{"id":1636,"date":"2022-03-07T07:23:36","date_gmt":"2022-03-07T07:23:36","guid":{"rendered":"https:\/\/bciconline.com\/2022-website\/?page_id=1636"},"modified":"2025-12-22T11:57:59","modified_gmt":"2025-12-22T16:57:59","slug":"report-claim","status":"publish","type":"page","link":"https:\/\/bciconline.com\/ba\/report-claim\/","title":{"rendered":"Report a Claim"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1636\" class=\"elementor elementor-1636\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-2dd8e6e elementor-section-stretched elementor-section-height-min-height elementor-section-content-middle elementor-section-full_width elementor-section-height-default elementor-section-items-middle\" data-eae-slider=\"86394\" data-id=\"2dd8e6e\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;background_background&quot;:&quot;classic&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-narrow\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-5ee15ba\" data-eae-slider=\"83428\" data-id=\"5ee15ba\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-inner-section elementor-element elementor-element-05abeee elementor-section-content-middle elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"3923\" data-id=\"05abeee\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-c91e052\" data-eae-slider=\"12876\" data-id=\"c91e052\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-9b9e52a elementor-widget elementor-widget-text-editor\" data-id=\"9b9e52a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>How to Make A Claim<span style=\"color: #ff0000;\">.<\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-eae30d7 elementor-widget elementor-widget-text-editor\" data-id=\"eae30d7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<span style=\"font-weight: 400;\">We know you need us the most when making a claim, our priority is to make it\u00a0 hassle free. <\/span>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-11a73cc elementor-widget elementor-widget-ha-creative-button happy-addon ha-creative-button\" data-id=\"11a73cc\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"ha-creative-button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div data-magnetic=\"no\" class=\"ha-creative-btn-wrap\">\n\t\t\t<a class=\"ha-creative-btn ha-stl--symbolab ha-eft--back-in-right\" href=\"#Report\" rel=\"nofollow\">Report a Claim<i aria-hidden=\"true\" class=\"icon icon-arrow-right\"><\/i><\/a>\n\t\t<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-inner-section elementor-element elementor-element-e93ed45 elementor-section-content-middle elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"7864\" data-id=\"e93ed45\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-1b065e9\" data-eae-slider=\"87287\" data-id=\"1b065e9\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-99ae2ed elementor-widget__width-auto elementor-icon-list--layout-traditional elementor-list-item-link-full_width elementor-widget elementor-widget-icon-list\" data-id=\"99ae2ed\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-list.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<ul class=\"elementor-icon-list-items\">\n\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"tel:246-621-7340\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"icon icon-phone-call1\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">or <B>Call us<\/b> 246-621-7340<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<\/ul>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-12be532 elementor-widget__width-auto ha-advanced-tooltip-enable ha-advanced-tooltip-right elementor-mobile-align-start elementor-widget-mobile__width-inherit ha-advanced-tooltip-mobile-bottom elementor-icon-list--layout-traditional elementor-list-item-link-full_width elementor-widget elementor-widget-icon-list\" data-id=\"12be532\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;ha_advanced_tooltip_content&quot;:&quot;Click to contact us&quot;,&quot;ha_advanced_tooltip_enable&quot;:&quot;enable&quot;,&quot;ha_advanced_tooltip_position&quot;:&quot;right&quot;,&quot;ha_advanced_tooltip_animation&quot;:&quot;ha_slideInDown&quot;,&quot;ha_advanced_tooltip_position_mobile&quot;:&quot;bottom&quot;,&quot;ha_advanced_tooltip_duration&quot;:1000,&quot;ha_advanced_tooltip_arrow&quot;:&quot;true&quot;,&quot;ha_advanced_tooltip_trigger&quot;:&quot;hover&quot;}\" data-widget_type=\"icon-list.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<ul class=\"elementor-icon-list-items\">\n\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"tel:1-888-227-7478\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"hm hm-mail-open\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\"><b>Email us<\/b> info@bcicbarbados.com<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<\/ul>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-inner-section elementor-element elementor-element-7f82c78 elementor-section-content-middle elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"43456\" data-id=\"7f82c78\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-b9ab1ff\" data-eae-slider=\"125\" data-id=\"b9ab1ff\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-20ef4fc elementor-widget elementor-widget-text-editor\" data-id=\"20ef4fc\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>scroll for more<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-e8601ae elementor-widget__width-inherit e-transform elementor-view-default elementor-widget elementor-widget-icon\" data-id=\"e8601ae\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;_transform_translateY_effect_hover&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:25,&quot;sizes&quot;:[]},&quot;_transform_translateX_effect_hover&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;_transform_translateX_effect_hover_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;_transform_translateX_effect_hover_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;_transform_translateY_effect_hover_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;_transform_translateY_effect_hover_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]}}\" data-widget_type=\"icon.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-icon-wrapper\">\n\t\t\t<div class=\"elementor-icon\">\n\t\t\t<i aria-hidden=\"true\" class=\"icon icon-down-arrow\"><\/i>\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-0f16dc4\" data-eae-slider=\"24632\" data-id=\"0f16dc4\" data-element_type=\"column\" data-e-type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-inner-section elementor-element elementor-element-f03ed97 elementor-section-height-min-height elementor-hidden-tablet elementor-hidden-mobile elementor-section-boxed elementor-section-height-default\" data-eae-slider=\"13300\" data-id=\"f03ed97\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-fa16e00\" data-eae-slider=\"72555\" data-id=\"fa16e00\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-157c023 elementor-widget__width-inherit elementor-widget elementor-widget-image\" data-id=\"157c023\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<img fetchpriority=\"high\" decoding=\"async\" width=\"938\" height=\"835\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2025\/01\/BCICMOTOR_CLAIMS-min.png\" class=\"attachment-large size-large wp-image-5130\" alt=\"\" srcset=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2025\/01\/BCICMOTOR_CLAIMS-min.png 938w, https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2025\/01\/BCICMOTOR_CLAIMS-min-300x267.png 300w, https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2025\/01\/BCICMOTOR_CLAIMS-min-768x684.png 768w\" sizes=\"(max-width: 938px) 100vw, 938px\" \/>\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-e927d00\" data-eae-slider=\"64270\" data-id=\"e927d00\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-929ec9f elementor-section-content-middle elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"66671\" data-id=\"929ec9f\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-f6f6b89\" data-eae-slider=\"11730\" data-id=\"f6f6b89\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-ed36411 elementor-widget elementor-widget-text-editor\" data-id=\"ed36411\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p>Report your Claim below<strong><span style=\"color: #ff0000;\">:<\/span><\/strong><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-01e5724 elementor-widget elementor-widget-text-editor\" data-id=\"01e5724\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\tIn an accident? Call BCIC ASSIST and we will handle everything for you. From taking pictures, witness statements, starting the claims process and towing your vehicle to safety. 1 888-2-ASSIST (277478)\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-d243cd1 elementor-hidden-mobile elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"83987\" data-id=\"d243cd1\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-no\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-520306e\" data-eae-slider=\"86106\" data-id=\"520306e\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-9ca0c8e elementor-widget elementor-widget-menu-anchor\" data-id=\"9ca0c8e\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"menu-anchor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-menu-anchor\" id=\"Report\"><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-476cdd8 elementor-widget elementor-widget-elementskit-simple-tab\" data-id=\"476cdd8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-simple-tab.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >        <div class=\"elementkit-tab-wraper   elementskit-fitcontent-tab \">\n            <ul class=\"nav nav-tabs elementkit-tab-nav  tab-nav-fluid\">\n                                    <li class=\"elementkit-nav-item elementor-repeater-item-242af55\">\n                        <a class=\"elementkit-nav-link  active show top-pos\" id=\"content-242af556a9c0ed52d4d9-tab\" data-ekit-handler-id=\"motor-claim\" data-ekit-toggle=\"tab\" data-target=\"#content-242af556a9c0ed52d4d9\" href=\"#Content-242af556a9c0ed52d4d9\"\n                            data-ekit-toggle-trigger=\"click\"\n                            aria-describedby=\"Content-242af556a9c0ed52d4d9\">\n                                                        <span class=\"elementskit-tab-title\">Motor Claim<\/span>\n                        <\/a>\n                    <\/li>\n                                        <li class=\"elementkit-nav-item elementor-repeater-item-23ba488\">\n                        <a class=\"elementkit-nav-link  top-pos\" id=\"content-23ba4886a9c0ed52d4d9-tab\" data-ekit-handler-id=\"home-and-contents\" data-ekit-toggle=\"tab\" data-target=\"#content-23ba4886a9c0ed52d4d9\" href=\"#Content-23ba4886a9c0ed52d4d9\"\n                            data-ekit-toggle-trigger=\"click\"\n                            aria-describedby=\"Content-23ba4886a9c0ed52d4d9\">\n                                                        <span class=\"elementskit-tab-title\">Home and Contents<\/span>\n                        <\/a>\n                    <\/li>\n                                        <li class=\"elementkit-nav-item elementor-repeater-item-89fdad1\">\n                        <a class=\"elementkit-nav-link  top-pos\" id=\"content-89fdad16a9c0ed52d4d9-tab\" data-ekit-handler-id=\"motorcyle\" data-ekit-toggle=\"tab\" data-target=\"#content-89fdad16a9c0ed52d4d9\" href=\"#Content-89fdad16a9c0ed52d4d9\"\n                            data-ekit-toggle-trigger=\"click\"\n                            aria-describedby=\"Content-89fdad16a9c0ed52d4d9\">\n                                                        <span class=\"elementskit-tab-title\">Motorcyle<\/span>\n                        <\/a>\n                    <\/li>\n                                        <li class=\"elementkit-nav-item elementor-repeater-item-a8518f4\">\n                        <a class=\"elementkit-nav-link  top-pos\" id=\"content-a8518f46a9c0ed52d4d9-tab\" data-ekit-handler-id=\"employers-and-public-liability\" data-ekit-toggle=\"tab\" data-target=\"#content-a8518f46a9c0ed52d4d9\" href=\"#Content-a8518f46a9c0ed52d4d9\"\n                            data-ekit-toggle-trigger=\"click\"\n                            aria-describedby=\"Content-a8518f46a9c0ed52d4d9\">\n                                                        <span class=\"elementskit-tab-title\">Employers' and Public Liability<\/span>\n                        <\/a>\n                    <\/li>\n                                        <li class=\"elementkit-nav-item elementor-repeater-item-009ac7c\">\n                        <a class=\"elementkit-nav-link  top-pos\" id=\"content-009ac7c6a9c0ed52d4d9-tab\" data-ekit-handler-id=\"glass-only\" data-ekit-toggle=\"tab\" data-target=\"#content-009ac7c6a9c0ed52d4d9\" href=\"#Content-009ac7c6a9c0ed52d4d9\"\n                            data-ekit-toggle-trigger=\"click\"\n                            aria-describedby=\"Content-009ac7c6a9c0ed52d4d9\">\n                                                        <span class=\"elementskit-tab-title\">Glass Only<\/span>\n                        <\/a>\n                    <\/li>\n                                <\/ul>\n\n            <div class=\"tab-content elementkit-tab-content\">\n                                    <div class=\"tab-pane elementkit-tab-pane elementor-repeater-item-242af55  active show\" id=\"content-242af556a9c0ed52d4d9\" role=\"tabpanel\"\n                         aria-labelledby=\"content-242af556a9c0ed52d4d9-tab\">\n                        <div class=\"animated fadeIn\">\n                            <p>\t\t<div data-elementor-type=\"section\" data-elementor-id=\"1944\" class=\"elementor elementor-1944\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\" data-elementor-post-type=\"elementor_library\">\n\t\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-a1ee19b premium-equal-height-yes elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"43103\" data-pa-eq-height=\"{&quot;targetType&quot;:&quot;widget&quot;,&quot;target&quot;:&quot;&quot;,&quot;trigger&quot;:&quot;load&quot;,&quot;enableOn&quot;:[&quot;desktop&quot;,&quot;tablet&quot;,&quot;mobile&quot;]}\" data-id=\"a1ee19b\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;premium_eq_height_switcher&quot;:&quot;yes&quot;,&quot;_ha_eqh_enable&quot;:&quot;yes&quot;,&quot;_ha_eqh_to&quot;:&quot;widget&quot;,&quot;_ha_eqh_disable_on_tablet&quot;:&quot;no&quot;,&quot;_ha_eqh_disable_on_mobile&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-narrow\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-4fe2dfa\" data-eae-slider=\"16149\" data-id=\"4fe2dfa\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-5d40cd6 ekit-equal-height-enable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"5d40cd6\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/collision-other-vehicle\/about-you\" target=\"_blank\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img decoding=\"async\" width=\"700\" height=\"467\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/05\/5-min-1.png\" class=\"attachment-full size-full wp-image-2751\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Collision Other Vehicle\/s Involved\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/collision-other-vehicle\/about-you\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-8586a9f\" data-eae-slider=\"66553\" data-id=\"8586a9f\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-1faeaf7 ekit-equal-height-disable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"1faeaf7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/collision-no-other-vehicle\/about-you\" target=\"_blank\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img decoding=\"async\" width=\"700\" height=\"467\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/05\/1-min-1.png\" class=\"attachment-full size-full wp-image-2747\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Collision No Other Vehicle\/s Involved\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/collision-no-other-vehicle\/about-you\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-1d458d1\" data-eae-slider=\"97962\" data-id=\"1d458d1\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-995a73a ekit-equal-height-disable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"995a73a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/theft\/about-you\" target=\"_blank\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"467\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/05\/3-min.png\" class=\"attachment-full size-full wp-image-2749\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Theft\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/theft\/about-you\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-5009051 premium-equal-height-yes elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"2814\" data-pa-eq-height=\"{&quot;targetType&quot;:&quot;widget&quot;,&quot;target&quot;:&quot;&quot;,&quot;trigger&quot;:&quot;load&quot;,&quot;enableOn&quot;:[&quot;desktop&quot;,&quot;tablet&quot;,&quot;mobile&quot;]}\" data-id=\"5009051\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;premium_eq_height_switcher&quot;:&quot;yes&quot;,&quot;_ha_eqh_enable&quot;:&quot;yes&quot;,&quot;_ha_eqh_to&quot;:&quot;widget&quot;,&quot;_ha_eqh_disable_on_tablet&quot;:&quot;no&quot;,&quot;_ha_eqh_disable_on_mobile&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-narrow\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-09175fc\" data-eae-slider=\"53799\" data-id=\"09175fc\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-9a277ac ekit-equal-height-disable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"9a277ac\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/fire\/about-you\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"467\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/05\/2-min.png\" class=\"attachment-full size-full wp-image-2748\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Fire\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/fire\/about-you\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-1a7e112\" data-eae-slider=\"89261\" data-id=\"1a7e112\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-f7baec8 ekit-equal-height-disable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"f7baec8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=Motor&#038;type=Flood-Hurricane-Storm-etc.&#038;region=ja\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"467\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/05\/6-min.png\" class=\"attachment-full size-full wp-image-2753\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Flood, Hurricane, Storm etc.\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=Motor&#038;type=Flood-Hurricane-Storm-etc.&#038;region=ja\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-4271858\" data-eae-slider=\"74245\" data-id=\"4271858\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-6ad0276 ekit-equal-height-disable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"6ad0276\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=Motor&#038;type=Lightning&#038;region=ja\" target=\"_blank\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"467\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/05\/4-min-1.png\" class=\"attachment-full size-full wp-image-2750\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Lightning\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=Motor&#038;type=Lightning&#038;region=ja\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-aa14e8a premium-equal-height-yes elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"17070\" data-pa-eq-height=\"{&quot;targetType&quot;:&quot;widget&quot;,&quot;target&quot;:&quot;&quot;,&quot;trigger&quot;:&quot;load&quot;,&quot;enableOn&quot;:[&quot;desktop&quot;,&quot;tablet&quot;,&quot;mobile&quot;]}\" data-id=\"aa14e8a\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;premium_eq_height_switcher&quot;:&quot;yes&quot;,&quot;_ha_eqh_enable&quot;:&quot;yes&quot;,&quot;_ha_eqh_to&quot;:&quot;widget&quot;,&quot;_ha_eqh_disable_on_tablet&quot;:&quot;no&quot;,&quot;_ha_eqh_disable_on_mobile&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-narrow\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-f839d0c\" data-eae-slider=\"73211\" data-id=\"f839d0c\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t<\/p>                        <\/div>\n                    <\/div>\n                                    <div class=\"tab-pane elementkit-tab-pane elementor-repeater-item-23ba488 \" id=\"content-23ba4886a9c0ed52d4d9\" role=\"tabpanel\"\n                         aria-labelledby=\"content-23ba4886a9c0ed52d4d9-tab\">\n                        <div class=\"animated fadeIn\">\n                            <p>\t\t<div data-elementor-type=\"section\" data-elementor-id=\"3443\" class=\"elementor elementor-3443\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\" data-elementor-post-type=\"elementor_library\">\n\t\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-aa14e8a premium-equal-height-yes elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"57882\" data-pa-eq-height=\"{&quot;targetType&quot;:&quot;widget&quot;,&quot;target&quot;:&quot;&quot;,&quot;trigger&quot;:&quot;load&quot;,&quot;enableOn&quot;:[&quot;desktop&quot;,&quot;tablet&quot;,&quot;mobile&quot;]}\" data-id=\"aa14e8a\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;premium_eq_height_switcher&quot;:&quot;yes&quot;,&quot;_ha_eqh_enable&quot;:&quot;yes&quot;,&quot;_ha_eqh_to&quot;:&quot;widget&quot;,&quot;_ha_eqh_disable_on_tablet&quot;:&quot;no&quot;,&quot;_ha_eqh_disable_on_mobile&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-narrow\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-f839d0c\" data-eae-slider=\"92848\" data-id=\"f839d0c\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-3c236ea elementor-widget elementor-widget-text-editor\" data-id=\"3c236ea\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><style type=\"text\/css\">#ipt_fsqm_form_wrap_7 .ipt_fsqm_form_logo img,\n\t#ipt_fsqm_form_wrap_7 .ipt-eform-width-restrain,\n\t#ipt_fsqm_form_wrap_7 .ipt_fsqm_form_message_restore,\n\t#ipt_fsqm_form_wrap_7 .ipt_fsqm_form_message_success,\n\t#ipt_fsqm_form_wrap_7 .ipt_fsqm_form_message_error,\n\t#ipt_fsqm_form_wrap_7 .ipt_fsqm_form_message_process,\n\t#ipt_fsqm_form_wrap_7 .ipt_fsqm_form_validation_error,\n\t#ipt_fsqm_form_wrap_7 .eform-ui-estimator {\n\t\tmax-width: 100%;\n\t\tmin-width: 240px;\n\t}\n\n\t\t\t#ipt_fsqm_form_wrap_7 .ipt-eform-content {\n\t\t\tbackground-image: none;\n\t\t\tbackground-position: 0% 0%;\n\t\t\tbackground-size: auto;\n\t\t\tbackground-repeat: repeat;\n\t\t\tbackground-origin: padding-box;\n\t\t\tbackground-clip: border-box;\n\t\t\tbackground-attachment: scroll;\n\t\t}\n\t\/**\/<\/style><div\nid=\"ipt_fsqm_form_wrap_7\"\nclass=\"ipt_uif_front ipt_uif_common ipt_fsqm_form type_2 ui-front eform-ltr eform-override-element-material eform-override-alignment-vertical\"\ndata-fsqmsayt=\"{&quot;auto_save&quot;:true,&quot;show_restore&quot;:true,&quot;restore&quot;:true,&quot;admin_override&quot;:false,&quot;user_update&quot;:false,&quot;interval_save&quot;:false,&quot;interval&quot;:&quot;30&quot;}\"\ndata-ui-type=\"2\"\ndata-ui-theme=\"[&quot;https:\\\/\\\/bciconline.com\\\/ba\\\/wp-content\\\/plugins\\\/wp-fsqm-pro\\\/static\\\/front\\\/css\\\/material-themes\\\/light-themes\\\/red.css?ver=4.19.1&quot;]\"\ndata-ui-theme-id=\"material-red\"\ndata-eformanim=\"1\"\ndata-fsqmga=\"{&quot;enabled&quot;:false,&quot;manual_load&quot;:false,&quot;tracking_id&quot;:&quot;&quot;,&quot;cookie&quot;:&quot;auto&quot;,&quot;user_update&quot;:false,&quot;name&quot;:&quot;Home and Contents&quot;,&quot;form_id&quot;:&quot;7&quot;}\"\ndata-fsqmreset=\"{&quot;reset&quot;:false,&quot;delay&quot;:10}\"\ndata-eformreg=\"{&quot;enabled&quot;:false,&quot;username_id&quot;:&quot;ipt_fsqm_form_7_pinfo_&quot;,&quot;password_id&quot;:&quot;ipt_fsqm_form_7_pinfo_&quot;,&quot;hide_pinfo&quot;:false,&quot;hide_meta&quot;:false,&quot;meta&quot;:[]}\"\ndata-eformscroll=\"{&quot;progress&quot;:true,&quot;message&quot;:true,&quot;offset&quot;:&quot;0&quot;,&quot;scrollOnError&quot;:true}\"\ndata-eform-cookie=\"0\"\ndata-subscription-form=\"false\"\ndata-instant-subscription=\"{&quot;doable&quot;:true,&quot;config&quot;:{&quot;enabled&quot;:false,&quot;min_tab&quot;:&quot;&quot;,&quot;debounce&quot;:&quot;3000&quot;},&quot;nonce&quot;:&quot;8284381fb6&quot;}\"\n><style type=\"text\/css\">\/**\/<\/style><noscript><div\nclass=\"ipt_fsqm_form_message_noscript ui-widget ui-widget-content ui-corner-all\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><div>Javascript is disabled<\/div><\/div><div\nclass=\"ui-widget-content ui-corner-bottom\"><p>Javascript is disabled on your browser. Please enable it in order to use this form.