consent":"Consent","consent_contact":"I agree to be contacted about this request.","consent_privacy":"I agree that these answers are stored so the request can be handled."},"pl":{"title":"Formularz zgłoszenia szkody","lede":"Zgłoszenie szkody. Opisz, co się stało, bez dokumentów zbędnych przy pierwszym zgłoszeniu.","submit":"Wyślij","thanks":"Wysłano. Dziękujemy.","file_too_big":"Do 3 plików, po 5 MiB, łącznie 10 MiB.","disclaimer":"Ten formularz nie jest umową ubezpieczenia ani prawnym zapisem szkody. Podaj tylko to, co jest potrzebne do wyceny lub rejestracji zgłoszenia. Dane o zdrowiu to szczególna kategoria w RODO — pomiń je, jeśli zgłoszenie da się obsłużyć bez nich.","section.policy":"Polisa","policy_number":"Numer polisy","cover_type":"Ochrona","cover_type.auto":"Samochód","cover_type.home":"Dom","cover_type.travel":"Podróż","cover_type.other":"Inne","incident_date":"Data zdarzenia","section.incident":"Co się stało","city":"Miasto","description":"Co się stało?","police_report":"Czy złożono zawiadomienie na policji?","police_report.yes":"Tak","police_report.no":"Nie","police_ref":"Numer zawiadomienia","section.contact":"Kontakt","name":"Imię","email":"E-mail","phone":"Telefon","section.evidence":"Zdjęcia","photo":"Jedno zdjęcie, do 5 MiB","photo_url":"Albo link do zdjęć","section.consent":"Zgoda","consent_contact":"Zgadzam się na kontakt w sprawie tego zgłoszenia.","consent_privacy":"Zgadzam się, aby te odpowiedzi zostały zapisane w celu obsługi zgłoszenia."},"tr":{"title":"Hasar bildirim formu","lede":"Hasar bildirimi. İlk kayıt için gerekmeyen belgeleri değil, olanı yazın.","submit":"Gönder","thanks":"Gönderildi. Teşekkürler.","file_too_big":"En fazla 3 dosya, dosya başına 5 MiB, toplam 10 MiB.","disclaimer":"Bu form bir sigorta sözleşmesi ya da hasarın yasal kaydı değildir. Teklif veya kayıt için gereken kadarını gönderin. Sağlık verisi GDPR'de özel niteliklidir; talep onsuz işlenebiliyorsa eklemeyin.","section.policy":"Poliçe","policy_number":"Poliçe numarası","cover_type":"Teminat","cover_type.auto":"Araç","cover_type.home":"Konut","cover_type.travel":"Seyahat","cover_type.other":"Diğer","incident_date":"Olay tarihi","section.incident":"Ne oldu","city":"Şehir","description":"Ne oldu?","police_report":"Polis tutanağı var mı?","police_report.yes":"Evet","police_report.no":"Hayır","police_ref":"Tutanak numarası","section.contact":"İletişim","name":"Ad","email":"E-posta","phone":"Telefon","section.evidence":"Fotoğraflar","photo":"Bir fotoğraf, en fazla 5 MiB","photo_url":"Ya da fotoğraf bağlantısı","section.consent":"Onay","consent_contact":"Bu talep hakkında benimle iletişime geçilmesini kabul ediyorum.","consent_privacy":"Bu yanıtların talebin işlenmesi için saklanmasını kabul ediyorum."}}</script>
<script>
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// Generated from src/content/industries.ts — npm run templates:write
import { useState, useEffect, useRef } from "react";
const ENDPOINT = "https://formgong.com/submit";
const FILE_MAX = 5242880;
const LABELS = {
"uk": {
"title": "Форма заяви про страховий випадок",
"lede": "Реєстрація випадку. Опишіть, що сталося, без документів, які не потрібні для першого повідомлення.",
"submit": "Надіслати",
"thanks": "Надіслано. Дякуємо.",
"file_too_big": "До 3 файлів, по 5 MiB, разом до 10 MiB.",
"disclaimer": "Ця форма не є договором страхування і не є юридичним записом про випадок. Надсилайте лише те, що потрібно для розрахунку чи реєстрації заявки. Дані про здоров'я — особлива категорія за GDPR: не додавайте їх, якщо без них заявку можна обробити.",
"section.policy": "Поліс",
"policy_number": "Номер поліса",
"cover_type": "Покриття",
"cover_type.auto": "Авто",
"cover_type.home": "Житло",
"cover_type.travel": "Подорож",
"cover_type.other": "Інше",
"incident_date": "Дата випадку",
"section.incident": "Що сталося",
"city": "Місто",
"description": "Що сталося?",
"police_report": "Чи є заява в поліцію?",
"police_report.yes": "Так",
"police_report.no": "Ні",
"police_ref": "Номер заяви",
"section.contact": "Контакт",
"name": "Ім'я",
"email": "Електронна пошта",
"phone": "Телефон",
"section.evidence": "Фото",
"photo": "Одне фото, до 5 MiB",
"photo_url": "Або посилання на фото",
"section.consent": "Згода",
"consent_contact": "Погоджуюсь, щоб зі мною зв'язалися щодо цієї заявки.",
"consent_privacy": "Погоджуюсь, що ці відповіді зберігаються, щоб заявку можна було обробити."
