Форма заяви про страховий випадок

Реєстрація випадку. Опишіть, що сталося, без документів, які не потрібні для першого повідомлення.

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.

Файл до 24 КБ надсилається текстом разом із заявкою. Більший файл краще дати посиланням. Formgong не зберігає окремий файл.

Перегляд

Поліс

Що сталося

Контакт

Фото

Згода

Код форми

HTML
<!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; }
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  form { display: grid; gap: 14px; position: relative; }
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  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">
<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 24 KB</span></label><input id="fg-photo" name="photo" type="file" accept="image/*"></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>
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<div class="cf-turnstile" data-sitekey="YOUR_TURNSTILE_SITE_KEY"></div>
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<button type="submit" data-i18n="submit">Send</button>
<p data-status role="status"></p>
</form>
</main>
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