<\/p><\/div><\/div>\n<\/noscript><style type=\"text\/css\">.ipt_uif_ajax_loader,\n\t\t\t.ipt_uif_ajax_loader *,\n\t\t\tipt_uif_ajax_loader *::before,\n\t\t\tipt_uif_ajax_loader *::after {\n\t\t\t\tbox-sizing: border-box;\n\t\t\t}<\/style><div\nclass=\"ipt_uif_init_loader ipt-eform-preloader-inline ipt_uif_ajax_loader\"><div\nclass=\"ipt-eform-preloader-inner\"><div\nclass=\"ipt-eform-preloader-circle\"><div\nclass=\"preloader-wrapper active\"><div\nclass=\"spinner-layer spinner-blue\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-red\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-yellow\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-green\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><\/div><\/div><div\nclass=\"ipt-eform-preloader-text\"><div\nclass=\"ipt-eform-preloader-text-inner ipt_uif_ajax_loader_text\">Loading<\/div><\/div><div\nclass=\"clear\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude class=\"ipt_uif_conditional_logic\" id=\"ipt_uif_conditional_logic_7\" value=\"{&quot;logics&quot;:{&quot;ipt_fsqm_form_7_pinfo_62&quot;:{&quot;active&quot;:true,&quot;status&quot;:true,&quot;change&quot;:true,&quot;logic&quot;:{},&quot;type&quot;:&quot;s_checkbox&quot;,&quot;m_type&quot;:&quot;pinfo&quot;}},&quot;indexes&quot;:[],&quot;base&quot;:&quot;7&quot;}\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude class=\"ipt_fsqm_timer_data\" id=\"ipt_fsqm_timer_data_7\" value=\"{&quot;type&quot;:&quot;none&quot;}\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude class=\"ipt_fsqm_epoc_data\" id=\"ipt_fsqm_epoc_data_7\" value=\"{&quot;CURRENTYEAR&quot;:2026,&quot;CURRENTDATE&quot;:1788594309000,&quot;CURRENTDAY&quot;:5,&quot;CURRENTMONTH&quot;:9,&quot;CURRENTHOUR&quot;:7,&quot;CURRENTMINUTE&quot;:45,&quot;CURRENTSECOND&quot;:9,&quot;CURRENTWEEK&quot;:36,&quot;CURRENTEPOC&quot;:20701}\" \/><div\nstyle=\"display: none;\" class=\"ipt_uif_hidden_init\"><div\nstyle=\"display: none;\" class=\"ipt_fsqm_form_message_restore ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><h3><a\nhref=\"#\" title=\"Hide\" class=\"ipt_fsqm_form_message_close\"><i\ntitle=\"\" class=\" ipt-icomoon-times ipticm prefix\"><\/i>\n<\/a><i\ntitle=\"\" class=\" ipt-icomoon-checkmark-circle ipticm prefix\"><\/i>\nForm successfully restored<\/h3><\/div><div\nclass=\"ui-widget-content ui-corner-all\"><p>The form has been restored from your last edit. If wish to start over, please click the button<\/p>\n<button\nstyle=\"margin-bottom: 0\" class=\"ipt_uif_button ipt_fsqm_sayt_reset secondary-button\">Start Over<\/button><\/div><\/div><form\nmethod=\"post\" action=\"\" class=\"ipt_uif_validate_form ipt_fsqm_main_form\" id=\"ipt_fsqm_form_7\" autocomplete=\"on\">\n<input\ntype=\"hidden\" data-sayt-exclude name=\"action\" id=\"action\" value=\"ipt_fsqm_save_form\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_epoc\" class=\"eform-epoc-value\" value=\"1788594309\" \/>\n<input\ntype=\"hidden\" class=\"ipt_fsqm_form_tab_pos\" name=\"fsqm_form7_tab_pos\" value=\"0\" id=\"fsqm_form7_tab_pos\" \/>\n<input\ntype=\"hidden\" id=\"ipt_fsqm_form_data_save\" name=\"ipt_fsqm_form_data_save\" value=\"83688bd1e8\" data-sayt-exclude \/>\t\t\t<input\ntype=\"hidden\" name=\"_wp_http_referer\" value=\"\/ba\/report-claim\/\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"form_id\" value=\"7\" \/><div\nclass=\"ipt-eform-width-restrain\"><div\nclass=\"ipt-eform-content \"><div\ndata-settings=\"{&quot;can_previous&quot;:true,&quot;show_progress_bar&quot;:true,&quot;progress_bar_bottom&quot;:true,&quot;block_previous&quot;:false,&quot;any_tab&quot;:false,&quot;type&quot;:&quot;2&quot;,&quot;scroll&quot;:true,&quot;decimal_point&quot;:2,&quot;auto_progress&quot;:false,&quot;auto_progress_delay&quot;:&quot;1500&quot;,&quot;auto_submit&quot;:false,&quot;hidden_buttons&quot;:false,&quot;scroll_on_error&quot;:true}\" class=\"ipt_fsqm_main_tab ipt_uif_tabs horizontal\"><div\nclass=\"ipt-eform-tab-nav-wrap\"><ul><li\nid=\"ipt_fsqm_form_7_tab_0_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_7_tab_0\"><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe269;\"><\/i>\n<span\nclass=\"eform-tab-labels\">Tell us what happened <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_7_tab_1_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_7_tab_1\"><span\nclass=\"eform-tab-labels\">About you <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_7_tab_2_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_7_tab_2\"><span\nclass=\"eform-tab-labels\">Damage <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_7_tab_3_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_7_tab_3\"><span\nclass=\"eform-tab-labels\">Other Details <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_7_tab_4_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_7_tab_4\"><span\nclass=\"eform-tab-labels\">Submit your Claim <\/span><\/a><\/li><\/ul>\n<i\nclass=\"eform-tab-nav eform-tab-nav-right ipt-icomoon-angle-right disabled eform-ripple\"><\/i>\n<i\nclass=\"eform-tab-nav eform-tab-nav-left ipt-icomoon-angle-left disabled eform-ripple\"><\/i>\n<span\nclass=\"eform-tab-passive-notifier\"><\/span>\n<span\nclass=\"eform-tab-active-notifier\"><\/span><\/div><div\nid=\"ipt_fsqm_form_7_tab_0\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_7_layout_0_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe269;\"><\/i>\n<span\nclass=\"ipt_uif_divider_text_inner\">\nTell us what happened<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][80][m_type]\" id=\"ipt_fsqm_form_7_pinfo_80_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][80][type]\" id=\"ipt_fsqm_form_7_pinfo_80_type\" value=\"p_select\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_select\" id=\"ipt_fsqm_form_7_pinfo_80\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_80\">What type of incident was it?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\">\n<select\nclass=\" check_me validate[required] ipt_uif_select ipt_uif_select_no_search\" name=\"ipt_fsqm_form_7[pinfo][80][options][]\" id=\"ipt_fsqm_form_7_pinfo_80_options_\"  data-theme=\"eform-material\"><option\nvalue=\"0\" data-num=\"\">Fire<\/option><option\nvalue=\"1\" data-num=\"\">Theft<\/option><option\nvalue=\"2\" data-num=\"\">Flood<\/option><option\nvalue=\"3\" data-num=\"\">Storm<\/option><option\nvalue=\"4\" data-num=\"\">Hurricane<\/option><option\nvalue=\"5\" data-num=\"\">Subsidence<\/option><option\nvalue=\"6\" data-num=\"\">Burglary<\/option><option\nvalue=\"7\" data-num=\"\">Escape of Water<\/option><option\nvalue=\"8\" data-num=\"\">Accidental Damage<\/option><option\nvalue=\"9\" data-num=\"\">Other<\/option>\n<\/select><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][0][m_type]\" id=\"ipt_fsqm_form_7_pinfo_0_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][0][type]\" id=\"ipt_fsqm_form_7_pinfo_0_type\" value=\"datetime\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_datetime\" id=\"ipt_fsqm_form_7_pinfo_0\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_0_value\">When Did It Happen?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field eform-dp-input-field has-icon\">\n<input\nclass=\"datepicker ipt_uif_datepicker  check_me validate[required] is-empty ipt_uif_text\"\ndata-dateFormat=\"dd-mm-yy\" data-timeFormat=\"hh:mm:ss TT\" data-year_range=\"50\"\t\ttype=\"text\"\nreadonly=\"readonly\"\nname=\"ipt_fsqm_form_7[pinfo][0][value]\"\nid=\"ipt_fsqm_form_7_pinfo_0_value\"\nmaxlength=\"524288\"\nvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipt-icomoon-calendar ipticm prefix\"><\/i>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_0_value\">Select Date<\/label>\n<a\nhref=\"javascript:;\" class=\"eform-dp-clear\" title=\"Clear\">&times;<\/a><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][4][m_type]\" id=\"ipt_fsqm_form_7_pinfo_4_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][4][type]\" id=\"ipt_fsqm_form_7_pinfo_4_type\" value=\"datetime\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_datetime\" id=\"ipt_fsqm_form_7_pinfo_4\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_4_value\">What time did it happen?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field eform-dp-input-field has-icon\">\n<input\nclass=\"datepicker ipt_uif_timepicker  check_me validate[required] is-empty ipt_uif_text\"\ndata-dateFormat=\"yy-mm-dd\" data-timeFormat=\"hh:mm:ss TT\" data-year_range=\"50\"\t\ttype=\"text\"\nreadonly=\"readonly\"\nname=\"ipt_fsqm_form_7[pinfo][4][value]\"\nid=\"ipt_fsqm_form_7_pinfo_4_value\"\nmaxlength=\"524288\"\nvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipt-icomoon-clock ipticm prefix\"><\/i>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_4_value\">Select Time<\/label>\n<a\nhref=\"javascript:;\" class=\"eform-dp-clear\" title=\"Clear\">&times;<\/a><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][1][m_type]\" id=\"ipt_fsqm_form_7_pinfo_1_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][1][type]\" id=\"ipt_fsqm_form_7_pinfo_1_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_7_pinfo_1\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_1_value\">Where did it Happen?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_7[pinfo][1][value]\"\nid=\"ipt_fsqm_form_7_pinfo_1_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe07d;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_1_value\">Enter precise location<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][6][m_type]\" id=\"ipt_fsqm_form_7_pinfo_6_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][6][type]\" id=\"ipt_fsqm_form_7_pinfo_6_type\" value=\"textarea\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textarea\" id=\"ipt_fsqm_form_7_pinfo_6\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_6_value\">Please describe in detail what happened (max 1400 characters)<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me validate[required,minSize[10],maxSize[1403]]\"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_7[pinfo][6][value]\"\n\t\tmaxlength=\"1403\"\t\tid=\"ipt_fsqm_form_7_pinfo_6_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe056;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_6_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_7_tab_1\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_7_layout_1_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<span\nclass=\"ipt_uif_divider_text_inner\">\nAbout you<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][7][m_type]\" id=\"ipt_fsqm_form_7_pinfo_7_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][7][type]\" id=\"ipt_fsqm_form_7_pinfo_7_type\" value=\"p_radio\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_radio\" id=\"ipt_fsqm_form_7_pinfo_7\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_7\">Are you a policyholder?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_7[pinfo][7][options][]\"\nid=\"ipt_fsqm_form_7_pinfo_7_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_7_pinfo_7_options__0\" data-labelcon=\"&#xe18e;\">\nYes\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_7[pinfo][7][options][]\"\nid=\"ipt_fsqm_form_7_pinfo_7_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_7_pinfo_7_options__1\" data-labelcon=\"&#xe18e;\">\nNo\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][8][m_type]\" id=\"ipt_fsqm_form_7_pinfo_8_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][8][type]\" id=\"ipt_fsqm_form_7_pinfo_8_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_7_pinfo_8\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_8_value\">Policy Number<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_7[pinfo][8][value]\"\nid=\"ipt_fsqm_form_7_pinfo_8_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe056;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_8_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][9][m_type]\" id=\"ipt_fsqm_form_7_pinfo_9_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][9][type]\" id=\"ipt_fsqm_form_7_pinfo_9_type\" value=\"f_name\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_f_name\" id=\"ipt_fsqm_form_7_pinfo_9\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_9_value\">Policy Holder First Name<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[custom[personName]] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_7[pinfo][9][value]\"\nid=\"ipt_fsqm_form_7_pinfo_9_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xf007;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_9_value\">First Name<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][10][m_type]\" id=\"ipt_fsqm_form_7_pinfo_10_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][10][type]\" id=\"ipt_fsqm_form_7_pinfo_10_type\" value=\"l_name\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_l_name\" id=\"ipt_fsqm_form_7_pinfo_10\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_10_value\">Policy Holder Last Name<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[custom[personName]] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_7[pinfo][10][value]\"\nid=\"ipt_fsqm_form_7_pinfo_10_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xf007;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_10_value\">Last Name<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][12][m_type]\" id=\"ipt_fsqm_form_7_pinfo_12_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][12][type]\" id=\"ipt_fsqm_form_7_pinfo_12_type\" value=\"phone\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_phone\" id=\"ipt_fsqm_form_7_pinfo_12\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_12_value\">Preferred Telephone Number<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[custom[phone]] ipt_uif_text\"\ntype=\"tel\"\nname=\"ipt_fsqm_form_7[pinfo][12][value]\"\nid=\"ipt_fsqm_form_7_pinfo_12_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe08c;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_12_value\">Phone<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][11][m_type]\" id=\"ipt_fsqm_form_7_pinfo_11_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][11][type]\" id=\"ipt_fsqm_form_7_pinfo_11_type\" value=\"email\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_email\" id=\"ipt_fsqm_form_7_pinfo_11\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_11_value\">Preferred Email Address<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[custom[email]] ipt_uif_text\"\ntype=\"email\"\nname=\"ipt_fsqm_form_7[pinfo][11][value]\"\nid=\"ipt_fsqm_form_7_pinfo_11_value\"\nvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xf0e0;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_11_value\">Email Address<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][13][m_type]\" id=\"ipt_fsqm_form_7_pinfo_13_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][13][type]\" id=\"ipt_fsqm_form_7_pinfo_13_type\" value=\"p_radio\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_radio\" id=\"ipt_fsqm_form_7_pinfo_13\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_13\">Contact Preference<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_7[pinfo][13][options][]\"\nid=\"ipt_fsqm_form_7_pinfo_13_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_7_pinfo_13_options__0\" data-labelcon=\"&#xe18e;\">\nEmail\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_7[pinfo][13][options][]\"\nid=\"ipt_fsqm_form_7_pinfo_13_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_7_pinfo_13_options__1\" data-labelcon=\"&#xe18e;\">\nPhone\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_7_tab_2\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_7_layout_2_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<span\nclass=\"ipt_uif_divider_text_inner\">\nDamage<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][18][m_type]\" id=\"ipt_fsqm_form_7_pinfo_18_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][18][type]\" id=\"ipt_fsqm_form_7_pinfo_18_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_7_pinfo_18\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_18_value\">How much do you think the lost or damaged items cost?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_7[pinfo][18][value]\"\nid=\"ipt_fsqm_form_7_pinfo_18_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_18_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][19][m_type]\" id=\"ipt_fsqm_form_7_pinfo_19_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][19][type]\" id=\"ipt_fsqm_form_7_pinfo_19_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_7_pinfo_19\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_19_value\">If you called the police, please give us the report reference number<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_7[pinfo][19][value]\"\nid=\"ipt_fsqm_form_7_pinfo_19_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_19_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][20][m_type]\" id=\"ipt_fsqm_form_7_pinfo_20_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][20][type]\" id=\"ipt_fsqm_form_7_pinfo_20_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_7_pinfo_20\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_20_value\">Please provide a descirption of the items lost or damaged<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_7[pinfo][20][value]\"\nid=\"ipt_fsqm_form_7_pinfo_20_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_20_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_7_tab_3\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_7_layout_3_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<span\nclass=\"ipt_uif_divider_text_inner\">\nOther Details<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[freetype][0][m_type]\" id=\"ipt_fsqm_form_7_freetype_0_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[freetype][0][type]\" id=\"ipt_fsqm_form_7_freetype_0_type\" value=\"upload\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_upload\" id=\"ipt_fsqm_form_7_freetype_0\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_container ipt_uif_iconbox\" data-opened=\"1\"><div\nclass=\"ipt_uif_container_head\"><h3>\t\t\t\t\t\t<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe002;\"><\/i>\n<span\nclass=\"ipt_uif_container_label\">Please attach photographs, estimates or relevant documents in support of your claim<\/span><\/h3><\/div><div\nclass=\"ipt_uif_container_inner\"><div\nclass=\"ipt_uif_uploader\" id=\"ipt_fsqm_file_upload_7_0__uploader_wrap\" data-settings=\"{&quot;accept_file_types&quot;:&quot;gif,jpeg,png,jpg,pdf,doc,docx&quot;,&quot;max_number_of_files&quot;:&quot;&quot;,&quot;min_number_of_files&quot;:&quot;&quot;,&quot;max_file_size&quot;:134217728,&quot;min_file_size&quot;:&quot;1&quot;,&quot;show_drop_zone&quot;:true,&quot;wp_media_integration&quot;:false,&quot;auto_upload&quot;:true,&quot;single_upload&quot;:false,&quot;drag_n_drop&quot;:true,&quot;progress_bar&quot;:true,&quot;preview_media&quot;:true,&quot;can_delete&quot;:true,&quot;required&quot;:false,&quot;minimal_ui&quot;:false,&quot;accept&quot;:&quot;all&quot;,&quot;capture&quot;:&quot;none&quot;,&quot;icon&quot;:&quot;57346&quot;,&quot;centered&quot;:false,&quot;dragdrop&quot;:&quot;Drag &#039;n Drop files here&quot;,&quot;upload_label&quot;:&quot;Select Files&quot;,&quot;recaptcha&quot;:false,&quot;site_key&quot;:&quot;&quot;,&quot;theme&quot;:&quot;light&quot;,&quot;type&quot;:&quot;image&quot;,&quot;size&quot;:&quot;normal&quot;,&quot;hl&quot;:&quot;en&quot;}\" data-configuration=\"{&quot;id&quot;:&quot;ipt_fsqm_file_upload_7_0_&quot;,&quot;upload_url&quot;:&quot;?action=ipt_fsqm_fu_upload&quot;,&quot;download_url&quot;:&quot;?action=ipt_fsqm_fu_download&quot;,&quot;do_download&quot;:false,&quot;show_ui&quot;:true,&quot;captcha_url&quot;:&quot;?action=ipt_fsqm_fu_captcha&quot;}\" data-formData=\"{&quot;data_id&quot;:null,&quot;form_id&quot;:&quot;7&quot;,&quot;nonce&quot;:&quot;6cbb6438b3&quot;,&quot;element_key&quot;:&quot;0&quot;,&quot;files_key&quot;:&quot;ipt_fsqm_file_upload_7_0&quot;}\"><div\nclass=\"fileinput-dragdrop ui-state-active\">\n<span>Drag &#8216;n Drop files here<\/span><\/div><div\nclass=\"fileupload-meta\"><p>Max file size: 128.00 MB. | Allowed file types: gif,jpeg,png,jpg,pdf,doc,docx<\/p><\/div><div\nclass=\"ipt_fsqm_fileuploader_list_wrap\"><table\nrole=\"presentation\" class=\"ipt_fsqm_fileuploader_list\"><thead><tr><td\ncolspan=\"4\"><div\nclass=\"fileupload-buttonbar\"><div\nclass=\"fileupload-buttons\">\n<span\nrole=\"button\" class=\"fileinput-button secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n<span\nclass=\"ui-button-icon-primary ui-icon ui-icon-plusthick\"><\/span>\n<span\nclass=\"ui-button-text\">\n<span\nclass=\"select secondary-button\">Select Files<\/span>\n<\/span>\n<input\nclass=\"ipt_uif_uploader_handle\" type=\"file\" multiple=\"multiple\" name=\"ipt_fsqm_file_upload_7_0[]\" id=\"ipt_fsqm_file_upload_7_0_\" \/>\n<\/span>\n<button\ntype=\"reset\" class=\"cancel secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n<span\nclass=\"ui-button-icon-primary ui-icon ui-icon-cancel\"><\/span>\n<span\nclass=\"ui-button-text\">\nCancel All Uploads\t\t\t\t\t\t\t\t\t\t<\/span>\n<\/button>\n<span\nclass=\"fileupload-process\"><\/span><\/div><div\nclass=\"fileupload-progress fade wp-eform-fileupload-globalprogress\" style=\"display: none;\"><div\nclass=\"progress ui-progressbar ui-widget ui-widget-content ui-corner-all\" role=\"progressbar\" aria-valuemin=\"0\" aria-valuemax=\"100\"><div\nclass=\"progress-bar ui-progressbar-value ui-widget-header ui-corner-left\" style=\"width: 0%;\"><\/div><\/div><div\nclass=\"progress-extended\">&nbsp;<\/div><\/div><\/div><\/td><td\nclass=\"delete_button\"><div\nclass=\"fileupload-buttonbar\"><div\nclass=\"fileupload-buttons\">\n<button\ntype=\"button\" class=\"delete secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n<span\nclass=\"ui-button-icon-primary ui-icon ui-icon-trash\"><\/span>\n<span\nclass=\"ui-button-text\">\nDelete Selected\t\t\t\t\t\t\t\t\t\t<\/span>\n<\/button><\/div><\/div><\/td><td\nclass=\"delete_toggle\"><div\nclass=\"fileupload-buttonbar\"><div\nclass=\"fileupload-buttons\"><div\nclass=\"ipt_uif_label_column\">\n<input\ntype=\"checkbox\" class=\"toggle ipt_uif_checkbox\" id=\"ipt_fsqm_file_upload_7_0__toggler\" \/>\n<label\ndata-labelcon=\"&#xe18e;\" for=\"ipt_fsqm_file_upload_7_0__toggler\"><\/label><\/div><\/div><\/div><\/td><\/tr><\/thead><tbody\nclass=\"files\"><\/tbody><\/table><\/div> <script class=\"template-upload\" id=\"ipt_fsqm_file_upload_7_0__tmpl_upload\" type=\"text\/x-tmpl\">{% for (var i=0, file; file=o.files[i]; i++) { %}\n\t<tr class=\"template-upload\">\n\t\t<td>\n\t\t\t<span class=\"preview\"><\/span>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p class=\"name\">{%=file.name%}<\/p>\n\t\t\t<strong class=\"error\"><\/strong>\n\t\t<\/td>\n\t\t<td class=\"fileupload_list_pb\">\n\t\t\t<p class=\"size\">Processing&hellip;<\/p>\n\t\t\t<div class=\"progress ui-progressbar ui-widget ui-widget-content ui-corner-all\" role=\"progressbar\" aria-valuemin=\"0\" aria-valuemax=\"100\">\n\t\t\t\t<div class=\"progress-bar ui-progressbar-value ui-widget-header ui-corner-left\" style=\"width: 0%;\"><\/div>\n\t\t\t<\/div>\n\t\t<\/td>\n\t\t<td colspan=\"3\">\n\t\t\t{% if (!i && !o.options.autoUpload) { %}\n\t\t\t\t<button class=\"start secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\" disabled>\n\t\t\t\t\t<span class=\"ui-button-icon-primary ui-icon ui-icon-circle-arrow-e\"><\/span>\n\t\t\t\t\t<span class=\"ui-button-text\">\n\t\t\t\t\t\tStart\t\t\t\t\t<\/span>\n\t\t\t\t<\/button>\n\t\t\t{% } %}\n\t\t\t{% if (!i) { %}\n\t\t\t\t<button class=\"cancel secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n\t\t\t\t\t<span class=\"ui-button-icon-primary ui-icon ui-icon-cancel\"><\/span>\n\t\t\t\t\t<span class=\"ui-button-text\">\n\t\t\t\t\t\tCancel\t\t\t\t\t<\/span>\n\t\t\t\t<\/button>\n\t\t\t{% } %}\n\t\t<\/td>\n\t<\/tr>\n{% } %}<\/script>  <script class=\"template-download\" id=\"ipt_fsqm_file_upload_7_0__tmpl_download\" type=\"text\/x-tmpl\">{%\n\twindow.ipt_fsqm_upload_count_global;\n\tif ( window.ipt_fsqm_upload_count_global == undefined ) {\n\t\twindow.ipt_fsqm_upload_count_global = 0;\n\t}\n%}\n{% for (var i=0, file; file=o.files[i]; i++) { %}\n{% var toggler_check_id = window.ipt_fsqm_upload_count_global++; %}\n\t<tr class=\"template-download\">\n\t\t<td class=\"preview_td\" colspan=\"2\">\n\t\t\t<span class=\"preview\">\n\t\t\t\t{% if (file.thumbnailUrl) { %}\n\t\t\t\t\t<a href=\"{%=file.url%}\" title=\"{%=file.name%}\" download=\"{%=file.name%}\" data-gallery><img decoding=\"async\" src=\"{%=file.thumbnailUrl%}\" \/><\/a>\n\t\t\t\t{% } else if ( file.validAudio ) { %}\n\t\t\t\t\t\t\t\t\t\t<audio controls=\"controls\">\n\t\t\t\t\t\t<source src=\"{%=file.url%}\" type=\"{%=file.type%}\" \/>\n\t\t\t\t\t\tYour browser does not support audio element.\t\t\t\t\t<\/audio>\n\t\t\t\t\t\t\t\t\t{% } else if ( file.validVideo ) { %}\n\t\t\t\t\t\t\t\t\t\t<video controls=\"controls\" height=\"100\" width=\"200\">\n\t\t\t\t\t\t<source src=\"{%=file.url%}\" type=\"{%=file.type%}\" \/>\n\t\t\t\t\t\tYour browser does not support video element.