},
"en": {
"title": "Insurance claim form",
"lede": "Register a claim. Send the facts of what happened, not documents you do not need for the first notice.",
"submit": "Send",
"thanks": "Sent. Thank you.",
"file_too_big": "Up to 3 files, 5 MiB each and 10 MiB combined.",
"disclaimer": "This form is not an insurance contract or a legal record of a claim. Send only what is needed to quote or register the request. Health details are special-category data under the GDPR — leave them out unless the request cannot be handled without them.",
"section.policy": "Policy",
"policy_number": "Policy number",
"cover_type": "Cover",
"cover_type.auto": "Car",
"cover_type.home": "Home",
"cover_type.travel": "Travel",
"cover_type.other": "Other",
"incident_date": "Date of the incident",
"section.incident": "What happened",
"city": "City",
"description": "What happened?",
"police_report": "Was a police report filed?",
"police_report.yes": "Yes",
"police_report.no": "No",
"police_ref": "Report number",
"section.contact": "Contact",
"name": "Name",
"email": "Email",
"phone": "Phone",
"section.evidence": "Photos",
"photo": "One photo, up to 5 MiB",
"photo_url": "Or a link to photos",
"section.consent": "Consent",
"consent_contact": "I agree to be contacted about this request.",
"consent_privacy": "I agree that these answers are stored so the request can be handled."
},
"pl": {
"title": "Formularz zgłoszenia szkody",
"lede": "Zgłoszenie szkody. Opisz, co się stało, bez dokumentów zbędnych przy pierwszym zgłoszeniu.",
"submit": "Wyślij",
"thanks": "Wysłano. Dziękujemy.",
"file_too_big": "Do 3 plików, po 5 MiB, łącznie 10 MiB.",
"disclaimer": "Ten formularz nie jest umową ubezpieczenia ani prawnym zapisem szkody. Podaj tylko to, co jest potrzebne do wyceny lub rejestracji zgłoszenia. Dane o zdrowiu to szczególna kategoria w RODO — pomiń je, jeśli zgłoszenie da się obsłużyć bez nich.",
"section.policy": "Polisa",
"policy_number": "Numer polisy",
"cover_type": "Ochrona",
"cover_type.auto": "Samochód",
"cover_type.home": "Dom",
"cover_type.travel": "Podróż",
"cover_type.other": "Inne",
"incident_date": "Data zdarzenia",
"section.incident": "Co się stało",
"city": "Miasto",
"description": "Co się stało?",
"police_report": "Czy złożono zawiadomienie na policji?",
"police_report.yes": "Tak",
"police_report.no": "Nie",
"police_ref": "Numer zawiadomienia",
"section.contact": "Kontakt",
"name": "Imię",
"email": "E-mail",
"phone": "Telefon",
"section.evidence": "Zdjęcia",
"photo": "Jedno zdjęcie, do 5 MiB",
"photo_url": "Albo link do zdjęć",
"section.consent": "Zgoda",
"consent_contact": "Zgadzam się na kontakt w sprawie tego zgłoszenia.",
"consent_privacy": "Zgadzam się, aby te odpowiedzi zostały zapisane w celu obsługi zgłoszenia."
},
"tr": {
"title": "Hasar bildirim formu",
"lede": "Hasar bildirimi. İlk kayıt için gerekmeyen belgeleri değil, olanı yazın.",
"submit": "Gönder",
"thanks": "Gönderildi. Teşekkürler.",
"file_too_big": "En fazla 3 dosya, dosya başına 5 MiB, toplam 10 MiB.",
"disclaimer": "Bu form bir sigorta sözleşmesi ya da hasarın yasal kaydı değildir. Teklif veya kayıt için gereken kadarını gönderin. Sağlık verisi GDPR'de özel niteliklidir; talep onsuz işlenebiliyorsa eklemeyin.",
"section.policy": "Poliçe",
"policy_number": "Poliçe numarası",
"cover_type": "Teminat",
"cover_type.auto": "Araç",
"cover_type.home": "Konut",
"cover_type.travel": "Seyahat",
"cover_type.other": "Diğer",
"incident_date": "Olay tarihi",
"section.incident": "Ne oldu",
"city": "Şehir",
"description": "Ne oldu?",
"police_report": "Polis tutanağı var mı?",
"police_report.yes": "Evet",
"police_report.no": "Hayır",
"police_ref": "Tutanak numarası",
"section.contact": "İletişim",
"name": "Ad",
"email": "E-posta",
"phone": "Telefon",
"section.evidence": "Fotoğraflar",
"photo": "Bir fotoğraf, en fazla 5 MiB",
"photo_url": "Ya da fotoğraf bağlantısı",
"section.consent": "Onay",
"consent_contact": "Bu talep hakkında benimle iletişime geçilmesini kabul ediyorum.",
"consent_privacy": "Bu yanıtların talebin işlenmesi için saklanmasını kabul ediyorum."
