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.

Увімкни вкладення в налаштуваннях форми та встанови Turnstile на сайті. PDF, JPEG і PNG до 5 MiB на файл зберігаються приватно; для скачування потрібен вхід власника.

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; }
  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>
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