\t\t\t\t\t<\/video>\n\t\t\t\t\t\t\t\t\t{% } %}\n\t\t\t<\/span>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p class=\"name\">\n\t\t\t\t<a href=\"{%=file.url%}\" title=\"{%=file.name%}\" download=\"{%=file.name%}\" {%=file.thumbnailUrl?'data-gallery':''%}>{%=file.name%}<\/a>\n\t\t\t<\/p>\n\t\t\t{% if (file.error) { %}\n\t\t\t\t<div><span class=\"error\">Error<\/span> {%=file.error%}<\/div>\n\t\t\t{% } %}\n\t\t\t<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[freetype][0][id][]\" value=\"{%=file.id%}\" \/>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<span class=\"size\">{%=o.formatFileSize(file.size)%}<\/span>\n\t\t<\/td>\n\t\t\t\t<td class=\"delete_button\">\n\t\t\t<button class=\"delete secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\" data-type=\"{%=file.deleteType%}\" data-url=\"{%=file.deleteUrl%}\"{% if (file.deleteWithCredentials) { %} data-xhr-fields='{\"withCredentials\":true}'{% } %}>\n\t\t\t\t<span class=\"ui-button-icon-primary ui-icon ui-icon-trash\"><\/span>\n\t\t\t\t<span class=\"ui-button-text\">\n\t\t\t\t\tDelete\t\t\t\t<\/span>\n\t\t\t<\/button>\n\t\t<\/td>\n\t\t\t\t\t<td class=\"delete_toggle\">\n\t\t\t\t<div class=\"ipt_uif_label_column\">\n\t\t\t\t\t<input type=\"checkbox\" name=\"delete\" value=\"1\" class=\"toggle ipt_uif_checkbox\" id=\"ipt_fsqm_file_upload_7_0__toggler_files_{%=toggler_check_id%}\" \/>\n\t\t\t\t\t<label data-labelcon=\"&#xe18e;\" for=\"ipt_fsqm_file_upload_7_0__toggler_files_{%=toggler_check_id%}\"><\/label>\n\t\t\t\t<\/div>\n\t\t\t<\/td>\n\t\t\t\t\t<\/tr>\n{% } %}<\/script> <\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_7_tab_4\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_7_layout_4_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<span\nclass=\"ipt_uif_divider_text_inner\">\nSubmit your Claim<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[design][23][m_type]\" id=\"ipt_fsqm_form_7_design_23_m_type\" value=\"design\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[design][23][type]\" id=\"ipt_fsqm_form_7_design_23_type\" value=\"richtext\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional\" id=\"ipt_fsqm_form_7_design_23\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_richtext\"><p>You\u2019re are almost done: Please complete the Declaration below and just click \u201cSubmit these claim details\u201d and we\u2019ll take it from there.<\/p><p\nclass=\"MsoNormal\" style=\"margin-bottom: 7.5pt; color: #222222; font-family: arial, sans-serif; font-size: small; text-align: justify; line-height: 13.5pt; vertical-align: baseline;\"><span\nstyle=\"font-size: 12pt;\">I hereby declare that to the best of my knowledge and belief that the information I have provided is correct and request you to deal on my behalf with any claims which may arise out of the accident in accordance with the terms and conditions of the Policy.<\/span><\/p><p\nclass=\"MsoNormal\" style=\"margin-bottom: 7.5pt; color: #222222; font-family: arial, sans-serif; font-size: small; text-align: justify; line-height: 13.5pt; vertical-align: baseline;\"><span\nstyle=\"font-size: 12pt;\">I authorize you and your attorneys-at-law on my behalf to make such admissions and settlements and give such consents as you consider necessary for the disposal of such claims and any litigation arising therefrom.<\/span><\/p><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][62][m_type]\" id=\"ipt_fsqm_form_7_pinfo_62_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][62][type]\" id=\"ipt_fsqm_form_7_pinfo_62_type\" value=\"s_checkbox\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_s_checkbox column-centered\" id=\"ipt_fsqm_form_7_pinfo_62\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_label_column column_1\">\n<input\ntype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in  ipt_uif_s_checkbox\"\nname=\"ipt_fsqm_form_7[pinfo][62][value]\" id=\"ipt_fsqm_form_7_pinfo_62_value_1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_7_pinfo_62_value_1\" data-labelcon=\"&#xf022;\">\nI agree\t\t\t\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear\"><\/div><div\nid=\"ipt_fsqm_form_7_button_container\" class=\"ipt_fsqm_form_button_container ipt_fsqm_form_button_container--classic ipt-eform-material-button-container\"><div\nclass=\"eform-button-container-inner\">\n<button\ntype=\"button\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_prev medium primary-button\" name=\"ipt_fsqm_form_7_button_prev\" id=\"ipt_fsqm_form_7_button_prev\"> Previous<\/button>\n<button\ntype=\"submit\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_submit medium primary-button\" name=\"ipt_fsqm_form_7_button_submit\" id=\"ipt_fsqm_form_7_button_submit\"> Submit<\/button>\n<button\ntype=\"button\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_next medium primary-button\" name=\"ipt_fsqm_form_7_button_next\" id=\"ipt_fsqm_form_7_button_next\"> Next<\/button>\n<button\ntype=\"reset\" title=\"Reset\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_reset ipt_uif_tooltip medium primary-button\" name=\"ipt_fsqm_form_7_button_reset\" id=\"ipt_fsqm_form_7_button_reset\"> <i\nclass=\"ipticm ipt-icomoon-refresh\"><\/i><\/button><\/div><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"ipt_fsqm_main_pb eform-mainpb-bottom ipt_uif_progress_bar\" data-start=\"0\" data-decimals=\"2\" id=\"ipt_fsqm_form_7_progressbar\"><div\nclass=\"ipt_uif_progress_value\"><span\nclass=\"eform-progress-value-span\"><\/span><\/div><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/form><\/div><div\nstyle=\"display: none;\" class=\"ipt_fsqm_form_message_success ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><h3><i\ntitle=\"\" class=\" ipt-icomoon-checkmark-circle ipticm prefix\"><\/i>\nYour claim has been submitted<\/h3><\/div><div\nclass=\"ui-widget-content ui-corner-all ipt_fsqm_success_wrap\"><p>Thank you for submitting your claim. This is to acknowledge receipt and advise you that we will contact you before the end of the next business day. Please click on the following link to learn more about next steps: https:\/\/bciconline.com\/claims-2\/<\/p><\/div><\/div><div\nstyle=\"display: none;\" class=\"ipt_fsqm_form_message_error ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><div><i\ntitle=\"\" class=\" ipt-icomoon-laptop ipticm prefix\"><\/i>\nServer Side Error<\/div><\/div><div\nclass=\"ui-widget-content ui-corner-all\"><p>We faced problems while connecting to the server or receiving data from the server. Please wait for a few seconds and try again.<\/p><p>If the problem persists, then check your internet connectivity. If all other sites open fine, then please contact the administrator of this website with the following information.<\/p><p\nclass=\"jqXHR\">\n<strong>TextStatus: <\/strong><span\nclass=\"textStatus\">undefined<\/span><br\n\/>\n<strong>HTTP Error: <\/strong><span\nclass=\"errorThrown\">undefined<\/span><\/p><\/div><\/div><div\nstyle=\"display: none\" class=\"ipt_uif_widget_box ipt_fsqm_form_message_process\"><div\nclass=\"ui-widget ui-widget-header ui-corner-all\"><style type=\"text\/css\">.ipt_uif_ajax_loader,\n\t\t\t.ipt_uif_ajax_loader *,\n\t\t\tipt_uif_ajax_loader *::before,\n\t\t\tipt_uif_ajax_loader *::after {\n\t\t\t\tbox-sizing: border-box;\n\t\t\t}<\/style><div\nclass=\"ipt-eform-preloader-inline ipt_uif_ajax_loader\"><div\nclass=\"ipt-eform-preloader-inner\"><div\nclass=\"ipt-eform-preloader-circle\"><div\nclass=\"preloader-wrapper active\"><div\nclass=\"spinner-layer spinner-blue\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-red\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-yellow\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-green\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><\/div><\/div><div\nclass=\"ipt-eform-preloader-text\"><div\nclass=\"ipt-eform-preloader-text-inner ipt_uif_ajax_loader_text\">Processing you request<\/div><\/div><div\nclass=\"clear\"><\/div><\/div><\/div><\/div><\/div><div\nstyle=\"display: none;\" class=\"ipt_fsqm_form_validation_error ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><div><i\ntitle=\"\" class=\" ipt-icomoon-warning2 ipticm prefix\"><\/i>\n<span\nclass=\"fsqm_ve_text\">Error<\/span><\/div><\/div><div\nclass=\"ui-widget-content ui-corner-all\"><p\nclass=\"fsqm_ve_msg\">Some error has occured.<\/p><\/div><\/div><\/div><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t<\/p>                        <\/div>\n                    <\/div>\n                                    <div class=\"tab-pane elementkit-tab-pane elementor-repeater-item-89fdad1 \" id=\"content-89fdad16a9c0ed52d4d9\" role=\"tabpanel\"\n                         aria-labelledby=\"content-89fdad16a9c0ed52d4d9-tab\">\n                        <div class=\"animated fadeIn\">\n                            <p>\t\t<div data-elementor-type=\"section\" data-elementor-id=\"3144\" class=\"elementor elementor-3144\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\" data-elementor-post-type=\"elementor_library\">\n\t\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-a1ee19b premium-equal-height-yes elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"25909\" data-pa-eq-height=\"{&quot;targetType&quot;:&quot;widget&quot;,&quot;target&quot;:&quot;&quot;,&quot;trigger&quot;:&quot;load&quot;,&quot;enableOn&quot;:[&quot;desktop&quot;,&quot;tablet&quot;,&quot;mobile&quot;]}\" data-id=\"a1ee19b\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;premium_eq_height_switcher&quot;:&quot;yes&quot;,&quot;_ha_eqh_enable&quot;:&quot;yes&quot;,&quot;_ha_eqh_to&quot;:&quot;widget&quot;,&quot;_ha_eqh_disable_on_tablet&quot;:&quot;no&quot;,&quot;_ha_eqh_disable_on_mobile&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-narrow\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-4fe2dfa\" data-eae-slider=\"66278\" data-id=\"4fe2dfa\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-5d40cd6 ekit-equal-height-enable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"5d40cd6\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=motorcycle&#038;type=Accident-Third-Party-Involved&#038;region=bb\" target=\"_blank\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img loading=\"lazy\" decoding=\"async\" width=\"1536\" height=\"1024\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/07\/candado-moto-destacada-1536x1024-1.jpeg\" class=\"attachment-full size-full wp-image-3151\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Accident Third Party Involved\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=motorcycle&#038;type=Accident-Third-Party-Involved&#038;region=ja\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-8586a9f\" data-eae-slider=\"11645\" data-id=\"8586a9f\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-1faeaf7 ekit-equal-height-disable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"1faeaf7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=motorcycle&#038;type=Accident-No-Third-Party-Involved&#038;region=bb\" target=\"_blank\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img loading=\"lazy\" decoding=\"async\" width=\"1536\" height=\"1024\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/07\/candado-moto-destacada-1536x1024-1.jpeg\" class=\"attachment-full size-full wp-image-3151\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Accident No Third Party Involved\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=motorcycle&#038;type=Accident-No-Third-Party-Involved&#038;region=ja\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-1d458d1\" data-eae-slider=\"43792\" data-id=\"1d458d1\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-995a73a ekit-equal-height-disable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"995a73a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=motorcycle&#038;type=theft&#038;region=bb\" target=\"_blank\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img loading=\"lazy\" decoding=\"async\" width=\"1536\" height=\"1024\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/07\/candado-moto-destacada-1536x1024-1.jpeg\" class=\"attachment-full size-full wp-image-3151\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Theft\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=motorcycle&#038;type=theft&#038;region=ja\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t<\/p>                        <\/div>\n                    <\/div>\n                                    <div class=\"tab-pane elementkit-tab-pane elementor-repeater-item-a8518f4 \" id=\"content-a8518f46a9c0ed52d4d9\" role=\"tabpanel\"\n                         aria-labelledby=\"content-a8518f46a9c0ed52d4d9-tab\">\n                        <div class=\"animated fadeIn\">\n                            <p>\t\t<div data-elementor-type=\"section\" data-elementor-id=\"3441\" class=\"elementor elementor-3441\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\" data-elementor-post-type=\"elementor_library\">\n\t\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-287e69d elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"61239\" data-id=\"287e69d\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-fcfa494\" data-eae-slider=\"81345\" data-id=\"fcfa494\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-6378153 elementor-widget elementor-widget-text-editor\" data-id=\"6378153\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><style type=\"text\/css\">#ipt_fsqm_form_wrap_8 .ipt_fsqm_form_logo img,\n\t#ipt_fsqm_form_wrap_8 .ipt-eform-width-restrain,\n\t#ipt_fsqm_form_wrap_8 .ipt_fsqm_form_message_restore,\n\t#ipt_fsqm_form_wrap_8 .ipt_fsqm_form_message_success,\n\t#ipt_fsqm_form_wrap_8 .ipt_fsqm_form_message_error,\n\t#ipt_fsqm_form_wrap_8 .ipt_fsqm_form_message_process,\n\t#ipt_fsqm_form_wrap_8 .ipt_fsqm_form_validation_error,\n\t#ipt_fsqm_form_wrap_8 .eform-ui-estimator {\n\t\tmax-width: 100%;\n\t\tmin-width: 240px;\n\t}\n\n\t\t\t#ipt_fsqm_form_wrap_8 .ipt-eform-content {\n\t\t\tbackground-image: none;\n\t\t\tbackground-position: 0% 0%;\n\t\t\tbackground-size: auto;\n\t\t\tbackground-repeat: repeat;\n\t\t\tbackground-origin: padding-box;\n\t\t\tbackground-clip: border-box;\n\t\t\tbackground-attachment: scroll;\n\t\t}\n\t\/**\/<\/style><div\nid=\"ipt_fsqm_form_wrap_8\"\nclass=\"ipt_uif_front ipt_uif_common ipt_fsqm_form type_2 ui-front eform-ltr eform-override-element-material eform-override-alignment-inherit\"\ndata-fsqmsayt=\"{&quot;auto_save&quot;:true,&quot;show_restore&quot;:true,&quot;restore&quot;:true,&quot;admin_override&quot;:false,&quot;user_update&quot;:false,&quot;interval_save&quot;:false,&quot;interval&quot;:&quot;30&quot;}\"\ndata-ui-type=\"2\"\ndata-ui-theme=\"[&quot;https:\\\/\\\/bciconline.com\\\/ba\\\/wp-content\\\/plugins\\\/wp-fsqm-pro\\\/static\\\/front\\\/css\\\/material-themes\\\/light-themes\\\/red.css?ver=4.19.1&quot;]\"\ndata-ui-theme-id=\"material-red\"\ndata-eformanim=\"1\"\ndata-fsqmga=\"{&quot;enabled&quot;:false,&quot;manual_load&quot;:false,&quot;tracking_id&quot;:&quot;&quot;,&quot;cookie&quot;:&quot;auto&quot;,&quot;user_update&quot;:false,&quot;name&quot;:&quot;Employer Liability&quot;,&quot;form_id&quot;:&quot;8&quot;}\"\ndata-fsqmreset=\"{&quot;reset&quot;:false,&quot;delay&quot;:10}\"\ndata-eformreg=\"{&quot;enabled&quot;:false,&quot;username_id&quot;:&quot;ipt_fsqm_form_8_pinfo_&quot;,&quot;password_id&quot;:&quot;ipt_fsqm_form_8_pinfo_&quot;,&quot;hide_pinfo&quot;:false,&quot;hide_meta&quot;:false,&quot;meta&quot;:[]}\"\ndata-eformscroll=\"{&quot;progress&quot;:true,&quot;message&quot;:true,&quot;offset&quot;:&quot;0&quot;,&quot;scrollOnError&quot;:true}\"\ndata-eform-cookie=\"0\"\ndata-subscription-form=\"false\"\ndata-instant-subscription=\"{&quot;doable&quot;:true,&quot;config&quot;:{&quot;enabled&quot;:false,&quot;min_tab&quot;:&quot;&quot;,&quot;debounce&quot;:&quot;3000&quot;},&quot;nonce&quot;:&quot;7e33152a53&quot;}\"\n><style type=\"text\/css\">\/**\/<\/style><noscript><div\nclass=\"ipt_fsqm_form_message_noscript ui-widget ui-widget-content ui-corner-all\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><div>Javascript is disabled<\/div><\/div><div\nclass=\"ui-widget-content ui-corner-bottom\"><p>Javascript is disabled on your browser. Please enable it in order to use this form.<\/p><\/div><\/div>\n<\/noscript><style type=\"text\/css\">.ipt_uif_ajax_loader,\n\t\t\t.ipt_uif_ajax_loader *,\n\t\t\tipt_uif_ajax_loader *::before,\n\t\t\tipt_uif_ajax_loader *::after {\n\t\t\t\tbox-sizing: border-box;\n\t\t\t}<\/style><div\nclass=\"ipt_uif_init_loader ipt-eform-preloader-inline ipt_uif_ajax_loader\"><div\nclass=\"ipt-eform-preloader-inner\"><div\nclass=\"ipt-eform-preloader-circle\"><div\nclass=\"preloader-wrapper active\"><div\nclass=\"spinner-layer spinner-blue\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-red\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-yellow\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-green\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><\/div><\/div><div\nclass=\"ipt-eform-preloader-text\"><div\nclass=\"ipt-eform-preloader-text-inner ipt_uif_ajax_loader_text\">Loading<\/div><\/div><div\nclass=\"clear\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude class=\"ipt_uif_conditional_logic\" id=\"ipt_uif_conditional_logic_8\" value=\"{&quot;logics&quot;:{&quot;ipt_fsqm_form_8_pinfo_62&quot;:{&quot;active&quot;:true,&quot;status&quot;:true,&quot;change&quot;:true,&quot;logic&quot;:{},&quot;type&quot;:&quot;s_checkbox&quot;,&quot;m_type&quot;:&quot;pinfo&quot;}},&quot;indexes&quot;:[],&quot;base&quot;:&quot;8&quot;}\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude class=\"ipt_fsqm_timer_data\" id=\"ipt_fsqm_timer_data_8\" value=\"{&quot;type&quot;:&quot;none&quot;}\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude class=\"ipt_fsqm_epoc_data\" id=\"ipt_fsqm_epoc_data_8\" value=\"{&quot;CURRENTYEAR&quot;:2026,&quot;CURRENTDATE&quot;:1788594309000,&quot;CURRENTDAY&quot;:5,&quot;CURRENTMONTH&quot;:9,&quot;CURRENTHOUR&quot;:7,&quot;CURRENTMINUTE&quot;:45,&quot;CURRENTSECOND&quot;:9,&quot;CURRENTWEEK&quot;:36,&quot;CURRENTEPOC&quot;:20701}\" \/><div\nstyle=\"display: none;\" class=\"ipt_uif_hidden_init\"><div\nstyle=\"display: none;\" class=\"ipt_fsqm_form_message_restore ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><h3><a\nhref=\"#\" title=\"Hide\" class=\"ipt_fsqm_form_message_close\"><i\ntitle=\"\" class=\" ipt-icomoon-times ipticm prefix\"><\/i>\n<\/a><i\ntitle=\"\" class=\" ipt-icomoon-checkmark-circle ipticm prefix\"><\/i>\nForm successfully restored<\/h3><\/div><div\nclass=\"ui-widget-content ui-corner-all\"><p>The form has been restored from your last edit. If wish to start over, please click the button<\/p>\n<button\nstyle=\"margin-bottom: 0\" class=\"ipt_uif_button ipt_fsqm_sayt_reset secondary-button\">Start Over<\/button><\/div><\/div><form\nmethod=\"post\" action=\"\" class=\"ipt_uif_validate_form ipt_fsqm_main_form\" id=\"ipt_fsqm_form_8\" autocomplete=\"on\">\n<input\ntype=\"hidden\" data-sayt-exclude name=\"action\" id=\"action\" value=\"ipt_fsqm_save_form\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_epoc\" class=\"eform-epoc-value\" value=\"1788594309\" \/>\n<input\ntype=\"hidden\" class=\"ipt_fsqm_form_tab_pos\" name=\"fsqm_form8_tab_pos\" value=\"0\" id=\"fsqm_form8_tab_pos\" \/>\n<input\ntype=\"hidden\" id=\"ipt_fsqm_form_data_save\" name=\"ipt_fsqm_form_data_save\" value=\"879df1d96e\" data-sayt-exclude \/>\t\t\t<input\ntype=\"hidden\" name=\"_wp_http_referer\" value=\"\/ba\/report-claim\/\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"form_id\" value=\"8\" \/><div\nclass=\"ipt-eform-width-restrain\"><div\nclass=\"ipt-eform-content \"><div\ndata-settings=\"{&quot;can_previous&quot;:true,&quot;show_progress_bar&quot;:true,&quot;progress_bar_bottom&quot;:true,&quot;block_previous&quot;:false,&quot;any_tab&quot;:false,&quot;type&quot;:&quot;2&quot;,&quot;scroll&quot;:true,&quot;decimal_point&quot;:2,&quot;auto_progress&quot;:false,&quot;auto_progress_delay&quot;:&quot;1500&quot;,&quot;auto_submit&quot;:false,&quot;hidden_buttons&quot;:false,&quot;scroll_on_error&quot;:true}\" class=\"ipt_fsqm_main_tab ipt_uif_tabs horizontal\"><div\nclass=\"ipt-eform-tab-nav-wrap\"><ul><li\nid=\"ipt_fsqm_form_8_tab_0_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_8_tab_0\"><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe269;\"><\/i>\n<span\nclass=\"eform-tab-labels\">Tell us what happened <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_8_tab_1_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_8_tab_1\"><span\nclass=\"eform-tab-labels\">About you <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_8_tab_2_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_8_tab_2\"><span\nclass=\"eform-tab-labels\">About the Incident <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_8_tab_3_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_8_tab_3\"><span\nclass=\"eform-tab-labels\">Other Details <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_8_tab_4_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_8_tab_4\"><span\nclass=\"eform-tab-labels\">Submit your Claim <\/span><\/a><\/li><\/ul>\n<i\nclass=\"eform-tab-nav eform-tab-nav-right ipt-icomoon-angle-right disabled eform-ripple\"><\/i>\n<i\nclass=\"eform-tab-nav eform-tab-nav-left ipt-icomoon-angle-left disabled eform-ripple\"><\/i>\n<span\nclass=\"eform-tab-passive-notifier\"><\/span>\n<span\nclass=\"eform-tab-active-notifier\"><\/span><\/div><div\nid=\"ipt_fsqm_form_8_tab_0\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_8_layout_0_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe269;\"><\/i>\n<span\nclass=\"ipt_uif_divider_text_inner\">\nTell us what happened<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][0][m_type]\" id=\"ipt_fsqm_form_8_pinfo_0_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][0][type]\" id=\"ipt_fsqm_form_8_pinfo_0_type\" value=\"datetime\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_datetime\" id=\"ipt_fsqm_form_8_pinfo_0\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_0_value\">When Did It Happen?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field eform-dp-input-field has-icon\">\n<input\nclass=\"datepicker ipt_uif_datepicker  check_me validate[required] is-empty ipt_uif_text\"\ndata-dateFormat=\"mm\/dd\/yy\" data-timeFormat=\"hh:mm:ss TT\" data-year_range=\"50\"\t\ttype=\"text\"\nreadonly=\"readonly\"\nname=\"ipt_fsqm_form_8[pinfo][0][value]\"\nid=\"ipt_fsqm_form_8_pinfo_0_value\"\nmaxlength=\"524288\"\nvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipt-icomoon-calendar ipticm prefix\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_0_value\">Select Date<\/label>\n<a\nhref=\"javascript:;\" class=\"eform-dp-clear\" title=\"Clear\">&times;<\/a><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][4][m_type]\" id=\"ipt_fsqm_form_8_pinfo_4_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][4][type]\" id=\"ipt_fsqm_form_8_pinfo_4_type\" value=\"datetime\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_datetime\" id=\"ipt_fsqm_form_8_pinfo_4\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_4_value\">What time did it happen?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field eform-dp-input-field has-icon\">\n<input\nclass=\"datepicker ipt_uif_timepicker  check_me validate[required] is-empty ipt_uif_text\"\ndata-dateFormat=\"yy-mm-dd\" data-timeFormat=\"hh:mm:ss TT\" data-year_range=\"50\"\t\ttype=\"text\"\nreadonly=\"readonly\"\nname=\"ipt_fsqm_form_8[pinfo][4][value]\"\nid=\"ipt_fsqm_form_8_pinfo_4_value\"\nmaxlength=\"524288\"\nvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipt-icomoon-clock ipticm prefix\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_4_value\">Select Time<\/label>\n<a\nhref=\"javascript:;\" class=\"eform-dp-clear\" title=\"Clear\">&times;<\/a><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][1][m_type]\" id=\"ipt_fsqm_form_8_pinfo_1_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][1][type]\" id=\"ipt_fsqm_form_8_pinfo_1_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_1\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_1_value\">Where did it Happen?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][1][value]\"\nid=\"ipt_fsqm_form_8_pinfo_1_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe07d;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_1_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][83][m_type]\" id=\"ipt_fsqm_form_8_pinfo_83_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][83][type]\" id=\"ipt_fsqm_form_8_pinfo_83_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_83\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_83_value\">Who in your opinion is responsible for the incident?<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][83][value]\"\nid=\"ipt_fsqm_form_8_pinfo_83_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe056;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_83_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][6][m_type]\" id=\"ipt_fsqm_form_8_pinfo_6_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][6][type]\" id=\"ipt_fsqm_form_8_pinfo_6_type\" value=\"textarea\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textarea\" id=\"ipt_fsqm_form_8_pinfo_6\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_6_value\">Please describe in detail what happened (max 1300 characters)<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me validate[required,minSize[10],maxSize[1303]]\"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_8[pinfo][6][value]\"\n\t\tmaxlength=\"1303\"\t\tid=\"ipt_fsqm_form_8_pinfo_6_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe056;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_6_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_8_tab_1\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_8_layout_1_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<span\nclass=\"ipt_uif_divider_text_inner\">\nAbout you<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][7][m_type]\" id=\"ipt_fsqm_form_8_pinfo_7_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][7][type]\" id=\"ipt_fsqm_form_8_pinfo_7_type\" value=\"p_radio\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_radio\" id=\"ipt_fsqm_form_8_pinfo_7\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_7\">Are you a policyholder?