}
};
export function IndustryForm({ lang = "en", accessKey = "fk_your_access_key", turnstileSiteKey = "" }) {
const t = LABELS[lang] || LABELS.en;
const [status, setStatus] = useState("");
const captcha = useRef(null);
useEffect(() => mountCaptcha(captcha.current, turnstileSiteKey), [turnstileSiteKey]);
const [values, setValues] = useState({ police_report: "" });
function setField(name, value) {
setValues((current) => ({ ...current, [name]: value }));
}
async function onSubmit(event) {
const form = event.currentTarget;
event.preventDefault();
const body = new FormData(form);
const files = Array.from(body.values()).filter(value => value instanceof File && value.size);
if (files.length > 3 || files.some(file => file.size > FILE_MAX) || files.reduce((sum,file) => sum + file.size,0) > 10 * 1024 * 1024) {
setStatus(t.file_too_big);
return;
}
const button = form.querySelector("button[type=submit]");
if (button) button.disabled = true;
try {
const response = await fetch(ENDPOINT, { method: "POST", headers: { Accept: "application/json" }, body });
const result = await response.json();
setStatus(result.success ? t.thanks : (result.message || "error"));
} catch { setStatus("error"); }
finally { if (button) button.disabled = false; resetCaptcha(form); }
}
return (
<form onSubmit={onSubmit}>
<h1>{t.title}</h1>
<p>{t.lede}</p>
{t.disclaimer ? <p>{t.disclaimer}</p> : null}
<input type="hidden" name="access_key" value={accessKey} />
<div aria-hidden="true" style={{ position: "absolute", left: "-10000px", width: 1, height: 1, overflow: "hidden" }}>
<input name="botcheck" tabIndex={-1} autoComplete="off" />
</div>
<section><h2>{t["section.policy"]}</h2>
<label><span>{t["policy_number"]}</span><input name="policy_number" type="text" required maxLength={40} /></label>
<label><span>{t["cover_type"]}</span><select name="cover_type" required><option value="">—</option><option value="auto">{t["cover_type.auto"]}</option><option value="home">{t["cover_type.home"]}</option><option value="travel">{t["cover_type.travel"]}</option><option value="other">{t["cover_type.other"]}</option></select></label>
<label><span>{t["incident_date"]}</span><input name="incident_date" type="date" required /></label></section>
<section><h2>{t["section.incident"]}</h2>
<label><span>{t["city"]}</span><input name="city" type="text" required maxLength={80} autoComplete="address-level2" /></label>
<label><span>{t["description"]}</span><textarea name="description" required maxLength={1000} /></label>
<label><span>{t["police_report"]}</span><select name="police_report" required value={values["police_report"]} onChange={(event) => setField("police_report", event.target.value)}><option value="">—</option><option value="yes">{t["police_report.yes"]}</option><option value="no">{t["police_report.no"]}</option></select></label>
{values["police_report"] === "yes" ? (<label><span>{t["police_ref"]}</span><input name="police_ref" type="text" maxLength={40} /></label>) : null}</section>
<section><h2>{t["section.contact"]}</h2>
<label><span>{t["name"]}</span><input name="name" type="text" required maxLength={80} autoComplete="name" /></label>
<label><span>{t["email"]}</span><input name="email" type="email" required maxLength={120} autoComplete="email" /></label>
<label><span>{t["phone"]}</span><input name="phone" type="tel" required maxLength={40} autoComplete="tel" /></label></section>
<section><h2>{t["section.evidence"]}</h2>
<label><span>{t["photo"]}</span><input name="photo" type="file" accept=".jpg,.jpeg,.png" /></label>
<label><span>{t["photo_url"]}</span><input name="photo_url" type="url" maxLength={300} /></label></section>
<section><h2>{t["section.consent"]}</h2>
<label className="check"><input name="consent_contact" type="checkbox" value="yes" required /><span>{t["consent_contact"]}</span></label>
<label className="check"><input name="consent_privacy" type="checkbox" value="yes" required /><span>{t["consent_privacy"]}</span></label></section>
{/* Set turnstileSiteKey to YOUR_TURNSTILE_SITE_KEY. Required for attachments. */}
<div ref={captcha} data-turnstile />
<button type="submit">{t.submit}</button>
<p>{status}</p>
</form>
);
}