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][7][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_7_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_7_options__0\" data-labelcon=\"&#xe18e;\">\nYes\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][7][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_7_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_7_options__1\" data-labelcon=\"&#xe18e;\">\nNo\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][8][m_type]\" id=\"ipt_fsqm_form_8_pinfo_8_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][8][type]\" id=\"ipt_fsqm_form_8_pinfo_8_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_8\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_8_value\">Policy Number<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][8][value]\"\nid=\"ipt_fsqm_form_8_pinfo_8_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe056;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_8_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][9][m_type]\" id=\"ipt_fsqm_form_8_pinfo_9_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][9][type]\" id=\"ipt_fsqm_form_8_pinfo_9_type\" value=\"f_name\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_f_name\" id=\"ipt_fsqm_form_8_pinfo_9\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_9_value\">Policy Holder First Name<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[custom[personName]] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][9][value]\"\nid=\"ipt_fsqm_form_8_pinfo_9_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xf007;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_9_value\">First Name<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][10][m_type]\" id=\"ipt_fsqm_form_8_pinfo_10_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][10][type]\" id=\"ipt_fsqm_form_8_pinfo_10_type\" value=\"l_name\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_l_name\" id=\"ipt_fsqm_form_8_pinfo_10\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_10_value\">Policy Holder Last Name<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[custom[personName]] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][10][value]\"\nid=\"ipt_fsqm_form_8_pinfo_10_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xf007;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_10_value\">Last Name<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][12][m_type]\" id=\"ipt_fsqm_form_8_pinfo_12_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][12][type]\" id=\"ipt_fsqm_form_8_pinfo_12_type\" value=\"phone\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_phone\" id=\"ipt_fsqm_form_8_pinfo_12\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_12_value\">Preferred Telephone Number<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[custom[phone]] ipt_uif_text\"\ntype=\"tel\"\nname=\"ipt_fsqm_form_8[pinfo][12][value]\"\nid=\"ipt_fsqm_form_8_pinfo_12_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe08c;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_12_value\">Phone<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][11][m_type]\" id=\"ipt_fsqm_form_8_pinfo_11_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][11][type]\" id=\"ipt_fsqm_form_8_pinfo_11_type\" value=\"email\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_email\" id=\"ipt_fsqm_form_8_pinfo_11\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_11_value\">Preferred Email Address<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[custom[email]] ipt_uif_text\"\ntype=\"email\"\nname=\"ipt_fsqm_form_8[pinfo][11][value]\"\nid=\"ipt_fsqm_form_8_pinfo_11_value\"\nvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xf0e0;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_11_value\">Email Address<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][13][m_type]\" id=\"ipt_fsqm_form_8_pinfo_13_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][13][type]\" id=\"ipt_fsqm_form_8_pinfo_13_type\" value=\"p_radio\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_radio\" id=\"ipt_fsqm_form_8_pinfo_13\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_13\">Contact Preference<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][13][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_13_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_13_options__0\" data-labelcon=\"&#xe18e;\">\nEmail\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][13][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_13_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_13_options__1\" data-labelcon=\"&#xe18e;\">\nPhone\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_8_tab_2\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_8_layout_2_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<span\nclass=\"ipt_uif_divider_text_inner\">\nAbout the Incident<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][96][m_type]\" id=\"ipt_fsqm_form_8_pinfo_96_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][96][type]\" id=\"ipt_fsqm_form_8_pinfo_96_type\" value=\"p_radio\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_radio\" id=\"ipt_fsqm_form_8_pinfo_96\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_96\">Was machinery being used? <span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][96][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_96_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_96_options__0\" data-labelcon=\"&#xe18e;\">\nYes\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][96][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_96_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_96_options__1\" data-labelcon=\"&#xe18e;\">\nNo\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][88][m_type]\" id=\"ipt_fsqm_form_8_pinfo_88_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][88][type]\" id=\"ipt_fsqm_form_8_pinfo_88_type\" value=\"textarea\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textarea\" id=\"ipt_fsqm_form_8_pinfo_88\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_88_value\">If yes, please state exactly what machinery was involved in the incident?<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_8[pinfo][88][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_8_pinfo_88_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe056;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_88_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][18][m_type]\" id=\"ipt_fsqm_form_8_pinfo_18_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][18][type]\" id=\"ipt_fsqm_form_8_pinfo_18_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_18\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_18_value\">Employee\u2019s full name<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][18][value]\"\nid=\"ipt_fsqm_form_8_pinfo_18_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_18_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][19][m_type]\" id=\"ipt_fsqm_form_8_pinfo_19_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][19][type]\" id=\"ipt_fsqm_form_8_pinfo_19_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_19\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_19_value\">Employee\u2019s address<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][19][value]\"\nid=\"ipt_fsqm_form_8_pinfo_19_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_19_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][20][m_type]\" id=\"ipt_fsqm_form_8_pinfo_20_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][20][type]\" id=\"ipt_fsqm_form_8_pinfo_20_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_20\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_20_value\">Employee\u2019s occupation<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][20][value]\"\nid=\"ipt_fsqm_form_8_pinfo_20_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_20_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][21][m_type]\" id=\"ipt_fsqm_form_8_pinfo_21_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][21][type]\" id=\"ipt_fsqm_form_8_pinfo_21_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_21\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_21_value\">Employee\u2019s age<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][21][value]\"\nid=\"ipt_fsqm_form_8_pinfo_21_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_21_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][87][m_type]\" id=\"ipt_fsqm_form_8_pinfo_87_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][87][type]\" id=\"ipt_fsqm_form_8_pinfo_87_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_87\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_87_value\">Department in which employee worked at the time of the incident<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][87][value]\"\nid=\"ipt_fsqm_form_8_pinfo_87_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_87_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][90][m_type]\" id=\"ipt_fsqm_form_8_pinfo_90_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][90][type]\" id=\"ipt_fsqm_form_8_pinfo_90_type\" value=\"p_radio\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_radio\" id=\"ipt_fsqm_form_8_pinfo_90\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_90\"> Was the employee in your direct employment? <span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][90][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_90_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_90_options__0\" data-labelcon=\"&#xe18e;\">\nYes\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][90][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_90_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_90_options__1\" data-labelcon=\"&#xe18e;\">\nNo\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][98][m_type]\" id=\"ipt_fsqm_form_8_pinfo_98_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][98][type]\" id=\"ipt_fsqm_form_8_pinfo_98_type\" value=\"datetime\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_datetime\" id=\"ipt_fsqm_form_8_pinfo_98\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_98_value\">If yes, since what date? <\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field eform-dp-input-field has-icon\">\n<input\nclass=\"datepicker ipt_uif_datepicker  check_me  is-empty ipt_uif_text\"\ndata-dateFormat=\"yy-mm-dd\" data-timeFormat=\"HH:mm:ss\" data-year_range=\"50\"\t\ttype=\"text\"\nreadonly=\"readonly\"\nname=\"ipt_fsqm_form_8[pinfo][98][value]\"\nid=\"ipt_fsqm_form_8_pinfo_98_value\"\nmaxlength=\"524288\"\nvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipt-icomoon-calendar ipticm prefix\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_98_value\">Select Date<\/label>\n<a\nhref=\"javascript:;\" class=\"eform-dp-clear\" title=\"Clear\">&times;<\/a><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][99][m_type]\" id=\"ipt_fsqm_form_8_pinfo_99_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][99][type]\" id=\"ipt_fsqm_form_8_pinfo_99_type\" value=\"p_radio\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_radio\" id=\"ipt_fsqm_form_8_pinfo_99\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_99\">Was the employee injured? <span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][99][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_99_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_99_options__0\" data-labelcon=\"&#xe18e;\">\nYes\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][99][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_99_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_99_options__1\" data-labelcon=\"&#xe18e;\">\nNo\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][97][m_type]\" id=\"ipt_fsqm_form_8_pinfo_97_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][97][type]\" id=\"ipt_fsqm_form_8_pinfo_97_type\" value=\"textarea\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textarea\" id=\"ipt_fsqm_form_8_pinfo_97\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_97_value\">If yes, please state the nature of injuries or damage<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_8[pinfo][97][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_8_pinfo_97_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe056;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_97_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][103][m_type]\" id=\"ipt_fsqm_form_8_pinfo_103_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][103][type]\" id=\"ipt_fsqm_form_8_pinfo_103_type\" value=\"p_radio\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_radio\" id=\"ipt_fsqm_form_8_pinfo_103\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_103\">Did the employee receive medical care for the injuries sustained?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][103][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_103_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_103_options__0\" data-labelcon=\"&#xe18e;\">\nYes\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][103][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_103_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_103_options__1\" data-labelcon=\"&#xe18e;\">\nNo\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][101][m_type]\" id=\"ipt_fsqm_form_8_pinfo_101_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][101][type]\" id=\"ipt_fsqm_form_8_pinfo_101_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_101\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_101_value\">If yes, where did he\/she receive medical care?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][101][value]\"\nid=\"ipt_fsqm_form_8_pinfo_101_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_101_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][102][m_type]\" id=\"ipt_fsqm_form_8_pinfo_102_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][102][type]\" id=\"ipt_fsqm_form_8_pinfo_102_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_102\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_102_value\">What is the monthly wage of the employee?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][102][value]\"\nid=\"ipt_fsqm_form_8_pinfo_102_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_102_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][100][m_type]\" id=\"ipt_fsqm_form_8_pinfo_100_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][100][type]\" id=\"ipt_fsqm_form_8_pinfo_100_type\" value=\"p_radio\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_radio\" id=\"ipt_fsqm_form_8_pinfo_100\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_100\">Did the emploee work after the incident?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][100][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_100_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_100_options__0\" data-labelcon=\"&#xe18e;\">\nYes\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][100][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_100_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_100_options__1\" data-labelcon=\"&#xe18e;\">\nNo\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][104][m_type]\" id=\"ipt_fsqm_form_8_pinfo_104_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][104][type]\" id=\"ipt_fsqm_form_8_pinfo_104_type\" value=\"datetime\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_datetime\" id=\"ipt_fsqm_form_8_pinfo_104\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_104_value\">If yes, what date? <\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field eform-dp-input-field has-icon\">\n<input\nclass=\"datepicker ipt_uif_datetimepicker  check_me  is-empty ipt_uif_text\"\ndata-dateFormat=\"yy-mm-dd\" data-timeFormat=\"HH:mm:ss\" data-year_range=\"50\"\t\ttype=\"text\"\nreadonly=\"readonly\"\nname=\"ipt_fsqm_form_8[pinfo][104][value]\"\nid=\"ipt_fsqm_form_8_pinfo_104_value\"\nmaxlength=\"524288\"\nvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipt-icomoon-calendar ipticm prefix\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_104_value\">Select Date<\/label>\n<a\nhref=\"javascript:;\" class=\"eform-dp-clear\" title=\"Clear\">&times;<\/a><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_8_tab_3\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_8_layout_3_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<span\nclass=\"ipt_uif_divider_text_inner\">\nOther Details<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][24][m_type]\" id=\"ipt_fsqm_form_8_design_24_m_type\" value=\"design\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][24][type]\" id=\"ipt_fsqm_form_8_design_24_type\" value=\"richtext\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional\" id=\"ipt_fsqm_form_8_design_24\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_richtext\"><p\nclass=\"MsoNormal\" style=\"margin-bottom: 7.5pt; color: #222222; font-family: arial, sans-serif; font-size: 12.8px; text-align: justify; vertical-align: baseline;\"><span\nstyle=\"font-size: 14pt;\">Did any one witness the incident? If yes please provide their details below including full name and contact details<\/span><\/p><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][25][m_type]\" id=\"ipt_fsqm_form_8_design_25_m_type\" value=\"design\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][25][type]\" id=\"ipt_fsqm_form_8_design_25_type\" value=\"col_half\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half\" id=\"ipt_fsqm_form_8_design_25\"><div\nclass=\"ipt_uif_column_inner\">\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][27][m_type]\" id=\"ipt_fsqm_form_8_design_27_m_type\" value=\"design\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][27][type]\" id=\"ipt_fsqm_form_8_design_27_type\" value=\"richtext\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional\" id=\"ipt_fsqm_form_8_design_27\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_richtext\"><p>Names<\/p><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][91][m_type]\" id=\"ipt_fsqm_form_8_pinfo_91_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][91][type]\" id=\"ipt_fsqm_form_8_pinfo_91_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_91\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_full\"><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][91][value]\"\nid=\"ipt_fsqm_form_8_pinfo_91_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_91_value\">Name<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][93][m_type]\" id=\"ipt_fsqm_form_8_pinfo_93_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][93][type]\" id=\"ipt_fsqm_form_8_pinfo_93_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_93\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_full\"><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][93][value]\"\nid=\"ipt_fsqm_form_8_pinfo_93_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_93_value\">Name<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][26][m_type]\" id=\"ipt_fsqm_form_8_design_26_m_type\" value=\"design\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][26][type]\" id=\"ipt_fsqm_form_8_design_26_type\" value=\"col_half\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half\" id=\"ipt_fsqm_form_8_design_26\"><div\nclass=\"ipt_uif_column_inner\">\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][28][m_type]\" id=\"ipt_fsqm_form_8_design_28_m_type\" value=\"design\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][28][type]\" id=\"ipt_fsqm_form_8_design_28_type\" value=\"richtext\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional\" id=\"ipt_fsqm_form_8_design_28\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_richtext\"><p>Contact Details<\/p><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][92][m_type]\" id=\"ipt_fsqm_form_8_pinfo_92_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][92][type]\" id=\"ipt_fsqm_form_8_pinfo_92_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_92\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_full\"><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][92][value]\"\nid=\"ipt_fsqm_form_8_pinfo_92_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_92_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][95][m_type]\" id=\"ipt_fsqm_form_8_pinfo_95_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][95][type]\" id=\"ipt_fsqm_form_8_pinfo_95_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_95\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_full\"><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][95][value]\"\nid=\"ipt_fsqm_form_8_pinfo_95_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_95_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[freetype][0][m_type]\" id=\"ipt_fsqm_form_8_freetype_0_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[freetype][0][type]\" id=\"ipt_fsqm_form_8_freetype_0_type\" value=\"upload\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_upload\" id=\"ipt_fsqm_form_8_freetype_0\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_container ipt_uif_iconbox\" data-opened=\"1\"><div\nclass=\"ipt_uif_container_head\"><h3>\t\t\t\t\t\t<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe002;\"><\/i>\n<span\nclass=\"ipt_uif_container_label\">Please attach photographs or relevant documents to support your claim<\/span><\/h3><\/div><div\nclass=\"ipt_uif_container_inner\"><div\nclass=\"ipt_uif_uploader\" id=\"ipt_fsqm_file_upload_8_0__uploader_wrap\" data-settings=\"{&quot;accept_file_types&quot;:&quot;gif,jpeg,png,jpg,pdf,doc,docx&quot;,&quot;max_number_of_files&quot;:&quot;&quot;,&quot;min_number_of_files&quot;:&quot;&quot;,&quot;max_file_size&quot;:134217728,&quot;min_file_size&quot;:&quot;1&quot;,&quot;show_drop_zone&quot;:true,&quot;wp_media_integration&quot;:false,&quot;auto_upload&quot;:true,&quot;single_upload&quot;:false,&quot;drag_n_drop&quot;:true,&quot;progress_bar&quot;:true,&quot;preview_media&quot;:true,&quot;can_delete&quot;:true,&quot;required&quot;:false,&quot;minimal_ui&quot;:false,&quot;accept&quot;:&quot;all&quot;,&quot;capture&quot;:&quot;none&quot;,&quot;icon&quot;:&quot;57346&quot;,&quot;centered&quot;:false,&quot;dragdrop&quot;:&quot;Drag &#039;n Drop files here&quot;,&quot;upload_label&quot;:&quot;Select Files&quot;,&quot;recaptcha&quot;:false,&quot;site_key&quot;:&quot;&quot;,&quot;theme&quot;:&quot;light&quot;,&quot;type&quot;:&quot;image&quot;,&quot;size&quot;:&quot;normal&quot;,&quot;hl&quot;:&quot;en&quot;}\" data-configuration=\"{&quot;id&quot;:&quot;ipt_fsqm_file_upload_8_0_&quot;,&quot;upload_url&quot;:&quot;?action=ipt_fsqm_fu_upload&quot;,&quot;download_url&quot;:&quot;?action=ipt_fsqm_fu_download&quot;,&quot;do_download&quot;:false,&quot;show_ui&quot;:true,&quot;captcha_url&quot;:&quot;?action=ipt_fsqm_fu_captcha&quot;}\" data-formData=\"{&quot;data_id&quot;:null,&quot;form_id&quot;:&quot;8&quot;,&quot;nonce&quot;:&quot;490620fee6&quot;,&quot;element_key&quot;:&quot;0&quot;,&quot;files_key&quot;:&quot;ipt_fsqm_file_upload_8_0&quot;}\"><div\nclass=\"fileinput-dragdrop ui-state-active\">\n<span>Drag &#8216;n Drop files here<\/span><\/div><div\nclass=\"fileupload-meta\"><p>Max file size: 128.00 MB. | Allowed file types: gif,jpeg,png,jpg,pdf,doc,docx<\/p><\/div><div\nclass=\"ipt_fsqm_fileuploader_list_wrap\"><table\nrole=\"presentation\" class=\"ipt_fsqm_fileuploader_list\"><thead><tr><td\ncolspan=\"4\"><div\nclass=\"fileupload-buttonbar\"><div\nclass=\"fileupload-buttons\">\n<span\nrole=\"button\" class=\"fileinput-button secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n<span\nclass=\"ui-button-icon-primary ui-icon ui-icon-plusthick\"><\/span>\n<span\nclass=\"ui-button-text\">\n<span\nclass=\"select secondary-button\">Select Files<\/span>\n<\/span>\n<input\nclass=\"ipt_uif_uploader_handle\" type=\"file\" multiple=\"multiple\" name=\"ipt_fsqm_file_upload_8_0[]\" id=\"ipt_fsqm_file_upload_8_0_\" \/>\n<\/span>\n<button\ntype=\"reset\" class=\"cancel secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n<span\nclass=\"ui-button-icon-primary ui-icon ui-icon-cancel\"><\/span>\n<span\nclass=\"ui-button-text\">\nCancel All Uploads\t\t\t\t\t\t\t\t\t\t<\/span>\n<\/button>\n<span\nclass=\"fileupload-process\"><\/span><\/div><div\nclass=\"fileupload-progress fade wp-eform-fileupload-globalprogress\" style=\"display: none;\"><div\nclass=\"progress ui-progressbar ui-widget ui-widget-content ui-corner-all\" role=\"progressbar\" aria-valuemin=\"0\" aria-valuemax=\"100\"><div\nclass=\"progress-bar ui-progressbar-value ui-widget-header ui-corner-left\" style=\"width: 0%;\"><\/div><\/div><div\nclass=\"progress-extended\">&nbsp;<\/div><\/div><\/div><\/td><td\nclass=\"delete_button\"><div\nclass=\"fileupload-buttonbar\"><div\nclass=\"fileupload-buttons\">\n<button\ntype=\"button\" class=\"delete secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n<span\nclass=\"ui-button-icon-primary ui-icon ui-icon-trash\"><\/span>\n<span\nclass=\"ui-button-text\">\nDelete Selected\t\t\t\t\t\t\t\t\t\t<\/span>\n<\/button><\/div><\/div><\/td><td\nclass=\"delete_toggle\"><div\nclass=\"fileupload-buttonbar\"><div\nclass=\"fileupload-buttons\"><div\nclass=\"ipt_uif_label_column\">\n<input\ntype=\"checkbox\" class=\"toggle ipt_uif_checkbox\" id=\"ipt_fsqm_file_upload_8_0__toggler\" \/>\n<label\ndata-labelcon=\"&#xe18e;\" for=\"ipt_fsqm_file_upload_8_0__toggler\"><\/label><\/div><\/div><\/div><\/td><\/tr><\/thead><tbody\nclass=\"files\"><\/tbody><\/table><\/div> <script class=\"template-upload\" id=\"ipt_fsqm_file_upload_8_0__tmpl_upload\" type=\"text\/x-tmpl\">{% for (var i=0, file; file=o.files[i]; i++) { %}\n\t<tr class=\"template-upload\">\n\t\t<td>\n\t\t\t<span class=\"preview\"><\/span>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p class=\"name\">{%=file.name%}<\/p>\n\t\t\t<strong class=\"error\"><\/strong>\n\t\t<\/td>\n\t\t<td class=\"fileupload_list_pb\">\n\t\t\t<p class=\"size\">Processing&hellip;<\/p>\n\t\t\t<div class=\"progress ui-progressbar ui-widget ui-widget-content ui-corner-all\" role=\"progressbar\" aria-valuemin=\"0\" aria-valuemax=\"100\">\n\t\t\t\t<div class=\"progress-bar ui-progressbar-value ui-widget-header ui-corner-left\" style=\"width: 0%;\"><\/div>\n\t\t\t<\/div>\n\t\t<\/td>\n\t\t<td colspan=\"3\">\n\t\t\t{% if (!i && !o.options.autoUpload) { %}\n\t\t\t\t<button class=\"start secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\" disabled>\n\t\t\t\t\t<span class=\"ui-button-icon-primary ui-icon ui-icon-circle-arrow-e\"><\/span>\n\t\t\t\t\t<span class=\"ui-button-text\">\n\t\t\t\t\t\tStart\t\t\t\t\t<\/span>\n\t\t\t\t<\/button>\n\t\t\t{% } %}\n\t\t\t{% if (!i) { %}\n\t\t\t\t<button class=\"cancel secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n\t\t\t\t\t<span class=\"ui-button-icon-primary ui-icon ui-icon-cancel\"><\/span>\n\t\t\t\t\t<span class=\"ui-button-text\">\n\t\t\t\t\t\tCancel\t\t\t\t\t<\/span>\n\t\t\t\t<\/button>\n\t\t\t{% } %}\n\t\t<\/td>\n\t<\/tr>\n{% } %}<\/script>  <script class=\"template-download\" id=\"ipt_fsqm_file_upload_8_0__tmpl_download\" type=\"text\/x-tmpl\">{%\n\twindow.ipt_fsqm_upload_count_global;\n\tif ( window.ipt_fsqm_upload_count_global == undefined ) {\n\t\twindow.ipt_fsqm_upload_count_global = 0;\n\t}\n%}\n{% for (var i=0, file; file=o.files[i]; i++) { %}\n{% var toggler_check_id = window.ipt_fsqm_upload_count_global++; %}\n\t<tr class=\"template-download\">\n\t\t<td class=\"preview_td\" colspan=\"2\">\n\t\t\t<span class=\"preview\">\n\t\t\t\t{% if (file.thumbnailUrl) { %}\n\t\t\t\t\t<a href=\"{%=file.url%}\" title=\"{%=file.name%}\" download=\"{%=file.name%}\" data-gallery><img decoding=\"async\" src=\"{%=file.thumbnailUrl%}\" \/><\/a>\n\t\t\t\t{% } else if ( file.validAudio ) { %}\n\t\t\t\t\t\t\t\t\t\t<audio controls=\"controls\">\n\t\t\t\t\t\t<source src=\"{%=file.url%}\" type=\"{%=file.type%}\" \/>\n\t\t\t\t\t\tYour browser does not support audio element.\t\t\t\t\t<\/audio>\n\t\t\t\t\t\t\t\t\t{% } else if ( file.validVideo ) { %}\n\t\t\t\t\t\t\t\t\t\t<video controls=\"controls\" height=\"100\" width=\"200\">\n\t\t\t\t\t\t<source src=\"{%=file.url%}\" type=\"{%=file.type%}\" \/>\n\t\t\t\t\t\tYour browser does not support video element.\t\t\t\t\t<\/video>\n\t\t\t\t\t\t\t\t\t{% } %}\n\t\t\t<\/span>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p class=\"name\">\n\t\t\t\t<a href=\"{%=file.url%}\" title=\"{%=file.name%}\" download=\"{%=file.name%}\" {%=file.thumbnailUrl?'data-gallery':''%}>{%=file.name%}<\/a>\n\t\t\t<\/p>\n\t\t\t{% if (file.error) { %}\n\t\t\t\t<div><span class=\"error\">Error<\/span> {%=file.error%}<\/div>\n\t\t\t{% } %}\n\t\t\t<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[freetype][0][id][]\" value=\"{%=file.id%}\" \/>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<span class=\"size\">{%=o.formatFileSize(file.size)%}<\/span>\n\t\t<\/td>\n\t\t\t\t<td class=\"delete_button\">\n\t\t\t<button class=\"delete secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\" data-type=\"{%=file.deleteType%}\" data-url=\"{%=file.deleteUrl%}\"{% if (file.deleteWithCredentials) { %} data-xhr-fields='{\"withCredentials\":true}'{% } %}>\n\t\t\t\t<span class=\"ui-button-icon-primary ui-icon ui-icon-trash\"><\/span>\n\t\t\t\t<span class=\"ui-button-text\">\n\t\t\t\t\tDelete\t\t\t\t<\/span>\n\t\t\t<\/button>\n\t\t<\/td>\n\t\t\t\t\t<td class=\"delete_toggle\">\n\t\t\t\t<div class=\"ipt_uif_label_column\">\n\t\t\t\t\t<input type=\"checkbox\" name=\"delete\" value=\"1\" class=\"toggle ipt_uif_checkbox\" id=\"ipt_fsqm_file_upload_8_0__toggler_files_{%=toggler_check_id%}\" \/>\n\t\t\t\t\t<label data-labelcon=\"&#xe18e;\" for=\"ipt_fsqm_file_upload_8_0__toggler_files_{%=toggler_check_id%}\"><\/label>\n\t\t\t\t<\/div>\n\t\t\t<\/td>\n\t\t\t\t\t<\/tr>\n{% } %}<\/script> <\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_8_tab_4\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_8_layout_4_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<span\nclass=\"ipt_uif_divider_text_inner\">\nSubmit your Claim<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][23][m_type]\" id=\"ipt_fsqm_form_8_design_23_m_type\" value=\"design\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][23][type]\" id=\"ipt_fsqm_form_8_design_23_type\" value=\"richtext\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional\" id=\"ipt_fsqm_form_8_design_23\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_richtext\"><p>You\u2019re are almost done: Please complete the Declaration below and just click \u201cSubmit these claim details\u201d and we\u2019ll take it from there.<\/p><p\nclass=\"MsoNormal\" style=\"margin-bottom: 7.5pt; color: #222222; font-family: arial, sans-serif; font-size: small; text-align: justify; line-height: 13.5pt; vertical-align: baseline;\"><span\nstyle=\"font-size: 12pt;\">I hereby declare that to the best of my knowledge and belief that the information I have provided is correct and request you to deal on my behalf with any claims which may arise out of the accident in accordance with the terms and conditions of the Policy.<\/span><\/p><p\nclass=\"MsoNormal\" style=\"margin-bottom: 7.5pt; color: #222222; font-family: arial, sans-serif; font-size: small; text-align: justify; line-height: 13.5pt; vertical-align: baseline;\"><span\nstyle=\"font-size: 12pt;\">I authorize you and your attorneys-at-law on my behalf to make such admissions and settlements and give such consents as you consider necessary for the disposal of such claims and any litigation arising therefrom.<\/span><\/p><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][62][m_type]\" id=\"ipt_fsqm_form_8_pinfo_62_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][62][type]\" id=\"ipt_fsqm_form_8_pinfo_62_type\" value=\"s_checkbox\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_s_checkbox column-centered\" id=\"ipt_fsqm_form_8_pinfo_62\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_label_column column_1\">\n<input\ntype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in  ipt_uif_s_checkbox\"\nname=\"ipt_fsqm_form_8[pinfo][62][value]\" id=\"ipt_fsqm_form_8_pinfo_62_value_1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_62_value_1\" data-labelcon=\"&#xf022;\">\nI agree\t\t\t\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear\"><\/div><div\nid=\"ipt_fsqm_form_8_button_container\" class=\"ipt_fsqm_form_button_container ipt_fsqm_form_button_container--classic ipt-eform-material-button-container\"><div\nclass=\"eform-button-container-inner\">\n<button\ntype=\"button\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_prev medium primary-button\" name=\"ipt_fsqm_form_8_button_prev\" id=\"ipt_fsqm_form_8_button_prev\"> Previous<\/button>\n<button\ntype=\"submit\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_submit medium primary-button\" name=\"ipt_fsqm_form_8_button_submit\" id=\"ipt_fsqm_form_8_button_submit\"> Submit<\/button>\n<button\ntype=\"button\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_next medium primary-button\" name=\"ipt_fsqm_form_8_button_next\" id=\"ipt_fsqm_form_8_button_next\"> Next<\/button>\n<button\ntype=\"reset\" title=\"Reset\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_reset ipt_uif_tooltip medium primary-button\" name=\"ipt_fsqm_form_8_button_reset\" id=\"ipt_fsqm_form_8_button_reset\"> <i\nclass=\"ipticm ipt-icomoon-refresh\"><\/i><\/button><\/div><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"ipt_fsqm_main_pb eform-mainpb-bottom ipt_uif_progress_bar\" data-start=\"0\" data-decimals=\"2\" id=\"ipt_fsqm_form_8_progressbar\"><div\nclass=\"ipt_uif_progress_value\"><span\nclass=\"eform-progress-value-span\"><\/span><\/div><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/form><\/div><div\nstyle=\"display: none;\" class=\"ipt_fsqm_form_message_success ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><h3><i\ntitle=\"\" class=\" ipt-icomoon-checkmark-circle ipticm prefix\"><\/i>\nYour claim has been submitted<\/h3><\/div><div\nclass=\"ui-widget-content ui-corner-all ipt_fsqm_success_wrap\"><p>Thank you for submitting your claim. This is to acknowledge receipt and advise you that we will contact you before the end of the next business day.<\/p><\/div><\/div><div\nstyle=\"display: none;\" class=\"ipt_fsqm_form_message_error ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><div><i\ntitle=\"\" class=\" ipt-icomoon-laptop ipticm prefix\"><\/i>\nServer Side Error<\/div><\/div><div\nclass=\"ui-widget-content ui-corner-all\"><p>We faced problems while connecting to the server or receiving data from the server. Please wait for a few seconds and try again.<\/p><p>If the problem persists, then check your internet connectivity. If all other sites open fine, then please contact the administrator of this website with the following information.<\/p><p\nclass=\"jqXHR\">\n<strong>TextStatus: <\/strong><span\nclass=\"textStatus\">undefined<\/span><br\n\/>\n<strong>HTTP Error: <\/strong><span\nclass=\"errorThrown\">undefined<\/span><\/p><\/div><\/div><div\nstyle=\"display: none\" class=\"ipt_uif_widget_box ipt_fsqm_form_message_process\"><div\nclass=\"ui-widget ui-widget-header ui-corner-all\"><style type=\"text\/css\">.ipt_uif_ajax_loader,\n\t\t\t.ipt_uif_ajax_loader *,\n\t\t\tipt_uif_ajax_loader *::before,\n\t\t\tipt_uif_ajax_loader *::after {\n\t\t\t\tbox-sizing: border-box;\n\t\t\t}<\/style><div\nclass=\"ipt-eform-preloader-inline ipt_uif_ajax_loader\"><div\nclass=\"ipt-eform-preloader-inner\"><div\nclass=\"ipt-eform-preloader-circle\"><div\nclass=\"preloader-wrapper active\"><div\nclass=\"spinner-layer spinner-blue\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-red\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-yellow\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-green\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><\/div><\/div><div\nclass=\"ipt-eform-preloader-text\"><div\nclass=\"ipt-eform-preloader-text-inner ipt_uif_ajax_loader_text\">Processing you request<\/div><\/div><div\nclass=\"clear\"><\/div><\/div><\/div><\/div><\/div><div\nstyle=\"display: none;\" class=\"ipt_fsqm_form_validation_error ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><div><i\ntitle=\"\" class=\" ipt-icomoon-warning2 ipticm prefix\"><\/i>\n<span\nclass=\"fsqm_ve_text\">Error<\/span><\/div><\/div><div\nclass=\"ui-widget-content ui-corner-all\"><p\nclass=\"fsqm_ve_msg\">Some error has occured.<\/p><\/div><\/div><\/div><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t<\/p>                        <\/div>\n                    <\/div>\n                                    <div class=\"tab-pane elementkit-tab-pane elementor-repeater-item-009ac7c \" id=\"content-009ac7c6a9c0ed52d4d9\" role=\"tabpanel\"\n                         aria-labelledby=\"content-009ac7c6a9c0ed52d4d9-tab\">\n                        <div class=\"animated fadeIn\">\n                            <p>\t\t<div data-elementor-type=\"section\" data-elementor-id=\"3146\" class=\"elementor elementor-3146\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\" data-elementor-post-type=\"elementor_library\">\n\t\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-a1ee19b premium-equal-height-yes elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"2938\" data-pa-eq-height=\"{&quot;targetType&quot;:&quot;widget&quot;,&quot;target&quot;:&quot;&quot;,&quot;trigger&quot;:&quot;load&quot;,&quot;enableOn&quot;:[&quot;desktop&quot;,&quot;tablet&quot;,&quot;mobile&quot;]}\" data-id=\"a1ee19b\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;premium_eq_height_switcher&quot;:&quot;yes&quot;,&quot;_ha_eqh_enable&quot;:&quot;yes&quot;,&quot;_ha_eqh_to&quot;:&quot;widget&quot;,&quot;_ha_eqh_disable_on_tablet&quot;:&quot;no&quot;,&quot;_ha_eqh_disable_on_mobile&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-narrow\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-4fe2dfa\" data-eae-slider=\"83378\" data-id=\"4fe2dfa\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-8586a9f\" data-eae-slider=\"54772\" data-id=\"8586a9f\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-1faeaf7 ekit-equal-height-disable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"1faeaf7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/windscreen\/about-you\" target=\"_blank\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img loading=\"lazy\" decoding=\"async\" width=\"1024\" height=\"683\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/07\/fmf-D1l9o8a-1024x683-1.jpeg\" class=\"attachment-full size-full wp-image-3153\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Glass Only\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/windscreen\/about-you\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-1d458d1\" data-eae-slider=\"71786\" data-id=\"1d458d1\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t<\/p>                        <\/div>\n                    <\/div>\n                                \n            <\/div>\n                    <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-c5e4435 elementor-hidden-desktop elementor-hidden-tablet elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"67166\" data-id=\"c5e4435\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-a3c4dce\" data-eae-slider=\"15678\" data-id=\"a3c4dce\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-9b41312 elementor-widget elementor-widget-menu-anchor\" data-id=\"9b41312\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"menu-anchor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-menu-anchor\" id=\"Report1\"><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-0d2308d elementor-widget elementor-widget-toggle\" data-id=\"0d2308d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"toggle.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-toggle\">\n\t\t\t\t\t\t\t<div class=\"elementor-toggle-item\">\n\t\t\t\t\t<div id=\"elementor-tab-title-1371\" class=\"elementor-tab-title\" data-tab=\"1\" role=\"button\" aria-controls=\"elementor-tab-content-1371\" aria-expanded=\"false\">\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon elementor-toggle-icon-left\" aria-hidden=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon-closed\"><i class=\"fas fa-caret-right\"><\/i><\/span>\n\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon-opened\"><i class=\"elementor-toggle-icon-opened fas fa-caret-up\"><\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<a class=\"elementor-toggle-title\" tabindex=\"0\">Motor Claim<\/a>\n\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<div id=\"elementor-tab-content-1371\" class=\"elementor-tab-content elementor-clearfix\" data-tab=\"1\" role=\"region\" aria-labelledby=\"elementor-tab-title-1371\"><p>\t\t<div data-elementor-type=\"section\" data-elementor-id=\"1944\" class=\"elementor elementor-1944\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\" data-elementor-post-type=\"elementor_library\">\n\t\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-a1ee19b premium-equal-height-yes elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"43103\" data-pa-eq-height=\"{&quot;targetType&quot;:&quot;widget&quot;,&quot;target&quot;:&quot;&quot;,&quot;trigger&quot;:&quot;load&quot;,&quot;enableOn&quot;:[&quot;desktop&quot;,&quot;tablet&quot;,&quot;mobile&quot;]}\" data-id=\"a1ee19b\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;premium_eq_height_switcher&quot;:&quot;yes&quot;,&quot;_ha_eqh_enable&quot;:&quot;yes&quot;,&quot;_ha_eqh_to&quot;:&quot;widget&quot;,&quot;_ha_eqh_disable_on_tablet&quot;:&quot;no&quot;,&quot;_ha_eqh_disable_on_mobile&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-narrow\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-4fe2dfa\" data-eae-slider=\"16149\" data-id=\"4fe2dfa\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-5d40cd6 ekit-equal-height-enable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"5d40cd6\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/collision-other-vehicle\/about-you\" target=\"_blank\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img decoding=\"async\" width=\"700\" height=\"467\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/05\/5-min-1.png\" class=\"attachment-full size-full wp-image-2751\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Collision Other Vehicle\/s Involved\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/collision-other-vehicle\/about-you\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-8586a9f\" data-eae-slider=\"66553\" data-id=\"8586a9f\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-1faeaf7 ekit-equal-height-disable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"1faeaf7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/collision-no-other-vehicle\/about-you\" target=\"_blank\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img decoding=\"async\" width=\"700\" height=\"467\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/05\/1-min-1.png\" class=\"attachment-full size-full wp-image-2747\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Collision No Other Vehicle\/s Involved\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/collision-no-other-vehicle\/about-you\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-1d458d1\" data-eae-slider=\"97962\" data-id=\"1d458d1\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-995a73a ekit-equal-height-disable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"995a73a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/theft\/about-you\" target=\"_blank\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"467\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/05\/3-min.png\" class=\"attachment-full size-full wp-image-2749\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Theft\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/theft\/about-you\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-5009051 premium-equal-height-yes elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"2814\" data-pa-eq-height=\"{&quot;targetType&quot;:&quot;widget&quot;,&quot;target&quot;:&quot;&quot;,&quot;trigger&quot;:&quot;load&quot;,&quot;enableOn&quot;:[&quot;desktop&quot;,&quot;tablet&quot;,&quot;mobile&quot;]}\" data-id=\"5009051\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;premium_eq_height_switcher&quot;:&quot;yes&quot;,&quot;_ha_eqh_enable&quot;:&quot;yes&quot;,&quot;_ha_eqh_to&quot;:&quot;widget&quot;,&quot;_ha_eqh_disable_on_tablet&quot;:&quot;no&quot;,&quot;_ha_eqh_disable_on_mobile&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-narrow\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-09175fc\" data-eae-slider=\"53799\" data-id=\"09175fc\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-9a277ac ekit-equal-height-disable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"9a277ac\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/fire\/about-you\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"467\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/05\/2-min.png\" class=\"attachment-full size-full wp-image-2748\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Fire\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/fire\/about-you\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-1a7e112\" data-eae-slider=\"89261\" data-id=\"1a7e112\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-f7baec8 ekit-equal-height-disable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"f7baec8\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=Motor&#038;type=Flood-Hurricane-Storm-etc.&#038;region=ja\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"467\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/05\/6-min.png\" class=\"attachment-full size-full wp-image-2753\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Flood, Hurricane, Storm etc.\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=Motor&#038;type=Flood-Hurricane-Storm-etc.&#038;region=ja\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-4271858\" data-eae-slider=\"74245\" data-id=\"4271858\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-6ad0276 ekit-equal-height-disable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"6ad0276\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=Motor&#038;type=Lightning&#038;region=ja\" target=\"_blank\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img loading=\"lazy\" decoding=\"async\" width=\"700\" height=\"467\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/05\/4-min-1.png\" class=\"attachment-full size-full wp-image-2750\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Lightning\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=Motor&#038;type=Lightning&#038;region=ja\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-aa14e8a premium-equal-height-yes elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"17070\" data-pa-eq-height=\"{&quot;targetType&quot;:&quot;widget&quot;,&quot;target&quot;:&quot;&quot;,&quot;trigger&quot;:&quot;load&quot;,&quot;enableOn&quot;:[&quot;desktop&quot;,&quot;tablet&quot;,&quot;mobile&quot;]}\" data-id=\"aa14e8a\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;premium_eq_height_switcher&quot;:&quot;yes&quot;,&quot;_ha_eqh_enable&quot;:&quot;yes&quot;,&quot;_ha_eqh_to&quot;:&quot;widget&quot;,&quot;_ha_eqh_disable_on_tablet&quot;:&quot;no&quot;,&quot;_ha_eqh_disable_on_mobile&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-narrow\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-f839d0c\" data-eae-slider=\"73211\" data-id=\"f839d0c\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-toggle-item\">\n\t\t\t\t\t<div id=\"elementor-tab-title-1372\" class=\"elementor-tab-title\" data-tab=\"2\" role=\"button\" aria-controls=\"elementor-tab-content-1372\" aria-expanded=\"false\">\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon elementor-toggle-icon-left\" aria-hidden=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon-closed\"><i class=\"fas fa-caret-right\"><\/i><\/span>\n\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon-opened\"><i class=\"elementor-toggle-icon-opened fas fa-caret-up\"><\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<a class=\"elementor-toggle-title\" tabindex=\"0\">Home and Contents<\/a>\n\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<div id=\"elementor-tab-content-1372\" class=\"elementor-tab-content elementor-clearfix\" data-tab=\"2\" role=\"region\" aria-labelledby=\"elementor-tab-title-1372\"><p>\t\t<div data-elementor-type=\"section\" data-elementor-id=\"3443\" class=\"elementor elementor-3443\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\" data-elementor-post-type=\"elementor_library\">\n\t\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-aa14e8a premium-equal-height-yes elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"57882\" data-pa-eq-height=\"{&quot;targetType&quot;:&quot;widget&quot;,&quot;target&quot;:&quot;&quot;,&quot;trigger&quot;:&quot;load&quot;,&quot;enableOn&quot;:[&quot;desktop&quot;,&quot;tablet&quot;,&quot;mobile&quot;]}\" data-id=\"aa14e8a\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;premium_eq_height_switcher&quot;:&quot;yes&quot;,&quot;_ha_eqh_enable&quot;:&quot;yes&quot;,&quot;_ha_eqh_to&quot;:&quot;widget&quot;,&quot;_ha_eqh_disable_on_tablet&quot;:&quot;no&quot;,&quot;_ha_eqh_disable_on_mobile&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-narrow\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-f839d0c\" data-eae-slider=\"92848\" data-id=\"f839d0c\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-3c236ea elementor-widget elementor-widget-text-editor\" data-id=\"3c236ea\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><style type=\"text\/css\">#ipt_fsqm_form_wrap_7 .ipt_fsqm_form_logo img,\n\t#ipt_fsqm_form_wrap_7 .ipt-eform-width-restrain,\n\t#ipt_fsqm_form_wrap_7 .ipt_fsqm_form_message_restore,\n\t#ipt_fsqm_form_wrap_7 .ipt_fsqm_form_message_success,\n\t#ipt_fsqm_form_wrap_7 .ipt_fsqm_form_message_error,\n\t#ipt_fsqm_form_wrap_7 .ipt_fsqm_form_message_process,\n\t#ipt_fsqm_form_wrap_7 .ipt_fsqm_form_validation_error,\n\t#ipt_fsqm_form_wrap_7 .eform-ui-estimator {\n\t\tmax-width: 100%;\n\t\tmin-width: 240px;\n\t}\n\n\t\t\t#ipt_fsqm_form_wrap_7 .ipt-eform-content {\n\t\t\tbackground-image: none;\n\t\t\tbackground-position: 0% 0%;\n\t\t\tbackground-size: auto;\n\t\t\tbackground-repeat: repeat;\n\t\t\tbackground-origin: padding-box;\n\t\t\tbackground-clip: border-box;\n\t\t\tbackground-attachment: scroll;\n\t\t}\n\t\/**\/<\/style><div\nid=\"ipt_fsqm_form_wrap_7\"\nclass=\"ipt_uif_front ipt_uif_common ipt_fsqm_form type_2 ui-front eform-ltr eform-override-element-material eform-override-alignment-vertical\"\ndata-fsqmsayt=\"{&quot;auto_save&quot;:true,&quot;show_restore&quot;:true,&quot;restore&quot;:true,&quot;admin_override&quot;:false,&quot;user_update&quot;:false,&quot;interval_save&quot;:false,&quot;interval&quot;:&quot;30&quot;}\"\ndata-ui-type=\"2\"\ndata-ui-theme=\"[&quot;https:\\\/\\\/bciconline.com\\\/ba\\\/wp-content\\\/plugins\\\/wp-fsqm-pro\\\/static\\\/front\\\/css\\\/material-themes\\\/light-themes\\\/red.css?ver=4.19.1&quot;]\"\ndata-ui-theme-id=\"material-red\"\ndata-eformanim=\"1\"\ndata-fsqmga=\"{&quot;enabled&quot;:false,&quot;manual_load&quot;:false,&quot;tracking_id&quot;:&quot;&quot;,&quot;cookie&quot;:&quot;auto&quot;,&quot;user_update&quot;:false,&quot;name&quot;:&quot;Home and Contents&quot;,&quot;form_id&quot;:&quot;7&quot;}\"\ndata-fsqmreset=\"{&quot;reset&quot;:false,&quot;delay&quot;:10}\"\ndata-eformreg=\"{&quot;enabled&quot;:false,&quot;username_id&quot;:&quot;ipt_fsqm_form_7_pinfo_&quot;,&quot;password_id&quot;:&quot;ipt_fsqm_form_7_pinfo_&quot;,&quot;hide_pinfo&quot;:false,&quot;hide_meta&quot;:false,&quot;meta&quot;:[]}\"\ndata-eformscroll=\"{&quot;progress&quot;:true,&quot;message&quot;:true,&quot;offset&quot;:&quot;0&quot;,&quot;scrollOnError&quot;:true}\"\ndata-eform-cookie=\"0\"\ndata-subscription-form=\"false\"\ndata-instant-subscription=\"{&quot;doable&quot;:true,&quot;config&quot;:{&quot;enabled&quot;:false,&quot;min_tab&quot;:&quot;&quot;,&quot;debounce&quot;:&quot;3000&quot;},&quot;nonce&quot;:&quot;8284381fb6&quot;}\"\n><style type=\"text\/css\">\/**\/<\/style><noscript><div\nclass=\"ipt_fsqm_form_message_noscript ui-widget ui-widget-content ui-corner-all\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><div>Javascript is disabled<\/div><\/div><div\nclass=\"ui-widget-content ui-corner-bottom\"><p>Javascript is disabled on your browser. Please enable it in order to use this form.