function mountCaptcha(node, siteKey) {
if (!node || !siteKey) return () => {};
let disposed = false;
let widget;
function render() {
if (disposed || !window.turnstile) return;
window.turnstile.ready(() => {
if (disposed) return;
widget = window.turnstile.render(node, { sitekey: siteKey });
node.dataset.widgetId = widget;
});
}
if (window.turnstile) render();
else {
let script = document.querySelector('script[src^="https://challenges.cloudflare.com/turnstile/v0/api.js"]');
if (!script) {
script = document.createElement("script");
script.src = "https://challenges.cloudflare.com/turnstile/v0/api.js?render=explicit";
script.async = true;
document.head.appendChild(script);
}
script.addEventListener("load", render, { once: true });
}
return () => { disposed = true; if (widget !== undefined) window.turnstile?.remove(widget); };
}
function resetCaptcha(form) {
const widget = form.querySelector("[data-turnstile]")?.dataset.widgetId;
if (widget !== undefined) window.turnstile?.reset(widget);
}
<!-- Generated from src/content/industries.ts — npm run templates:write -->
<script setup>
import { reactive, ref, computed, onMounted, onBeforeUnmount } from "vue";
const props = defineProps({
lang: { type: String, default: "en" },
accessKey: { type: String, default: "fk_your_access_key" },
turnstileSiteKey: { type: String, default: "" },
});
const ENDPOINT = "https://formgong.com/submit";
const FILE_MAX = 5242880;
const LABELS = {
"uk": {
"title": "Форма заяви про страховий випадок",
"lede": "Реєстрація випадку. Опишіть, що сталося, без документів, які не потрібні для першого повідомлення.",
"submit": "Надіслати",
"thanks": "Надіслано. Дякуємо.",
"file_too_big": "До 3 файлів, по 5 MiB, разом до 10 MiB.",
"disclaimer": "Ця форма не є договором страхування і не є юридичним записом про випадок. Надсилайте лише те, що потрібно для розрахунку чи реєстрації заявки. Дані про здоров'я — особлива категорія за GDPR: не додавайте їх, якщо без них заявку можна обробити.",
"section.policy": "Поліс",
"policy_number": "Номер поліса",
"cover_type": "Покриття",
"cover_type.auto": "Авто",
"cover_type.home": "Житло",
"cover_type.travel": "Подорож",
"cover_type.other": "Інше",
"incident_date": "Дата випадку",
"section.incident": "Що сталося",
"city": "Місто",
"description": "Що сталося?",
"police_report": "Чи є заява в поліцію?",
"police_report.yes": "Так",
"police_report.no": "Ні",
"police_ref": "Номер заяви",
"section.contact": "Контакт",
"name": "Ім'я",
"email": "Електронна пошта",
"phone": "Телефон",
"section.evidence": "Фото",
"photo": "Одне фото, до 5 MiB",
"photo_url": "Або посилання на фото",
"section.consent": "Згода",
"consent_contact": "Погоджуюсь, щоб зі мною зв'язалися щодо цієї заявки.",
"consent_privacy": "Погоджуюсь, що ці відповіді зберігаються, щоб заявку можна було обробити."
},
"en": {
"title": "Insurance claim form",
"lede": "Register a claim. Send the facts of what happened, not documents you do not need for the first notice.",
"submit": "Send",
"thanks": "Sent. Thank you.",
"file_too_big": "Up to 3 files, 5 MiB each and 10 MiB combined.",
"disclaimer": "This form is not an insurance contract or a legal record of a claim. Send only what is needed to quote or register the request. Health details are special-category data under the GDPR — leave them out unless the request cannot be handled without them.",
"section.policy": "Policy",
"policy_number": "Policy number",
"cover_type": "Cover",
"cover_type.auto": "Car",
"cover_type.home": "Home",
"cover_type.travel": "Travel",
"cover_type.other": "Other",
"incident_date": "Date of the incident",
"section.incident": "What happened",
"city": "City",
"description": "What happened?",
"police_report": "Was a police report filed?",
"police_report.yes": "Yes",
"police_report.no": "No",
"police_ref": "Report number",
"section.contact": "Contact",
"name": "Name",
"email": "Email",
"phone": "Phone",
"section.evidence": "Photos",
"photo": "One photo, up to 5 MiB",
"photo_url": "Or a link to photos",
"section.consent": "Consent",
"consent_contact": "I agree to be contacted about this request.",
"consent_privacy": "I agree that these answers are stored so the request can be handled."