<\/p><\/div><\/div>\n<\/noscript><style type=\"text\/css\">.ipt_uif_ajax_loader,\n\t\t\t.ipt_uif_ajax_loader *,\n\t\t\tipt_uif_ajax_loader *::before,\n\t\t\tipt_uif_ajax_loader *::after {\n\t\t\t\tbox-sizing: border-box;\n\t\t\t}<\/style><div\nclass=\"ipt_uif_init_loader ipt-eform-preloader-inline ipt_uif_ajax_loader\"><div\nclass=\"ipt-eform-preloader-inner\"><div\nclass=\"ipt-eform-preloader-circle\"><div\nclass=\"preloader-wrapper active\"><div\nclass=\"spinner-layer spinner-blue\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-red\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-yellow\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-green\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><\/div><\/div><div\nclass=\"ipt-eform-preloader-text\"><div\nclass=\"ipt-eform-preloader-text-inner ipt_uif_ajax_loader_text\">Loading<\/div><\/div><div\nclass=\"clear\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude class=\"ipt_uif_conditional_logic\" id=\"ipt_uif_conditional_logic_7\" value=\"{&quot;logics&quot;:{&quot;ipt_fsqm_form_7_pinfo_62&quot;:{&quot;active&quot;:true,&quot;status&quot;:true,&quot;change&quot;:true,&quot;logic&quot;:{},&quot;type&quot;:&quot;s_checkbox&quot;,&quot;m_type&quot;:&quot;pinfo&quot;}},&quot;indexes&quot;:[],&quot;base&quot;:&quot;7&quot;}\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude class=\"ipt_fsqm_timer_data\" id=\"ipt_fsqm_timer_data_7\" value=\"{&quot;type&quot;:&quot;none&quot;}\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude class=\"ipt_fsqm_epoc_data\" id=\"ipt_fsqm_epoc_data_7\" value=\"{&quot;CURRENTYEAR&quot;:2026,&quot;CURRENTDATE&quot;:1788594309000,&quot;CURRENTDAY&quot;:5,&quot;CURRENTMONTH&quot;:9,&quot;CURRENTHOUR&quot;:7,&quot;CURRENTMINUTE&quot;:45,&quot;CURRENTSECOND&quot;:9,&quot;CURRENTWEEK&quot;:36,&quot;CURRENTEPOC&quot;:20701}\" \/><div\nstyle=\"display: none;\" class=\"ipt_uif_hidden_init\"><div\nstyle=\"display: none;\" class=\"ipt_fsqm_form_message_restore ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><h3><a\nhref=\"#\" title=\"Hide\" class=\"ipt_fsqm_form_message_close\"><i\ntitle=\"\" class=\" ipt-icomoon-times ipticm prefix\"><\/i>\n<\/a><i\ntitle=\"\" class=\" ipt-icomoon-checkmark-circle ipticm prefix\"><\/i>\nForm successfully restored<\/h3><\/div><div\nclass=\"ui-widget-content ui-corner-all\"><p>The form has been restored from your last edit. If wish to start over, please click the button<\/p>\n<button\nstyle=\"margin-bottom: 0\" class=\"ipt_uif_button ipt_fsqm_sayt_reset secondary-button\">Start Over<\/button><\/div><\/div><form\nmethod=\"post\" action=\"\" class=\"ipt_uif_validate_form ipt_fsqm_main_form\" id=\"ipt_fsqm_form_7\" autocomplete=\"on\">\n<input\ntype=\"hidden\" data-sayt-exclude name=\"action\" id=\"action\" value=\"ipt_fsqm_save_form\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_epoc\" class=\"eform-epoc-value\" value=\"1788594309\" \/>\n<input\ntype=\"hidden\" class=\"ipt_fsqm_form_tab_pos\" name=\"fsqm_form7_tab_pos\" value=\"0\" id=\"fsqm_form7_tab_pos\" \/>\n<input\ntype=\"hidden\" id=\"ipt_fsqm_form_data_save\" name=\"ipt_fsqm_form_data_save\" value=\"83688bd1e8\" data-sayt-exclude \/>\t\t\t<input\ntype=\"hidden\" name=\"_wp_http_referer\" value=\"\/ba\/report-claim\/\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"form_id\" value=\"7\" \/><div\nclass=\"ipt-eform-width-restrain\"><div\nclass=\"ipt-eform-content \"><div\ndata-settings=\"{&quot;can_previous&quot;:true,&quot;show_progress_bar&quot;:true,&quot;progress_bar_bottom&quot;:true,&quot;block_previous&quot;:false,&quot;any_tab&quot;:false,&quot;type&quot;:&quot;2&quot;,&quot;scroll&quot;:true,&quot;decimal_point&quot;:2,&quot;auto_progress&quot;:false,&quot;auto_progress_delay&quot;:&quot;1500&quot;,&quot;auto_submit&quot;:false,&quot;hidden_buttons&quot;:false,&quot;scroll_on_error&quot;:true}\" class=\"ipt_fsqm_main_tab ipt_uif_tabs horizontal\"><div\nclass=\"ipt-eform-tab-nav-wrap\"><ul><li\nid=\"ipt_fsqm_form_7_tab_0_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_7_tab_0\"><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe269;\"><\/i>\n<span\nclass=\"eform-tab-labels\">Tell us what happened <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_7_tab_1_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_7_tab_1\"><span\nclass=\"eform-tab-labels\">About you <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_7_tab_2_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_7_tab_2\"><span\nclass=\"eform-tab-labels\">Damage <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_7_tab_3_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_7_tab_3\"><span\nclass=\"eform-tab-labels\">Other Details <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_7_tab_4_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_7_tab_4\"><span\nclass=\"eform-tab-labels\">Submit your Claim <\/span><\/a><\/li><\/ul>\n<i\nclass=\"eform-tab-nav eform-tab-nav-right ipt-icomoon-angle-right disabled eform-ripple\"><\/i>\n<i\nclass=\"eform-tab-nav eform-tab-nav-left ipt-icomoon-angle-left disabled eform-ripple\"><\/i>\n<span\nclass=\"eform-tab-passive-notifier\"><\/span>\n<span\nclass=\"eform-tab-active-notifier\"><\/span><\/div><div\nid=\"ipt_fsqm_form_7_tab_0\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_7_layout_0_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe269;\"><\/i>\n<span\nclass=\"ipt_uif_divider_text_inner\">\nTell us what happened<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][80][m_type]\" id=\"ipt_fsqm_form_7_pinfo_80_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][80][type]\" id=\"ipt_fsqm_form_7_pinfo_80_type\" value=\"p_select\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_select\" id=\"ipt_fsqm_form_7_pinfo_80\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_80\">What type of incident was it?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\">\n<select\nclass=\" check_me validate[required] ipt_uif_select ipt_uif_select_no_search\" name=\"ipt_fsqm_form_7[pinfo][80][options][]\" id=\"ipt_fsqm_form_7_pinfo_80_options_\"  data-theme=\"eform-material\"><option\nvalue=\"0\" data-num=\"\">Fire<\/option><option\nvalue=\"1\" data-num=\"\">Theft<\/option><option\nvalue=\"2\" data-num=\"\">Flood<\/option><option\nvalue=\"3\" data-num=\"\">Storm<\/option><option\nvalue=\"4\" data-num=\"\">Hurricane<\/option><option\nvalue=\"5\" data-num=\"\">Subsidence<\/option><option\nvalue=\"6\" data-num=\"\">Burglary<\/option><option\nvalue=\"7\" data-num=\"\">Escape of Water<\/option><option\nvalue=\"8\" data-num=\"\">Accidental Damage<\/option><option\nvalue=\"9\" data-num=\"\">Other<\/option>\n<\/select><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][0][m_type]\" id=\"ipt_fsqm_form_7_pinfo_0_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][0][type]\" id=\"ipt_fsqm_form_7_pinfo_0_type\" value=\"datetime\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_datetime\" id=\"ipt_fsqm_form_7_pinfo_0\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_0_value\">When Did It Happen?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field eform-dp-input-field has-icon\">\n<input\nclass=\"datepicker ipt_uif_datepicker  check_me validate[required] is-empty ipt_uif_text\"\ndata-dateFormat=\"dd-mm-yy\" data-timeFormat=\"hh:mm:ss TT\" data-year_range=\"50\"\t\ttype=\"text\"\nreadonly=\"readonly\"\nname=\"ipt_fsqm_form_7[pinfo][0][value]\"\nid=\"ipt_fsqm_form_7_pinfo_0_value\"\nmaxlength=\"524288\"\nvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipt-icomoon-calendar ipticm prefix\"><\/i>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_0_value\">Select Date<\/label>\n<a\nhref=\"javascript:;\" class=\"eform-dp-clear\" title=\"Clear\">&times;<\/a><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][4][m_type]\" id=\"ipt_fsqm_form_7_pinfo_4_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][4][type]\" id=\"ipt_fsqm_form_7_pinfo_4_type\" value=\"datetime\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_datetime\" id=\"ipt_fsqm_form_7_pinfo_4\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_4_value\">What time did it happen?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field eform-dp-input-field has-icon\">\n<input\nclass=\"datepicker ipt_uif_timepicker  check_me validate[required] is-empty ipt_uif_text\"\ndata-dateFormat=\"yy-mm-dd\" data-timeFormat=\"hh:mm:ss TT\" data-year_range=\"50\"\t\ttype=\"text\"\nreadonly=\"readonly\"\nname=\"ipt_fsqm_form_7[pinfo][4][value]\"\nid=\"ipt_fsqm_form_7_pinfo_4_value\"\nmaxlength=\"524288\"\nvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipt-icomoon-clock ipticm prefix\"><\/i>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_4_value\">Select Time<\/label>\n<a\nhref=\"javascript:;\" class=\"eform-dp-clear\" title=\"Clear\">&times;<\/a><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][1][m_type]\" id=\"ipt_fsqm_form_7_pinfo_1_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][1][type]\" id=\"ipt_fsqm_form_7_pinfo_1_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_7_pinfo_1\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_1_value\">Where did it Happen?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_7[pinfo][1][value]\"\nid=\"ipt_fsqm_form_7_pinfo_1_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe07d;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_1_value\">Enter precise location<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][6][m_type]\" id=\"ipt_fsqm_form_7_pinfo_6_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][6][type]\" id=\"ipt_fsqm_form_7_pinfo_6_type\" value=\"textarea\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textarea\" id=\"ipt_fsqm_form_7_pinfo_6\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_6_value\">Please describe in detail what happened (max 1400 characters)<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me validate[required,minSize[10],maxSize[1403]]\"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_7[pinfo][6][value]\"\n\t\tmaxlength=\"1403\"\t\tid=\"ipt_fsqm_form_7_pinfo_6_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe056;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_6_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_7_tab_1\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_7_layout_1_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<span\nclass=\"ipt_uif_divider_text_inner\">\nAbout you<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][7][m_type]\" id=\"ipt_fsqm_form_7_pinfo_7_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][7][type]\" id=\"ipt_fsqm_form_7_pinfo_7_type\" value=\"p_radio\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_radio\" id=\"ipt_fsqm_form_7_pinfo_7\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_7\">Are you a policyholder?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_7[pinfo][7][options][]\"\nid=\"ipt_fsqm_form_7_pinfo_7_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_7_pinfo_7_options__0\" data-labelcon=\"&#xe18e;\">\nYes\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_7[pinfo][7][options][]\"\nid=\"ipt_fsqm_form_7_pinfo_7_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_7_pinfo_7_options__1\" data-labelcon=\"&#xe18e;\">\nNo\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][8][m_type]\" id=\"ipt_fsqm_form_7_pinfo_8_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][8][type]\" id=\"ipt_fsqm_form_7_pinfo_8_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_7_pinfo_8\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_8_value\">Policy Number<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_7[pinfo][8][value]\"\nid=\"ipt_fsqm_form_7_pinfo_8_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe056;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_8_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][9][m_type]\" id=\"ipt_fsqm_form_7_pinfo_9_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][9][type]\" id=\"ipt_fsqm_form_7_pinfo_9_type\" value=\"f_name\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_f_name\" id=\"ipt_fsqm_form_7_pinfo_9\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_9_value\">Policy Holder First Name<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[custom[personName]] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_7[pinfo][9][value]\"\nid=\"ipt_fsqm_form_7_pinfo_9_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xf007;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_9_value\">First Name<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][10][m_type]\" id=\"ipt_fsqm_form_7_pinfo_10_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][10][type]\" id=\"ipt_fsqm_form_7_pinfo_10_type\" value=\"l_name\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_l_name\" id=\"ipt_fsqm_form_7_pinfo_10\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_10_value\">Policy Holder Last Name<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[custom[personName]] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_7[pinfo][10][value]\"\nid=\"ipt_fsqm_form_7_pinfo_10_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xf007;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_10_value\">Last Name<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][12][m_type]\" id=\"ipt_fsqm_form_7_pinfo_12_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][12][type]\" id=\"ipt_fsqm_form_7_pinfo_12_type\" value=\"phone\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_phone\" id=\"ipt_fsqm_form_7_pinfo_12\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_12_value\">Preferred Telephone Number<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[custom[phone]] ipt_uif_text\"\ntype=\"tel\"\nname=\"ipt_fsqm_form_7[pinfo][12][value]\"\nid=\"ipt_fsqm_form_7_pinfo_12_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe08c;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_12_value\">Phone<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][11][m_type]\" id=\"ipt_fsqm_form_7_pinfo_11_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][11][type]\" id=\"ipt_fsqm_form_7_pinfo_11_type\" value=\"email\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_email\" id=\"ipt_fsqm_form_7_pinfo_11\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_11_value\">Preferred Email Address<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[custom[email]] ipt_uif_text\"\ntype=\"email\"\nname=\"ipt_fsqm_form_7[pinfo][11][value]\"\nid=\"ipt_fsqm_form_7_pinfo_11_value\"\nvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xf0e0;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_11_value\">Email Address<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][13][m_type]\" id=\"ipt_fsqm_form_7_pinfo_13_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][13][type]\" id=\"ipt_fsqm_form_7_pinfo_13_type\" value=\"p_radio\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_radio\" id=\"ipt_fsqm_form_7_pinfo_13\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_13\">Contact Preference<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_7[pinfo][13][options][]\"\nid=\"ipt_fsqm_form_7_pinfo_13_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_7_pinfo_13_options__0\" data-labelcon=\"&#xe18e;\">\nEmail\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_7[pinfo][13][options][]\"\nid=\"ipt_fsqm_form_7_pinfo_13_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_7_pinfo_13_options__1\" data-labelcon=\"&#xe18e;\">\nPhone\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_7_tab_2\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_7_layout_2_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<span\nclass=\"ipt_uif_divider_text_inner\">\nDamage<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][18][m_type]\" id=\"ipt_fsqm_form_7_pinfo_18_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][18][type]\" id=\"ipt_fsqm_form_7_pinfo_18_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_7_pinfo_18\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_18_value\">How much do you think the lost or damaged items cost?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_7[pinfo][18][value]\"\nid=\"ipt_fsqm_form_7_pinfo_18_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_18_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][19][m_type]\" id=\"ipt_fsqm_form_7_pinfo_19_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][19][type]\" id=\"ipt_fsqm_form_7_pinfo_19_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_7_pinfo_19\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_19_value\">If you called the police, please give us the report reference number<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_7[pinfo][19][value]\"\nid=\"ipt_fsqm_form_7_pinfo_19_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_19_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][20][m_type]\" id=\"ipt_fsqm_form_7_pinfo_20_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][20][type]\" id=\"ipt_fsqm_form_7_pinfo_20_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_7_pinfo_20\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_7_pinfo_20_value\">Please provide a descirption of the items lost or damaged<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_7[pinfo][20][value]\"\nid=\"ipt_fsqm_form_7_pinfo_20_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_7_pinfo_20_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_7_tab_3\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_7_layout_3_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<span\nclass=\"ipt_uif_divider_text_inner\">\nOther Details<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[freetype][0][m_type]\" id=\"ipt_fsqm_form_7_freetype_0_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[freetype][0][type]\" id=\"ipt_fsqm_form_7_freetype_0_type\" value=\"upload\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_upload\" id=\"ipt_fsqm_form_7_freetype_0\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_container ipt_uif_iconbox\" data-opened=\"1\"><div\nclass=\"ipt_uif_container_head\"><h3>\t\t\t\t\t\t<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe002;\"><\/i>\n<span\nclass=\"ipt_uif_container_label\">Please attach photographs, estimates or relevant documents in support of your claim<\/span><\/h3><\/div><div\nclass=\"ipt_uif_container_inner\"><div\nclass=\"ipt_uif_uploader\" id=\"ipt_fsqm_file_upload_7_0__uploader_wrap\" data-settings=\"{&quot;accept_file_types&quot;:&quot;gif,jpeg,png,jpg,pdf,doc,docx&quot;,&quot;max_number_of_files&quot;:&quot;&quot;,&quot;min_number_of_files&quot;:&quot;&quot;,&quot;max_file_size&quot;:134217728,&quot;min_file_size&quot;:&quot;1&quot;,&quot;show_drop_zone&quot;:true,&quot;wp_media_integration&quot;:false,&quot;auto_upload&quot;:true,&quot;single_upload&quot;:false,&quot;drag_n_drop&quot;:true,&quot;progress_bar&quot;:true,&quot;preview_media&quot;:true,&quot;can_delete&quot;:true,&quot;required&quot;:false,&quot;minimal_ui&quot;:false,&quot;accept&quot;:&quot;all&quot;,&quot;capture&quot;:&quot;none&quot;,&quot;icon&quot;:&quot;57346&quot;,&quot;centered&quot;:false,&quot;dragdrop&quot;:&quot;Drag &#039;n Drop files here&quot;,&quot;upload_label&quot;:&quot;Select Files&quot;,&quot;recaptcha&quot;:false,&quot;site_key&quot;:&quot;&quot;,&quot;theme&quot;:&quot;light&quot;,&quot;type&quot;:&quot;image&quot;,&quot;size&quot;:&quot;normal&quot;,&quot;hl&quot;:&quot;en&quot;}\" data-configuration=\"{&quot;id&quot;:&quot;ipt_fsqm_file_upload_7_0_&quot;,&quot;upload_url&quot;:&quot;?action=ipt_fsqm_fu_upload&quot;,&quot;download_url&quot;:&quot;?action=ipt_fsqm_fu_download&quot;,&quot;do_download&quot;:false,&quot;show_ui&quot;:true,&quot;captcha_url&quot;:&quot;?action=ipt_fsqm_fu_captcha&quot;}\" data-formData=\"{&quot;data_id&quot;:null,&quot;form_id&quot;:&quot;7&quot;,&quot;nonce&quot;:&quot;6cbb6438b3&quot;,&quot;element_key&quot;:&quot;0&quot;,&quot;files_key&quot;:&quot;ipt_fsqm_file_upload_7_0&quot;}\"><div\nclass=\"fileinput-dragdrop ui-state-active\">\n<span>Drag &#8216;n Drop files here<\/span><\/div><div\nclass=\"fileupload-meta\"><p>Max file size: 128.00 MB. | Allowed file types: gif,jpeg,png,jpg,pdf,doc,docx<\/p><\/div><div\nclass=\"ipt_fsqm_fileuploader_list_wrap\"><table\nrole=\"presentation\" class=\"ipt_fsqm_fileuploader_list\"><thead><tr><td\ncolspan=\"4\"><div\nclass=\"fileupload-buttonbar\"><div\nclass=\"fileupload-buttons\">\n<span\nrole=\"button\" class=\"fileinput-button secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n<span\nclass=\"ui-button-icon-primary ui-icon ui-icon-plusthick\"><\/span>\n<span\nclass=\"ui-button-text\">\n<span\nclass=\"select secondary-button\">Select Files<\/span>\n<\/span>\n<input\nclass=\"ipt_uif_uploader_handle\" type=\"file\" multiple=\"multiple\" name=\"ipt_fsqm_file_upload_7_0[]\" id=\"ipt_fsqm_file_upload_7_0_\" \/>\n<\/span>\n<button\ntype=\"reset\" class=\"cancel secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n<span\nclass=\"ui-button-icon-primary ui-icon ui-icon-cancel\"><\/span>\n<span\nclass=\"ui-button-text\">\nCancel All Uploads\t\t\t\t\t\t\t\t\t\t<\/span>\n<\/button>\n<span\nclass=\"fileupload-process\"><\/span><\/div><div\nclass=\"fileupload-progress fade wp-eform-fileupload-globalprogress\" style=\"display: none;\"><div\nclass=\"progress ui-progressbar ui-widget ui-widget-content ui-corner-all\" role=\"progressbar\" aria-valuemin=\"0\" aria-valuemax=\"100\"><div\nclass=\"progress-bar ui-progressbar-value ui-widget-header ui-corner-left\" style=\"width: 0%;\"><\/div><\/div><div\nclass=\"progress-extended\">&nbsp;<\/div><\/div><\/div><\/td><td\nclass=\"delete_button\"><div\nclass=\"fileupload-buttonbar\"><div\nclass=\"fileupload-buttons\">\n<button\ntype=\"button\" class=\"delete secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n<span\nclass=\"ui-button-icon-primary ui-icon ui-icon-trash\"><\/span>\n<span\nclass=\"ui-button-text\">\nDelete Selected\t\t\t\t\t\t\t\t\t\t<\/span>\n<\/button><\/div><\/div><\/td><td\nclass=\"delete_toggle\"><div\nclass=\"fileupload-buttonbar\"><div\nclass=\"fileupload-buttons\"><div\nclass=\"ipt_uif_label_column\">\n<input\ntype=\"checkbox\" class=\"toggle ipt_uif_checkbox\" id=\"ipt_fsqm_file_upload_7_0__toggler\" \/>\n<label\ndata-labelcon=\"&#xe18e;\" for=\"ipt_fsqm_file_upload_7_0__toggler\"><\/label><\/div><\/div><\/div><\/td><\/tr><\/thead><tbody\nclass=\"files\"><\/tbody><\/table><\/div> <script class=\"template-upload\" id=\"ipt_fsqm_file_upload_7_0__tmpl_upload\" type=\"text\/x-tmpl\">{% for (var i=0, file; file=o.files[i]; i++) { %}\n\t<tr class=\"template-upload\">\n\t\t<td>\n\t\t\t<span class=\"preview\"><\/span>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p class=\"name\">{%=file.name%}<\/p>\n\t\t\t<strong class=\"error\"><\/strong>\n\t\t<\/td>\n\t\t<td class=\"fileupload_list_pb\">\n\t\t\t<p class=\"size\">Processing&hellip;<\/p>\n\t\t\t<div class=\"progress ui-progressbar ui-widget ui-widget-content ui-corner-all\" role=\"progressbar\" aria-valuemin=\"0\" aria-valuemax=\"100\">\n\t\t\t\t<div class=\"progress-bar ui-progressbar-value ui-widget-header ui-corner-left\" style=\"width: 0%;\"><\/div>\n\t\t\t<\/div>\n\t\t<\/td>\n\t\t<td colspan=\"3\">\n\t\t\t{% if (!i && !o.options.autoUpload) { %}\n\t\t\t\t<button class=\"start secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\" disabled>\n\t\t\t\t\t<span class=\"ui-button-icon-primary ui-icon ui-icon-circle-arrow-e\"><\/span>\n\t\t\t\t\t<span class=\"ui-button-text\">\n\t\t\t\t\t\tStart\t\t\t\t\t<\/span>\n\t\t\t\t<\/button>\n\t\t\t{% } %}\n\t\t\t{% if (!i) { %}\n\t\t\t\t<button class=\"cancel secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n\t\t\t\t\t<span class=\"ui-button-icon-primary ui-icon ui-icon-cancel\"><\/span>\n\t\t\t\t\t<span class=\"ui-button-text\">\n\t\t\t\t\t\tCancel\t\t\t\t\t<\/span>\n\t\t\t\t<\/button>\n\t\t\t{% } %}\n\t\t<\/td>\n\t<\/tr>\n{% } %}<\/script>  <script class=\"template-download\" id=\"ipt_fsqm_file_upload_7_0__tmpl_download\" type=\"text\/x-tmpl\">{%\n\twindow.ipt_fsqm_upload_count_global;\n\tif ( window.ipt_fsqm_upload_count_global == undefined ) {\n\t\twindow.ipt_fsqm_upload_count_global = 0;\n\t}\n%}\n{% for (var i=0, file; file=o.files[i]; i++) { %}\n{% var toggler_check_id = window.ipt_fsqm_upload_count_global++; %}\n\t<tr class=\"template-download\">\n\t\t<td class=\"preview_td\" colspan=\"2\">\n\t\t\t<span class=\"preview\">\n\t\t\t\t{% if (file.thumbnailUrl) { %}\n\t\t\t\t\t<a href=\"{%=file.url%}\" title=\"{%=file.name%}\" download=\"{%=file.name%}\" data-gallery><img decoding=\"async\" src=\"{%=file.thumbnailUrl%}\" \/><\/a>\n\t\t\t\t{% } else if ( file.validAudio ) { %}\n\t\t\t\t\t\t\t\t\t\t<audio controls=\"controls\">\n\t\t\t\t\t\t<source src=\"{%=file.url%}\" type=\"{%=file.type%}\" \/>\n\t\t\t\t\t\tYour browser does not support audio element.\t\t\t\t\t<\/audio>\n\t\t\t\t\t\t\t\t\t{% } else if ( file.validVideo ) { %}\n\t\t\t\t\t\t\t\t\t\t<video controls=\"controls\" height=\"100\" width=\"200\">\n\t\t\t\t\t\t<source src=\"{%=file.url%}\" type=\"{%=file.type%}\" \/>\n\t\t\t\t\t\tYour browser does not support video element.\t\t\t\t\t<\/video>\n\t\t\t\t\t\t\t\t\t{% } %}\n\t\t\t<\/span>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p class=\"name\">\n\t\t\t\t<a href=\"{%=file.url%}\" title=\"{%=file.name%}\" download=\"{%=file.name%}\" {%=file.thumbnailUrl?'data-gallery':''%}>{%=file.name%}<\/a>\n\t\t\t<\/p>\n\t\t\t{% if (file.error) { %}\n\t\t\t\t<div><span class=\"error\">Error<\/span> {%=file.error%}<\/div>\n\t\t\t{% } %}\n\t\t\t<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[freetype][0][id][]\" value=\"{%=file.id%}\" \/>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<span class=\"size\">{%=o.formatFileSize(file.size)%}<\/span>\n\t\t<\/td>\n\t\t\t\t<td class=\"delete_button\">\n\t\t\t<button class=\"delete secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\" data-type=\"{%=file.deleteType%}\" data-url=\"{%=file.deleteUrl%}\"{% if (file.deleteWithCredentials) { %} data-xhr-fields='{\"withCredentials\":true}'{% } %}>\n\t\t\t\t<span class=\"ui-button-icon-primary ui-icon ui-icon-trash\"><\/span>\n\t\t\t\t<span class=\"ui-button-text\">\n\t\t\t\t\tDelete\t\t\t\t<\/span>\n\t\t\t<\/button>\n\t\t<\/td>\n\t\t\t\t\t<td class=\"delete_toggle\">\n\t\t\t\t<div class=\"ipt_uif_label_column\">\n\t\t\t\t\t<input type=\"checkbox\" name=\"delete\" value=\"1\" class=\"toggle ipt_uif_checkbox\" id=\"ipt_fsqm_file_upload_7_0__toggler_files_{%=toggler_check_id%}\" \/>\n\t\t\t\t\t<label data-labelcon=\"&#xe18e;\" for=\"ipt_fsqm_file_upload_7_0__toggler_files_{%=toggler_check_id%}\"><\/label>\n\t\t\t\t<\/div>\n\t\t\t<\/td>\n\t\t\t\t\t<\/tr>\n{% } %}<\/script> <\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_7_tab_4\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_7_layout_4_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<span\nclass=\"ipt_uif_divider_text_inner\">\nSubmit your Claim<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[design][23][m_type]\" id=\"ipt_fsqm_form_7_design_23_m_type\" value=\"design\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[design][23][type]\" id=\"ipt_fsqm_form_7_design_23_type\" value=\"richtext\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional\" id=\"ipt_fsqm_form_7_design_23\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_richtext\"><p>You\u2019re are almost done: Please complete the Declaration below and just click \u201cSubmit these claim details\u201d and we\u2019ll take it from there.<\/p><p\nclass=\"MsoNormal\" style=\"margin-bottom: 7.5pt; color: #222222; font-family: arial, sans-serif; font-size: small; text-align: justify; line-height: 13.5pt; vertical-align: baseline;\"><span\nstyle=\"font-size: 12pt;\">I hereby declare that to the best of my knowledge and belief that the information I have provided is correct and request you to deal on my behalf with any claims which may arise out of the accident in accordance with the terms and conditions of the Policy.<\/span><\/p><p\nclass=\"MsoNormal\" style=\"margin-bottom: 7.5pt; color: #222222; font-family: arial, sans-serif; font-size: small; text-align: justify; line-height: 13.5pt; vertical-align: baseline;\"><span\nstyle=\"font-size: 12pt;\">I authorize you and your attorneys-at-law on my behalf to make such admissions and settlements and give such consents as you consider necessary for the disposal of such claims and any litigation arising therefrom.<\/span><\/p><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][62][m_type]\" id=\"ipt_fsqm_form_7_pinfo_62_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_7[pinfo][62][type]\" id=\"ipt_fsqm_form_7_pinfo_62_type\" value=\"s_checkbox\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_s_checkbox column-centered\" id=\"ipt_fsqm_form_7_pinfo_62\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_label_column column_1\">\n<input\ntype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in  ipt_uif_s_checkbox\"\nname=\"ipt_fsqm_form_7[pinfo][62][value]\" id=\"ipt_fsqm_form_7_pinfo_62_value_1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_7_pinfo_62_value_1\" data-labelcon=\"&#xf022;\">\nI agree\t\t\t\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear\"><\/div><div\nid=\"ipt_fsqm_form_7_button_container\" class=\"ipt_fsqm_form_button_container ipt_fsqm_form_button_container--classic ipt-eform-material-button-container\"><div\nclass=\"eform-button-container-inner\">\n<button\ntype=\"button\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_prev medium primary-button\" name=\"ipt_fsqm_form_7_button_prev\" id=\"ipt_fsqm_form_7_button_prev\"> Previous<\/button>\n<button\ntype=\"submit\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_submit medium primary-button\" name=\"ipt_fsqm_form_7_button_submit\" id=\"ipt_fsqm_form_7_button_submit\"> Submit<\/button>\n<button\ntype=\"button\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_next medium primary-button\" name=\"ipt_fsqm_form_7_button_next\" id=\"ipt_fsqm_form_7_button_next\"> Next<\/button>\n<button\ntype=\"reset\" title=\"Reset\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_reset ipt_uif_tooltip medium primary-button\" name=\"ipt_fsqm_form_7_button_reset\" id=\"ipt_fsqm_form_7_button_reset\"> <i\nclass=\"ipticm ipt-icomoon-refresh\"><\/i><\/button><\/div><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"ipt_fsqm_main_pb eform-mainpb-bottom ipt_uif_progress_bar\" data-start=\"0\" data-decimals=\"2\" id=\"ipt_fsqm_form_7_progressbar\"><div\nclass=\"ipt_uif_progress_value\"><span\nclass=\"eform-progress-value-span\"><\/span><\/div><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/form><\/div><div\nstyle=\"display: none;\" class=\"ipt_fsqm_form_message_success ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><h3><i\ntitle=\"\" class=\" ipt-icomoon-checkmark-circle ipticm prefix\"><\/i>\nYour claim has been submitted<\/h3><\/div><div\nclass=\"ui-widget-content ui-corner-all ipt_fsqm_success_wrap\"><p>Thank you for submitting your claim. This is to acknowledge receipt and advise you that we will contact you before the end of the next business day. Please click on the following link to learn more about next steps: https:\/\/bciconline.com\/claims-2\/<\/p><\/div><\/div><div\nstyle=\"display: none;\" class=\"ipt_fsqm_form_message_error ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><div><i\ntitle=\"\" class=\" ipt-icomoon-laptop ipticm prefix\"><\/i>\nServer Side Error<\/div><\/div><div\nclass=\"ui-widget-content ui-corner-all\"><p>We faced problems while connecting to the server or receiving data from the server. Please wait for a few seconds and try again.<\/p><p>If the problem persists, then check your internet connectivity. If all other sites open fine, then please contact the administrator of this website with the following information.<\/p><p\nclass=\"jqXHR\">\n<strong>TextStatus: <\/strong><span\nclass=\"textStatus\">undefined<\/span><br\n\/>\n<strong>HTTP Error: <\/strong><span\nclass=\"errorThrown\">undefined<\/span><\/p><\/div><\/div><div\nstyle=\"display: none\" class=\"ipt_uif_widget_box ipt_fsqm_form_message_process\"><div\nclass=\"ui-widget ui-widget-header ui-corner-all\"><style type=\"text\/css\">.ipt_uif_ajax_loader,\n\t\t\t.ipt_uif_ajax_loader *,\n\t\t\tipt_uif_ajax_loader *::before,\n\t\t\tipt_uif_ajax_loader *::after {\n\t\t\t\tbox-sizing: border-box;\n\t\t\t}<\/style><div\nclass=\"ipt-eform-preloader-inline ipt_uif_ajax_loader\"><div\nclass=\"ipt-eform-preloader-inner\"><div\nclass=\"ipt-eform-preloader-circle\"><div\nclass=\"preloader-wrapper active\"><div\nclass=\"spinner-layer spinner-blue\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-red\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-yellow\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-green\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><\/div><\/div><div\nclass=\"ipt-eform-preloader-text\"><div\nclass=\"ipt-eform-preloader-text-inner ipt_uif_ajax_loader_text\">Processing you request<\/div><\/div><div\nclass=\"clear\"><\/div><\/div><\/div><\/div><\/div><div\nstyle=\"display: none;\" class=\"ipt_fsqm_form_validation_error ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><div><i\ntitle=\"\" class=\" ipt-icomoon-warning2 ipticm prefix\"><\/i>\n<span\nclass=\"fsqm_ve_text\">Error<\/span><\/div><\/div><div\nclass=\"ui-widget-content ui-corner-all\"><p\nclass=\"fsqm_ve_msg\">Some error has occured.<\/p><\/div><\/div><\/div><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-toggle-item\">\n\t\t\t\t\t<div id=\"elementor-tab-title-1373\" class=\"elementor-tab-title\" data-tab=\"3\" role=\"button\" aria-controls=\"elementor-tab-content-1373\" aria-expanded=\"false\">\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon elementor-toggle-icon-left\" aria-hidden=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon-closed\"><i class=\"fas fa-caret-right\"><\/i><\/span>\n\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon-opened\"><i class=\"elementor-toggle-icon-opened fas fa-caret-up\"><\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<a class=\"elementor-toggle-title\" tabindex=\"0\">Motorcycle<\/a>\n\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<div id=\"elementor-tab-content-1373\" class=\"elementor-tab-content elementor-clearfix\" data-tab=\"3\" role=\"region\" aria-labelledby=\"elementor-tab-title-1373\"><p>\t\t<div data-elementor-type=\"section\" data-elementor-id=\"3144\" class=\"elementor elementor-3144\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\" data-elementor-post-type=\"elementor_library\">\n\t\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-a1ee19b premium-equal-height-yes elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"25909\" data-pa-eq-height=\"{&quot;targetType&quot;:&quot;widget&quot;,&quot;target&quot;:&quot;&quot;,&quot;trigger&quot;:&quot;load&quot;,&quot;enableOn&quot;:[&quot;desktop&quot;,&quot;tablet&quot;,&quot;mobile&quot;]}\" data-id=\"a1ee19b\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;premium_eq_height_switcher&quot;:&quot;yes&quot;,&quot;_ha_eqh_enable&quot;:&quot;yes&quot;,&quot;_ha_eqh_to&quot;:&quot;widget&quot;,&quot;_ha_eqh_disable_on_tablet&quot;:&quot;no&quot;,&quot;_ha_eqh_disable_on_mobile&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-narrow\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-4fe2dfa\" data-eae-slider=\"66278\" data-id=\"4fe2dfa\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-5d40cd6 ekit-equal-height-enable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"5d40cd6\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=motorcycle&#038;type=Accident-Third-Party-Involved&#038;region=bb\" target=\"_blank\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img loading=\"lazy\" decoding=\"async\" width=\"1536\" height=\"1024\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/07\/candado-moto-destacada-1536x1024-1.jpeg\" class=\"attachment-full size-full wp-image-3151\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Accident Third Party Involved\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=motorcycle&#038;type=Accident-Third-Party-Involved&#038;region=ja\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-8586a9f\" data-eae-slider=\"11645\" data-id=\"8586a9f\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-1faeaf7 ekit-equal-height-disable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"1faeaf7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=motorcycle&#038;type=Accident-No-Third-Party-Involved&#038;region=bb\" target=\"_blank\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img loading=\"lazy\" decoding=\"async\" width=\"1536\" height=\"1024\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/07\/candado-moto-destacada-1536x1024-1.jpeg\" class=\"attachment-full size-full wp-image-3151\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Accident No Third Party Involved\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=motorcycle&#038;type=Accident-No-Third-Party-Involved&#038;region=ja\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-1d458d1\" data-eae-slider=\"43792\" data-id=\"1d458d1\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-995a73a ekit-equal-height-disable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"995a73a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=motorcycle&#038;type=theft&#038;region=bb\" target=\"_blank\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img loading=\"lazy\" decoding=\"async\" width=\"1536\" height=\"1024\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/07\/candado-moto-destacada-1536x1024-1.jpeg\" class=\"attachment-full size-full wp-image-3151\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Theft\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/claims.bciconline.com\/reportaclaim\/?category=motorcycle&#038;type=theft&#038;region=ja\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-toggle-item\">\n\t\t\t\t\t<div id=\"elementor-tab-title-1374\" class=\"elementor-tab-title\" data-tab=\"4\" role=\"button\" aria-controls=\"elementor-tab-content-1374\" aria-expanded=\"false\">\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon elementor-toggle-icon-left\" aria-hidden=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon-closed\"><i class=\"fas fa-caret-right\"><\/i><\/span>\n\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon-opened\"><i class=\"elementor-toggle-icon-opened fas fa-caret-up\"><\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<a class=\"elementor-toggle-title\" tabindex=\"0\">Employers' and Public Liability<\/a>\n\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<div id=\"elementor-tab-content-1374\" class=\"elementor-tab-content elementor-clearfix\" data-tab=\"4\" role=\"region\" aria-labelledby=\"elementor-tab-title-1374\"><p>\t\t<div data-elementor-type=\"section\" data-elementor-id=\"3441\" class=\"elementor elementor-3441\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\" data-elementor-post-type=\"elementor_library\">\n\t\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-287e69d elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"61239\" data-id=\"287e69d\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-fcfa494\" data-eae-slider=\"81345\" data-id=\"fcfa494\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-6378153 elementor-widget elementor-widget-text-editor\" data-id=\"6378153\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><style type=\"text\/css\">#ipt_fsqm_form_wrap_8 .ipt_fsqm_form_logo img,\n\t#ipt_fsqm_form_wrap_8 .ipt-eform-width-restrain,\n\t#ipt_fsqm_form_wrap_8 .ipt_fsqm_form_message_restore,\n\t#ipt_fsqm_form_wrap_8 .ipt_fsqm_form_message_success,\n\t#ipt_fsqm_form_wrap_8 .ipt_fsqm_form_message_error,\n\t#ipt_fsqm_form_wrap_8 .ipt_fsqm_form_message_process,\n\t#ipt_fsqm_form_wrap_8 .ipt_fsqm_form_validation_error,\n\t#ipt_fsqm_form_wrap_8 .eform-ui-estimator {\n\t\tmax-width: 100%;\n\t\tmin-width: 240px;\n\t}\n\n\t\t\t#ipt_fsqm_form_wrap_8 .ipt-eform-content {\n\t\t\tbackground-image: none;\n\t\t\tbackground-position: 0% 0%;\n\t\t\tbackground-size: auto;\n\t\t\tbackground-repeat: repeat;\n\t\t\tbackground-origin: padding-box;\n\t\t\tbackground-clip: border-box;\n\t\t\tbackground-attachment: scroll;\n\t\t}\n\t\/**\/<\/style><div\nid=\"ipt_fsqm_form_wrap_8\"\nclass=\"ipt_uif_front ipt_uif_common ipt_fsqm_form type_2 ui-front eform-ltr eform-override-element-material eform-override-alignment-inherit\"\ndata-fsqmsayt=\"{&quot;auto_save&quot;:true,&quot;show_restore&quot;:true,&quot;restore&quot;:true,&quot;admin_override&quot;:false,&quot;user_update&quot;:false,&quot;interval_save&quot;:false,&quot;interval&quot;:&quot;30&quot;}\"\ndata-ui-type=\"2\"\ndata-ui-theme=\"[&quot;https:\\\/\\\/bciconline.com\\\/ba\\\/wp-content\\\/plugins\\\/wp-fsqm-pro\\\/static\\\/front\\\/css\\\/material-themes\\\/light-themes\\\/red.css?ver=4.19.1&quot;]\"\ndata-ui-theme-id=\"material-red\"\ndata-eformanim=\"1\"\ndata-fsqmga=\"{&quot;enabled&quot;:false,&quot;manual_load&quot;:false,&quot;tracking_id&quot;:&quot;&quot;,&quot;cookie&quot;:&quot;auto&quot;,&quot;user_update&quot;:false,&quot;name&quot;:&quot;Employer Liability&quot;,&quot;form_id&quot;:&quot;8&quot;}\"\ndata-fsqmreset=\"{&quot;reset&quot;:false,&quot;delay&quot;:10}\"\ndata-eformreg=\"{&quot;enabled&quot;:false,&quot;username_id&quot;:&quot;ipt_fsqm_form_8_pinfo_&quot;,&quot;password_id&quot;:&quot;ipt_fsqm_form_8_pinfo_&quot;,&quot;hide_pinfo&quot;:false,&quot;hide_meta&quot;:false,&quot;meta&quot;:[]}\"\ndata-eformscroll=\"{&quot;progress&quot;:true,&quot;message&quot;:true,&quot;offset&quot;:&quot;0&quot;,&quot;scrollOnError&quot;:true}\"\ndata-eform-cookie=\"0\"\ndata-subscription-form=\"false\"\ndata-instant-subscription=\"{&quot;doable&quot;:true,&quot;config&quot;:{&quot;enabled&quot;:false,&quot;min_tab&quot;:&quot;&quot;,&quot;debounce&quot;:&quot;3000&quot;},&quot;nonce&quot;:&quot;7e33152a53&quot;}\"\n><style type=\"text\/css\">\/**\/<\/style><noscript><div\nclass=\"ipt_fsqm_form_message_noscript ui-widget ui-widget-content ui-corner-all\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><div>Javascript is disabled<\/div><\/div><div\nclass=\"ui-widget-content ui-corner-bottom\"><p>Javascript is disabled on your browser. Please enable it in order to use this form.<\/p><\/div><\/div>\n<\/noscript><style type=\"text\/css\">.ipt_uif_ajax_loader,\n\t\t\t.ipt_uif_ajax_loader *,\n\t\t\tipt_uif_ajax_loader *::before,\n\t\t\tipt_uif_ajax_loader *::after {\n\t\t\t\tbox-sizing: border-box;\n\t\t\t}<\/style><div\nclass=\"ipt_uif_init_loader ipt-eform-preloader-inline ipt_uif_ajax_loader\"><div\nclass=\"ipt-eform-preloader-inner\"><div\nclass=\"ipt-eform-preloader-circle\"><div\nclass=\"preloader-wrapper active\"><div\nclass=\"spinner-layer spinner-blue\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-red\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-yellow\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-green\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><\/div><\/div><div\nclass=\"ipt-eform-preloader-text\"><div\nclass=\"ipt-eform-preloader-text-inner ipt_uif_ajax_loader_text\">Loading<\/div><\/div><div\nclass=\"clear\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude class=\"ipt_uif_conditional_logic\" id=\"ipt_uif_conditional_logic_8\" value=\"{&quot;logics&quot;:{&quot;ipt_fsqm_form_8_pinfo_62&quot;:{&quot;active&quot;:true,&quot;status&quot;:true,&quot;change&quot;:true,&quot;logic&quot;:{},&quot;type&quot;:&quot;s_checkbox&quot;,&quot;m_type&quot;:&quot;pinfo&quot;}},&quot;indexes&quot;:[],&quot;base&quot;:&quot;8&quot;}\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude class=\"ipt_fsqm_timer_data\" id=\"ipt_fsqm_timer_data_8\" value=\"{&quot;type&quot;:&quot;none&quot;}\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude class=\"ipt_fsqm_epoc_data\" id=\"ipt_fsqm_epoc_data_8\" value=\"{&quot;CURRENTYEAR&quot;:2026,&quot;CURRENTDATE&quot;:1788594309000,&quot;CURRENTDAY&quot;:5,&quot;CURRENTMONTH&quot;:9,&quot;CURRENTHOUR&quot;:7,&quot;CURRENTMINUTE&quot;:45,&quot;CURRENTSECOND&quot;:9,&quot;CURRENTWEEK&quot;:36,&quot;CURRENTEPOC&quot;:20701}\" \/><div\nstyle=\"display: none;\" class=\"ipt_uif_hidden_init\"><div\nstyle=\"display: none;\" class=\"ipt_fsqm_form_message_restore ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><h3><a\nhref=\"#\" title=\"Hide\" class=\"ipt_fsqm_form_message_close\"><i\ntitle=\"\" class=\" ipt-icomoon-times ipticm prefix\"><\/i>\n<\/a><i\ntitle=\"\" class=\" ipt-icomoon-checkmark-circle ipticm prefix\"><\/i>\nForm successfully restored<\/h3><\/div><div\nclass=\"ui-widget-content ui-corner-all\"><p>The form has been restored from your last edit. If wish to start over, please click the button<\/p>\n<button\nstyle=\"margin-bottom: 0\" class=\"ipt_uif_button ipt_fsqm_sayt_reset secondary-button\">Start Over<\/button><\/div><\/div><form\nmethod=\"post\" action=\"\" class=\"ipt_uif_validate_form ipt_fsqm_main_form\" id=\"ipt_fsqm_form_8\" autocomplete=\"on\">\n<input\ntype=\"hidden\" data-sayt-exclude name=\"action\" id=\"action\" value=\"ipt_fsqm_save_form\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_epoc\" class=\"eform-epoc-value\" value=\"1788594309\" \/>\n<input\ntype=\"hidden\" class=\"ipt_fsqm_form_tab_pos\" name=\"fsqm_form8_tab_pos\" value=\"0\" id=\"fsqm_form8_tab_pos\" \/>\n<input\ntype=\"hidden\" id=\"ipt_fsqm_form_data_save\" name=\"ipt_fsqm_form_data_save\" value=\"879df1d96e\" data-sayt-exclude \/>\t\t\t<input\ntype=\"hidden\" name=\"_wp_http_referer\" value=\"\/ba\/report-claim\/\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"form_id\" value=\"8\" \/><div\nclass=\"ipt-eform-width-restrain\"><div\nclass=\"ipt-eform-content \"><div\ndata-settings=\"{&quot;can_previous&quot;:true,&quot;show_progress_bar&quot;:true,&quot;progress_bar_bottom&quot;:true,&quot;block_previous&quot;:false,&quot;any_tab&quot;:false,&quot;type&quot;:&quot;2&quot;,&quot;scroll&quot;:true,&quot;decimal_point&quot;:2,&quot;auto_progress&quot;:false,&quot;auto_progress_delay&quot;:&quot;1500&quot;,&quot;auto_submit&quot;:false,&quot;hidden_buttons&quot;:false,&quot;scroll_on_error&quot;:true}\" class=\"ipt_fsqm_main_tab ipt_uif_tabs horizontal\"><div\nclass=\"ipt-eform-tab-nav-wrap\"><ul><li\nid=\"ipt_fsqm_form_8_tab_0_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_8_tab_0\"><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe269;\"><\/i>\n<span\nclass=\"eform-tab-labels\">Tell us what happened <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_8_tab_1_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_8_tab_1\"><span\nclass=\"eform-tab-labels\">About you <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_8_tab_2_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_8_tab_2\"><span\nclass=\"eform-tab-labels\">About the Incident <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_8_tab_3_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_8_tab_3\"><span\nclass=\"eform-tab-labels\">Other Details <\/span><\/a><\/li><li\nid=\"ipt_fsqm_form_8_tab_4_control_li\"><a\nclass=\"eform-ripple\" href=\"#ipt_fsqm_form_8_tab_4\"><span\nclass=\"eform-tab-labels\">Submit your Claim <\/span><\/a><\/li><\/ul>\n<i\nclass=\"eform-tab-nav eform-tab-nav-right ipt-icomoon-angle-right disabled eform-ripple\"><\/i>\n<i\nclass=\"eform-tab-nav eform-tab-nav-left ipt-icomoon-angle-left disabled eform-ripple\"><\/i>\n<span\nclass=\"eform-tab-passive-notifier\"><\/span>\n<span\nclass=\"eform-tab-active-notifier\"><\/span><\/div><div\nid=\"ipt_fsqm_form_8_tab_0\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_8_layout_0_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe269;\"><\/i>\n<span\nclass=\"ipt_uif_divider_text_inner\">\nTell us what happened<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][0][m_type]\" id=\"ipt_fsqm_form_8_pinfo_0_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][0][type]\" id=\"ipt_fsqm_form_8_pinfo_0_type\" value=\"datetime\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_datetime\" id=\"ipt_fsqm_form_8_pinfo_0\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_0_value\">When Did It Happen?