},
"pl": {
"title": "Formularz zgłoszenia szkody",
"lede": "Zgłoszenie szkody. Opisz, co się stało, bez dokumentów zbędnych przy pierwszym zgłoszeniu.",
"submit": "Wyślij",
"thanks": "Wysłano. Dziękujemy.",
"file_too_big": "Do 3 plików, po 5 MiB, łącznie 10 MiB.",
"disclaimer": "Ten formularz nie jest umową ubezpieczenia ani prawnym zapisem szkody. Podaj tylko to, co jest potrzebne do wyceny lub rejestracji zgłoszenia. Dane o zdrowiu to szczególna kategoria w RODO — pomiń je, jeśli zgłoszenie da się obsłużyć bez nich.",
"section.policy": "Polisa",
"policy_number": "Numer polisy",
"cover_type": "Ochrona",
"cover_type.auto": "Samochód",
"cover_type.home": "Dom",
"cover_type.travel": "Podróż",
"cover_type.other": "Inne",
"incident_date": "Data zdarzenia",
"section.incident": "Co się stało",
"city": "Miasto",
"description": "Co się stało?",
"police_report": "Czy złożono zawiadomienie na policji?",
"police_report.yes": "Tak",
"police_report.no": "Nie",
"police_ref": "Numer zawiadomienia",
"section.contact": "Kontakt",
"name": "Imię",
"email": "E-mail",
"phone": "Telefon",
"section.evidence": "Zdjęcia",
"photo": "Jedno zdjęcie, do 5 MiB",
"photo_url": "Albo link do zdjęć",
"section.consent": "Zgoda",
"consent_contact": "Zgadzam się na kontakt w sprawie tego zgłoszenia.",
"consent_privacy": "Zgadzam się, aby te odpowiedzi zostały zapisane w celu obsługi zgłoszenia."
},
"tr": {
"title": "Hasar bildirim formu",
"lede": "Hasar bildirimi. İlk kayıt için gerekmeyen belgeleri değil, olanı yazın.",
"submit": "Gönder",
"thanks": "Gönderildi. Teşekkürler.",
"file_too_big": "En fazla 3 dosya, dosya başına 5 MiB, toplam 10 MiB.",
"disclaimer": "Bu form bir sigorta sözleşmesi ya da hasarın yasal kaydı değildir. Teklif veya kayıt için gereken kadarını gönderin. Sağlık verisi GDPR'de özel niteliklidir; talep onsuz işlenebiliyorsa eklemeyin.",
"section.policy": "Poliçe",
"policy_number": "Poliçe numarası",
"cover_type": "Teminat",
"cover_type.auto": "Araç",
"cover_type.home": "Konut",
"cover_type.travel": "Seyahat",
"cover_type.other": "Diğer",
"incident_date": "Olay tarihi",
"section.incident": "Ne oldu",
"city": "Şehir",
"description": "Ne oldu?",
"police_report": "Polis tutanağı var mı?",
"police_report.yes": "Evet",
"police_report.no": "Hayır",
"police_ref": "Tutanak numarası",
"section.contact": "İletişim",
"name": "Ad",
"email": "E-posta",
"phone": "Telefon",
"section.evidence": "Fotoğraflar",
"photo": "Bir fotoğraf, en fazla 5 MiB",
"photo_url": "Ya da fotoğraf bağlantısı",
"section.consent": "Onay",
"consent_contact": "Bu talep hakkında benimle iletişime geçilmesini kabul ediyorum.",
"consent_privacy": "Bu yanıtların talebin işlenmesi için saklanmasını kabul ediyorum."
}
};
const t = computed(() => LABELS[props.lang] || LABELS.en);
const status = ref("");
const captcha = ref(null);
let disposeCaptcha;
onMounted(() => { disposeCaptcha = mountCaptcha(captcha.value, props.turnstileSiteKey); });
onBeforeUnmount(() => disposeCaptcha?.());
const values = reactive({ police_report: "" });
function mountCaptcha(node, siteKey) {
if (!node || !siteKey) return () => {};
let disposed = false;
let widget;
function render() {
if (disposed || !window.turnstile) return;
window.turnstile.ready(() => {
if (disposed) return;
widget = window.turnstile.render(node, { sitekey: siteKey });
node.dataset.widgetId = widget;
});
}
if (window.turnstile) render();
else {
let script = document.querySelector('script[src^="https://challenges.cloudflare.com/turnstile/v0/api.js"]');
if (!script) {
script = document.createElement("script");
script.src = "https://challenges.cloudflare.com/turnstile/v0/api.js?render=explicit";
script.async = true;
document.head.appendChild(script);
}
script.addEventListener("load", render, { once: true });
}
return () => { disposed = true; if (widget !== undefined) window.turnstile?.remove(widget); };
}
function resetCaptcha(form) {
const widget = form.querySelector("[data-turnstile]")?.dataset.widgetId;
if (widget !== undefined) window.turnstile?.reset(widget);
}
async function onSubmit(event) {
const form = event.currentTarget;
event.preventDefault();
const body = new FormData(form);
const files = Array.from(body.values()).filter(value => value instanceof File && value.size);
if (files.length > 3 || files.some(file => file.size > FILE_MAX) || files.reduce((sum,file) => sum + file.size,0) > 10 * 1024 * 1024) {
status.value = t.value.file_too_big;
return;
}
const button = form.querySelector("button[type=submit]");
if (button) button.disabled = true;
try {
const response = await fetch(ENDPOINT, { method: "POST", headers: { Accept: "application/json" }, body });
const result = await response.json();
status.value = result.success ? t.value.thanks : (result.message || "error");
} catch { status.value = "error"; }
finally { if (button) button.disabled = false; resetCaptcha(form); }
}
</script>
<template>
<form @submit.prevent="onSubmit">
<h1>{{ t.title }}</h1>
<p>{{ t.lede }}</p>
<p v-if="t.disclaimer">{{ t.disclaimer }}</p>
<input type="hidden" name="access_key" :value="accessKey">
<div aria-hidden="true" style="position:absolute;left:-10000px;width:1px;height:1px;overflow:hidden">
<input name="botcheck" tabindex="-1" autocomplete="off">
</div>
<section><h2>{{ t["section.policy"] }}</h2>
<label><span>{{ t["policy_number"] }}</span><input name="policy_number" type="text" required maxlength="40"></label>
<label><span>{{ t["cover_type"] }}</span><select name="cover_type" required><option value="">—</option><option value="auto">{{ t["cover_type.auto"] }}</option><option value="home">{{ t["cover_type.home"] }}</option><option value="travel">{{ t["cover_type.travel"] }}</option><option value="other">{{ t["cover_type.other"] }}</option></select></label>
<label><span>{{ t["incident_date"] }}</span><input name="incident_date" type="date" required></label></section>
<section><h2>{{ t["section.incident"] }}</h2>
<label><span>{{ t["city"] }}</span><input name="city" type="text" required maxlength="80" autocomplete="address-level2"></label>
<label><span>{{ t["description"] }}</span><textarea name="description" required maxlength="1000"></textarea></label>
<label><span>{{ t["police_report"] }}</span><select name="police_report" required v-model="values.police_report"><option value="">—</option><option value="yes">{{ t["police_report.yes"] }}</option><option value="no">{{ t["police_report.no"] }}</option></select></label>
<template v-if="values["police_report"] === 'yes'"><label><span>{{ t["police_ref"] }}</span><input name="police_ref" type="text" maxlength="40"></label></template></section>
<section><h2>{{ t["section.contact"] }}</h2>
<label><span>{{ t["name"] }}</span><input name="name" type="text" required maxlength="80" autocomplete="name"></label>
<label><span>{{ t["email"] }}</span><input name="email" type="email" required maxlength="120" autocomplete="email"></label>
<label><span>{{ t["phone"] }}</span><input name="phone" type="tel" required maxlength="40" autocomplete="tel"></label></section>
<section><h2>{{ t["section.evidence"] }}</h2>
<label><span>{{ t["photo"] }}</span><input name="photo" type="file" accept=".jpg,.jpeg,.png"></label>
<label><span>{{ t["photo_url"] }}</span><input name="photo_url" type="url" maxlength="300"></label></section>
<section><h2>{{ t["section.consent"] }}</h2>
<label class="check"><input name="consent_contact" type="checkbox" value="yes" required><span>{{ t["consent_contact"] }}</span></label>
<label class="check"><input name="consent_privacy" type="checkbox" value="yes" required><span>{{ t["consent_privacy"] }}</span></label></section>
<!-- Set turnstileSiteKey to YOUR_TURNSTILE_SITE_KEY. Required for attachments. -->
<div ref="captcha" data-turnstile></div>
<button type="submit">{{ t.submit }}</button>
<p>{{ status }}</p>
</form>
</template>
<!-- Generated from src/content/industries.ts — npm run templates:write -->
<script>
import { onMount } from "svelte";
let { lang = "en", accessKey = "fk_your_access_key", turnstileSiteKey = "" } = $props();
let captcha;
onMount(() => mountCaptcha(captcha, turnstileSiteKey));
const ENDPOINT = "https://formgong.com/submit";
const FILE_MAX = 5242880;
const LABELS = {
"uk": {
"title": "Форма заяви про страховий випадок",
"lede": "Реєстрація випадку. Опишіть, що сталося, без документів, які не потрібні для першого повідомлення.",
"submit": "Надіслати",
"thanks": "Надіслано. Дякуємо.",
"file_too_big": "До 3 файлів, по 5 MiB, разом до 10 MiB.",
"disclaimer": "Ця форма не є договором страхування і не є юридичним записом про випадок. Надсилайте лише те, що потрібно для розрахунку чи реєстрації заявки. Дані про здоров'я — особлива категорія за GDPR: не додавайте їх, якщо без них заявку можна обробити.",
"section.policy": "Поліс",
"policy_number": "Номер поліса",
"cover_type": "Покриття",
"cover_type.auto": "Авто",
"cover_type.home": "Житло",
"cover_type.travel": "Подорож",
"cover_type.other": "Інше",
"incident_date": "Дата випадку",
"section.incident": "Що сталося",
"city": "Місто",
"description": "Що сталося?",
"police_report": "Чи є заява в поліцію?",
"police_report.yes": "Так",
"police_report.no": "Ні",
"police_ref": "Номер заяви",
"section.contact": "Контакт",
"name": "Ім'я",
"email": "Електронна пошта",
"phone": "Телефон",
"section.evidence": "Фото",
"photo": "Одне фото, до 5 MiB",
"photo_url": "Або посилання на фото",
"section.consent": "Згода",
"consent_contact": "Погоджуюсь, щоб зі мною зв'язалися щодо цієї заявки.",
"consent_privacy": "Погоджуюсь, що ці відповіді зберігаються, щоб заявку можна було обробити."
},
"en": {
"title": "Insurance claim form",
"lede": "Register a claim. Send the facts of what happened, not documents you do not need for the first notice.",
"submit": "Send",
"thanks": "Sent. Thank you.",
"file_too_big": "Up to 3 files, 5 MiB each and 10 MiB combined.",
"disclaimer": "This form is not an insurance contract or a legal record of a claim. Send only what is needed to quote or register the request. Health details are special-category data under the GDPR — leave them out unless the request cannot be handled without them.",
"section.policy": "Policy",
"policy_number": "Policy number",
"cover_type": "Cover",
"cover_type.auto": "Car",
"cover_type.home": "Home",
"cover_type.travel": "Travel",
"cover_type.other": "Other",
"incident_date": "Date of the incident",
"section.incident": "What happened",
"city": "City",
"description": "What happened?",
"police_report": "Was a police report filed?",
"police_report.yes": "Yes",
"police_report.no": "No",
"police_ref": "Report number",
"section.contact": "Contact",
"name": "Name",
"email": "Email",
"phone": "Phone",
"section.evidence": "Photos",
"photo": "One photo, up to 5 MiB",
"photo_url": "Or a link to photos",
"section.consent": "Consent",
"consent_contact": "I agree to be contacted about this request.",
"consent_privacy": "I agree that these answers are stored so the request can be handled."
},
"pl": {
"title": "Formularz zgłoszenia szkody",
"lede": "Zgłoszenie szkody. Opisz, co się stało, bez dokumentów zbędnych przy pierwszym zgłoszeniu.",
"submit": "Wyślij",
"thanks": "Wysłano. Dziękujemy.",
"file_too_big": "Do 3 plików, po 5 MiB, łącznie 10 MiB.",
"disclaimer": "Ten formularz nie jest umową ubezpieczenia ani prawnym zapisem szkody. Podaj tylko to, co jest potrzebne do wyceny lub rejestracji zgłoszenia. Dane o zdrowiu to szczególna kategoria w RODO — pomiń je, jeśli zgłoszenie da się obsłużyć bez nich.",
"section.policy": "Polisa",
"policy_number": "Numer polisy",
"cover_type": "Ochrona",
"cover_type.auto": "Samochód",
"cover_type.home": "Dom",
"cover_type.travel": "Podróż",
"cover_type.other": "Inne",
"incident_date": "Data zdarzenia",
"section.incident": "Co się stało",
"city": "Miasto",
"description": "Co się stało?",
"police_report": "Czy złożono zawiadomienie na policji?",
"police_report.yes": "Tak",
"police_report.no": "Nie",
"police_ref": "Numer zawiadomienia",
"section.contact": "Kontakt",
"name": "Imię",
"email": "E-mail",
"phone": "Telefon",
"section.evidence": "Zdjęcia",
"photo": "Jedno zdjęcie, do 5 MiB",
"photo_url": "Albo link do zdjęć",
"section.consent": "Zgoda",
"consent_contact": "Zgadzam się na kontakt w sprawie tego zgłoszenia.",
"consent_privacy": "Zgadzam się, aby te odpowiedzi zostały zapisane w celu obsługi zgłoszenia."
},
"tr": {
"title": "Hasar bildirim formu",
"lede": "Hasar bildirimi. İlk kayıt için gerekmeyen belgeleri değil, olanı yazın.",
"submit": "Gönder",
"thanks": "Gönderildi. Teşekkürler.",
"file_too_big": "En fazla 3 dosya, dosya başına 5 MiB, toplam 10 MiB.",
"disclaimer": "Bu form bir sigorta sözleşmesi ya da hasarın yasal kaydı değildir. Teklif veya kayıt için gereken kadarını gönderin. Sağlık verisi GDPR'de özel niteliklidir; talep onsuz işlenebiliyorsa eklemeyin.",
"section.policy": "Poliçe",
"policy_number": "Poliçe numarası",
"cover_type": "Teminat",
"cover_type.auto": "Araç",
"cover_type.home": "Konut",
"cover_type.travel": "Seyahat",
"cover_type.other": "Diğer",
"incident_date": "Olay tarihi",
"section.incident": "Ne oldu",
"city": "Şehir",
"description": "Ne oldu?",
"police_report": "Polis tutanağı var mı?",
"police_report.yes": "Evet",
"police_report.no": "Hayır",
"police_ref": "Tutanak numarası",
"section.contact": "İletişim",
"name": "Ad",
"email": "E-posta",
"phone": "Telefon",
"section.evidence": "Fotoğraflar",
"photo": "Bir fotoğraf, en fazla 5 MiB",
"photo_url": "Ya da fotoğraf bağlantısı",
"section.consent": "Onay",
"consent_contact": "Bu talep hakkında benimle iletişime geçilmesini kabul ediyorum.",
"consent_privacy": "Bu yanıtların talebin işlenmesi için saklanmasını kabul ediyorum."
}
};
let status = $state("");
let values = $state({ police_report: "" });
const t = $derived(LABELS[lang] || LABELS.en);
function mountCaptcha(node, siteKey) {
if (!node || !siteKey) return () => {};
let disposed = false;
let widget;
function render() {
if (disposed || !window.turnstile) return;
window.turnstile.ready(() => {
if (disposed) return;
widget = window.turnstile.render(node, { sitekey: siteKey });
node.dataset.widgetId = widget;
});
}
if (window.turnstile) render();
else {
let script = document.querySelector('script[src^="https://challenges.cloudflare.com/turnstile/v0/api.js"]');
if (!script) {
script = document.createElement("script");
script.src = "https://challenges.cloudflare.com/turnstile/v0/api.js?render=explicit";
script.async = true;
document.head.appendChild(script);
}
script.addEventListener("load", render, { once: true });
}
return () => { disposed = true; if (widget !== undefined) window.turnstile?.remove(widget); };
}
function resetCaptcha(form) {
const widget = form.querySelector("[data-turnstile]")?.dataset.widgetId;
if (widget !== undefined) window.turnstile?.reset(widget);
}
async function onSubmit(event) {
const form = event.currentTarget;
event.preventDefault();
const body = new FormData(form);
const files = Array.from(body.values()).filter(value => value instanceof File && value.size);
if (files.length > 3 || files.some(file => file.size > FILE_MAX) || files.reduce((sum,file) => sum + file.size,0) > 10 * 1024 * 1024) {
status = t.file_too_big;
return;
}
const button = form.querySelector("button[type=submit]");
if (button) button.disabled = true;
try {
const response = await fetch(ENDPOINT, { method: "POST", headers: { Accept: "application/json" }, body });
const result = await response.json();
status = result.success ? t.thanks : (result.message || "error");
} catch { status = "error"; }
finally { if (button) button.disabled = false; resetCaptcha(form); }
}
</script>
<form onsubmit={onSubmit}>
<h1>{t.title}</h1>
<p>{t.lede}</p>
{#if t.disclaimer}<p>{t.disclaimer}</p>{/if}
<input type="hidden" name="access_key" value={accessKey}>
<div aria-hidden="true" style="position:absolute;left:-10000px;width:1px;height:1px;overflow:hidden">
<input name="botcheck" tabindex="-1" autocomplete="off">
</div>
<section><h2>{t["section.policy"]}</h2>
<label><span>{t["policy_number"]}</span><input name="policy_number" type="text" required maxlength="40"></label>
<label><span>{t["cover_type"]}</span><select name="cover_type" required><option value="">—</option><option value="auto">{t["cover_type.auto"]}</option><option value="home">{t["cover_type.home"]}</option><option value="travel">{t["cover_type.travel"]}</option><option value="other">{t["cover_type.other"]}</option></select></label>
<label><span>{t["incident_date"]}</span><input name="incident_date" type="date" required></label></section>
<section><h2>{t["section.incident"]}</h2>
<label><span>{t["city"]}</span><input name="city" type="text" required maxlength="80"></label>
<label><span>{t["description"]}</span><textarea name="description" required maxlength="1000"></textarea></label>
<label><span>{t["police_report"]}</span><select name="police_report" required bind:value={values.police_report}><option value="">—</option><option value="yes">{t["police_report.yes"]}</option><option value="no">{t["police_report.no"]}</option></select></label>
{#if values.police_report === "yes"}<label><span>{t["police_ref"]}</span><input name="police_ref" type="text" maxlength="40"></label>{/if}</section>
<section><h2>{t["section.contact"]}</h2>
<label><span>{t["name"]}</span><input name="name" type="text" required maxlength="80"></label>
<label><span>{t["email"]}</span><input name="email" type="email" required maxlength="120"></label>
<label><span>{t["phone"]}</span><input name="phone" type="tel" required maxlength="40"></label></section>
<section><h2>{t["section.evidence"]}</h2>
<label><span>{t["photo"]}</span><input name="photo" type="file" accept=".jpg,.jpeg,.png"></label>
<label><span>{t["photo_url"]}</span><input name="photo_url" type="url" maxlength="300"></label></section>
<section><h2>{t["section.consent"]}</h2>
<label class="check"><input name="consent_contact" type="checkbox" value="yes" required><span>{t["consent_contact"]}</span></label>
<label class="check"><input name="consent_privacy" type="checkbox" value="yes" required><span>{t["consent_privacy"]}</span></label></section>
<!-- Set turnstileSiteKey to YOUR_TURNSTILE_SITE_KEY. Required for attachments. -->
<div bind:this={captcha} data-turnstile></div>
<button type="submit">{t.submit}</button>
<p>{status}</p>
</form>