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field eform-dp-input-field has-icon\">\n<input\nclass=\"datepicker ipt_uif_datepicker  check_me validate[required] is-empty ipt_uif_text\"\ndata-dateFormat=\"mm\/dd\/yy\" data-timeFormat=\"hh:mm:ss TT\" data-year_range=\"50\"\t\ttype=\"text\"\nreadonly=\"readonly\"\nname=\"ipt_fsqm_form_8[pinfo][0][value]\"\nid=\"ipt_fsqm_form_8_pinfo_0_value\"\nmaxlength=\"524288\"\nvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipt-icomoon-calendar ipticm prefix\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_0_value\">Select Date<\/label>\n<a\nhref=\"javascript:;\" class=\"eform-dp-clear\" title=\"Clear\">&times;<\/a><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][4][m_type]\" id=\"ipt_fsqm_form_8_pinfo_4_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][4][type]\" id=\"ipt_fsqm_form_8_pinfo_4_type\" value=\"datetime\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_datetime\" id=\"ipt_fsqm_form_8_pinfo_4\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_4_value\">What time did it happen?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field eform-dp-input-field has-icon\">\n<input\nclass=\"datepicker ipt_uif_timepicker  check_me validate[required] is-empty ipt_uif_text\"\ndata-dateFormat=\"yy-mm-dd\" data-timeFormat=\"hh:mm:ss TT\" data-year_range=\"50\"\t\ttype=\"text\"\nreadonly=\"readonly\"\nname=\"ipt_fsqm_form_8[pinfo][4][value]\"\nid=\"ipt_fsqm_form_8_pinfo_4_value\"\nmaxlength=\"524288\"\nvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipt-icomoon-clock ipticm prefix\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_4_value\">Select Time<\/label>\n<a\nhref=\"javascript:;\" class=\"eform-dp-clear\" title=\"Clear\">&times;<\/a><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][1][m_type]\" id=\"ipt_fsqm_form_8_pinfo_1_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][1][type]\" id=\"ipt_fsqm_form_8_pinfo_1_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_1\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_1_value\">Where did it Happen?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][1][value]\"\nid=\"ipt_fsqm_form_8_pinfo_1_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe07d;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_1_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][83][m_type]\" id=\"ipt_fsqm_form_8_pinfo_83_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][83][type]\" id=\"ipt_fsqm_form_8_pinfo_83_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_83\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_83_value\">Who in your opinion is responsible for the incident?<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][83][value]\"\nid=\"ipt_fsqm_form_8_pinfo_83_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe056;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_83_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][6][m_type]\" id=\"ipt_fsqm_form_8_pinfo_6_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][6][type]\" id=\"ipt_fsqm_form_8_pinfo_6_type\" value=\"textarea\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textarea\" id=\"ipt_fsqm_form_8_pinfo_6\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_6_value\">Please describe in detail what happened (max 1300 characters)<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me validate[required,minSize[10],maxSize[1303]]\"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_8[pinfo][6][value]\"\n\t\tmaxlength=\"1303\"\t\tid=\"ipt_fsqm_form_8_pinfo_6_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe056;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_6_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_8_tab_1\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_8_layout_1_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<span\nclass=\"ipt_uif_divider_text_inner\">\nAbout you<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][7][m_type]\" id=\"ipt_fsqm_form_8_pinfo_7_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][7][type]\" id=\"ipt_fsqm_form_8_pinfo_7_type\" value=\"p_radio\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_radio\" id=\"ipt_fsqm_form_8_pinfo_7\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_7\">Are you a policyholder?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][7][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_7_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_7_options__0\" data-labelcon=\"&#xe18e;\">\nYes\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][7][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_7_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_7_options__1\" data-labelcon=\"&#xe18e;\">\nNo\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][8][m_type]\" id=\"ipt_fsqm_form_8_pinfo_8_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][8][type]\" id=\"ipt_fsqm_form_8_pinfo_8_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_8\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_8_value\">Policy Number<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][8][value]\"\nid=\"ipt_fsqm_form_8_pinfo_8_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe056;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_8_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][9][m_type]\" id=\"ipt_fsqm_form_8_pinfo_9_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][9][type]\" id=\"ipt_fsqm_form_8_pinfo_9_type\" value=\"f_name\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_f_name\" id=\"ipt_fsqm_form_8_pinfo_9\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_9_value\">Policy Holder First Name<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[custom[personName]] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][9][value]\"\nid=\"ipt_fsqm_form_8_pinfo_9_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xf007;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_9_value\">First Name<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][10][m_type]\" id=\"ipt_fsqm_form_8_pinfo_10_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][10][type]\" id=\"ipt_fsqm_form_8_pinfo_10_type\" value=\"l_name\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_l_name\" id=\"ipt_fsqm_form_8_pinfo_10\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_10_value\">Policy Holder Last Name<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[custom[personName]] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][10][value]\"\nid=\"ipt_fsqm_form_8_pinfo_10_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xf007;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_10_value\">Last Name<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][12][m_type]\" id=\"ipt_fsqm_form_8_pinfo_12_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][12][type]\" id=\"ipt_fsqm_form_8_pinfo_12_type\" value=\"phone\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_phone\" id=\"ipt_fsqm_form_8_pinfo_12\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_12_value\">Preferred Telephone Number<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[custom[phone]] ipt_uif_text\"\ntype=\"tel\"\nname=\"ipt_fsqm_form_8[pinfo][12][value]\"\nid=\"ipt_fsqm_form_8_pinfo_12_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe08c;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_12_value\">Phone<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][11][m_type]\" id=\"ipt_fsqm_form_8_pinfo_11_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][11][type]\" id=\"ipt_fsqm_form_8_pinfo_11_type\" value=\"email\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_email\" id=\"ipt_fsqm_form_8_pinfo_11\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_11_value\">Preferred Email Address<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\">\n<input\nclass=\" check_me validate[custom[email]] ipt_uif_text\"\ntype=\"email\"\nname=\"ipt_fsqm_form_8[pinfo][11][value]\"\nid=\"ipt_fsqm_form_8_pinfo_11_value\"\nvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xf0e0;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_11_value\">Email Address<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][13][m_type]\" id=\"ipt_fsqm_form_8_pinfo_13_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][13][type]\" id=\"ipt_fsqm_form_8_pinfo_13_type\" value=\"p_radio\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_radio\" id=\"ipt_fsqm_form_8_pinfo_13\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_13\">Contact Preference<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][13][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_13_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_13_options__0\" data-labelcon=\"&#xe18e;\">\nEmail\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][13][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_13_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_13_options__1\" data-labelcon=\"&#xe18e;\">\nPhone\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_8_tab_2\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_8_layout_2_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<span\nclass=\"ipt_uif_divider_text_inner\">\nAbout the Incident<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][96][m_type]\" id=\"ipt_fsqm_form_8_pinfo_96_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][96][type]\" id=\"ipt_fsqm_form_8_pinfo_96_type\" value=\"p_radio\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_radio\" id=\"ipt_fsqm_form_8_pinfo_96\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_96\">Was machinery being used? <span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][96][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_96_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_96_options__0\" data-labelcon=\"&#xe18e;\">\nYes\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][96][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_96_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_96_options__1\" data-labelcon=\"&#xe18e;\">\nNo\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][88][m_type]\" id=\"ipt_fsqm_form_8_pinfo_88_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][88][type]\" id=\"ipt_fsqm_form_8_pinfo_88_type\" value=\"textarea\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textarea\" id=\"ipt_fsqm_form_8_pinfo_88\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_88_value\">If yes, please state exactly what machinery was involved in the incident?<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_8[pinfo][88][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_8_pinfo_88_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe056;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_88_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][18][m_type]\" id=\"ipt_fsqm_form_8_pinfo_18_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][18][type]\" id=\"ipt_fsqm_form_8_pinfo_18_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_18\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_18_value\">Employee\u2019s full name<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][18][value]\"\nid=\"ipt_fsqm_form_8_pinfo_18_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_18_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][19][m_type]\" id=\"ipt_fsqm_form_8_pinfo_19_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][19][type]\" id=\"ipt_fsqm_form_8_pinfo_19_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_19\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_19_value\">Employee\u2019s address<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][19][value]\"\nid=\"ipt_fsqm_form_8_pinfo_19_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_19_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][20][m_type]\" id=\"ipt_fsqm_form_8_pinfo_20_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][20][type]\" id=\"ipt_fsqm_form_8_pinfo_20_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_20\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_20_value\">Employee\u2019s occupation<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][20][value]\"\nid=\"ipt_fsqm_form_8_pinfo_20_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_20_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][21][m_type]\" id=\"ipt_fsqm_form_8_pinfo_21_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][21][type]\" id=\"ipt_fsqm_form_8_pinfo_21_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_21\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_21_value\">Employee\u2019s age<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][21][value]\"\nid=\"ipt_fsqm_form_8_pinfo_21_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_21_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][87][m_type]\" id=\"ipt_fsqm_form_8_pinfo_87_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][87][type]\" id=\"ipt_fsqm_form_8_pinfo_87_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_87\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_87_value\">Department in which employee worked at the time of the incident<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][87][value]\"\nid=\"ipt_fsqm_form_8_pinfo_87_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_87_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][90][m_type]\" id=\"ipt_fsqm_form_8_pinfo_90_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][90][type]\" id=\"ipt_fsqm_form_8_pinfo_90_type\" value=\"p_radio\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_radio\" id=\"ipt_fsqm_form_8_pinfo_90\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_90\"> Was the employee in your direct employment? <span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][90][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_90_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_90_options__0\" data-labelcon=\"&#xe18e;\">\nYes\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][90][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_90_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_90_options__1\" data-labelcon=\"&#xe18e;\">\nNo\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][98][m_type]\" id=\"ipt_fsqm_form_8_pinfo_98_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][98][type]\" id=\"ipt_fsqm_form_8_pinfo_98_type\" value=\"datetime\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_datetime\" id=\"ipt_fsqm_form_8_pinfo_98\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_98_value\">If yes, since what date? <\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field eform-dp-input-field has-icon\">\n<input\nclass=\"datepicker ipt_uif_datepicker  check_me  is-empty ipt_uif_text\"\ndata-dateFormat=\"yy-mm-dd\" data-timeFormat=\"HH:mm:ss\" data-year_range=\"50\"\t\ttype=\"text\"\nreadonly=\"readonly\"\nname=\"ipt_fsqm_form_8[pinfo][98][value]\"\nid=\"ipt_fsqm_form_8_pinfo_98_value\"\nmaxlength=\"524288\"\nvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipt-icomoon-calendar ipticm prefix\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_98_value\">Select Date<\/label>\n<a\nhref=\"javascript:;\" class=\"eform-dp-clear\" title=\"Clear\">&times;<\/a><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][99][m_type]\" id=\"ipt_fsqm_form_8_pinfo_99_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][99][type]\" id=\"ipt_fsqm_form_8_pinfo_99_type\" value=\"p_radio\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_radio\" id=\"ipt_fsqm_form_8_pinfo_99\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_99\">Was the employee injured? <span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][99][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_99_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_99_options__0\" data-labelcon=\"&#xe18e;\">\nYes\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][99][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_99_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_99_options__1\" data-labelcon=\"&#xe18e;\">\nNo\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][97][m_type]\" id=\"ipt_fsqm_form_8_pinfo_97_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][97][type]\" id=\"ipt_fsqm_form_8_pinfo_97_type\" value=\"textarea\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textarea\" id=\"ipt_fsqm_form_8_pinfo_97\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_97_value\">If yes, please state the nature of injuries or damage<\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field has-icon\"><textarea class=\"ipt_uif_textarea materialize-textarea  check_me \"\n\t\trows=\"4\"\n\t\t\t\t\t\t\t\tname=\"ipt_fsqm_form_8[pinfo][97][value]\"\n\t\tmaxlength=\"\"\t\tid=\"ipt_fsqm_form_8_pinfo_97_value\"><\/textarea><i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe056;\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_97_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][103][m_type]\" id=\"ipt_fsqm_form_8_pinfo_103_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][103][type]\" id=\"ipt_fsqm_form_8_pinfo_103_type\" value=\"p_radio\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_radio\" id=\"ipt_fsqm_form_8_pinfo_103\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_103\">Did the employee receive medical care for the injuries sustained?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][103][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_103_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_103_options__0\" data-labelcon=\"&#xe18e;\">\nYes\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][103][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_103_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_103_options__1\" data-labelcon=\"&#xe18e;\">\nNo\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][101][m_type]\" id=\"ipt_fsqm_form_8_pinfo_101_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][101][type]\" id=\"ipt_fsqm_form_8_pinfo_101_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_101\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_101_value\">If yes, where did he\/she receive medical care?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][101][value]\"\nid=\"ipt_fsqm_form_8_pinfo_101_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_101_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][102][m_type]\" id=\"ipt_fsqm_form_8_pinfo_102_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][102][type]\" id=\"ipt_fsqm_form_8_pinfo_102_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_102\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_102_value\">What is the monthly wage of the employee?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me validate[required] ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][102][value]\"\nid=\"ipt_fsqm_form_8_pinfo_102_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_102_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][100][m_type]\" id=\"ipt_fsqm_form_8_pinfo_100_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][100][type]\" id=\"ipt_fsqm_form_8_pinfo_100_type\" value=\"p_radio\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_p_radio\" id=\"ipt_fsqm_form_8_pinfo_100\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_100\">Did the emploee work after the incident?<span\nclass=\"ipt_uif_question_required\">*<\/span><\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][100][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_100_options__0\"\nvalue=\"0\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_100_options__0\" data-labelcon=\"&#xe18e;\">\nYes\t<\/label><\/div><div\nclass=\"ipt_uif_label_column column_2\">\n<input\ndata-num=\"\"\t\t\t\ttype=\"radio\"\nclass=\"check_me validate[required] ipt_uif_radio with-gap\"\nname=\"ipt_fsqm_form_8[pinfo][100][options][]\"\nid=\"ipt_fsqm_form_8_pinfo_100_options__1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_100_options__1\" data-labelcon=\"&#xe18e;\">\nNo\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][104][m_type]\" id=\"ipt_fsqm_form_8_pinfo_104_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][104][type]\" id=\"ipt_fsqm_form_8_pinfo_104_type\" value=\"datetime\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_datetime\" id=\"ipt_fsqm_form_8_pinfo_104\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question\"><div\nclass=\"ipt_uif_question_label\">\n<label\nclass=\"ipt_uif_question_title ipt_uif_label\" for=\"ipt_fsqm_form_8_pinfo_104_value\">If yes, what date? <\/label><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field eform-dp-input-field has-icon\">\n<input\nclass=\"datepicker ipt_uif_datetimepicker  check_me  is-empty ipt_uif_text\"\ndata-dateFormat=\"yy-mm-dd\" data-timeFormat=\"HH:mm:ss\" data-year_range=\"50\"\t\ttype=\"text\"\nreadonly=\"readonly\"\nname=\"ipt_fsqm_form_8[pinfo][104][value]\"\nid=\"ipt_fsqm_form_8_pinfo_104_value\"\nmaxlength=\"524288\"\nvalue=\"\" \/>\n<i\ntitle=\"\" class=\" ipt-icomoon-calendar ipticm prefix\"><\/i>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_104_value\">Select Date<\/label>\n<a\nhref=\"javascript:;\" class=\"eform-dp-clear\" title=\"Clear\">&times;<\/a><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_8_tab_3\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_8_layout_3_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<span\nclass=\"ipt_uif_divider_text_inner\">\nOther Details<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][24][m_type]\" id=\"ipt_fsqm_form_8_design_24_m_type\" value=\"design\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][24][type]\" id=\"ipt_fsqm_form_8_design_24_type\" value=\"richtext\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional\" id=\"ipt_fsqm_form_8_design_24\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_richtext\"><p\nclass=\"MsoNormal\" style=\"margin-bottom: 7.5pt; color: #222222; font-family: arial, sans-serif; font-size: 12.8px; text-align: justify; vertical-align: baseline;\"><span\nstyle=\"font-size: 14pt;\">Did any one witness the incident? If yes please provide their details below including full name and contact details<\/span><\/p><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][25][m_type]\" id=\"ipt_fsqm_form_8_design_25_m_type\" value=\"design\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][25][type]\" id=\"ipt_fsqm_form_8_design_25_type\" value=\"col_half\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half\" id=\"ipt_fsqm_form_8_design_25\"><div\nclass=\"ipt_uif_column_inner\">\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][27][m_type]\" id=\"ipt_fsqm_form_8_design_27_m_type\" value=\"design\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][27][type]\" id=\"ipt_fsqm_form_8_design_27_type\" value=\"richtext\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional\" id=\"ipt_fsqm_form_8_design_27\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_richtext\"><p>Names<\/p><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][91][m_type]\" id=\"ipt_fsqm_form_8_pinfo_91_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][91][type]\" id=\"ipt_fsqm_form_8_pinfo_91_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_91\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_full\"><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][91][value]\"\nid=\"ipt_fsqm_form_8_pinfo_91_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_91_value\">Name<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][93][m_type]\" id=\"ipt_fsqm_form_8_pinfo_93_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][93][type]\" id=\"ipt_fsqm_form_8_pinfo_93_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_93\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_full\"><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][93][value]\"\nid=\"ipt_fsqm_form_8_pinfo_93_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_93_value\">Name<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][26][m_type]\" id=\"ipt_fsqm_form_8_design_26_m_type\" value=\"design\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][26][type]\" id=\"ipt_fsqm_form_8_design_26_type\" value=\"col_half\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_half ipt_uif_conditional ipt_uif_column_custom ipt_fsqm_container_col_half\" id=\"ipt_fsqm_form_8_design_26\"><div\nclass=\"ipt_uif_column_inner\">\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][28][m_type]\" id=\"ipt_fsqm_form_8_design_28_m_type\" value=\"design\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][28][type]\" id=\"ipt_fsqm_form_8_design_28_type\" value=\"richtext\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional\" id=\"ipt_fsqm_form_8_design_28\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_richtext\"><p>Contact Details<\/p><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][92][m_type]\" id=\"ipt_fsqm_form_8_pinfo_92_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][92][type]\" id=\"ipt_fsqm_form_8_pinfo_92_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_92\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_full\"><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][92][value]\"\nid=\"ipt_fsqm_form_8_pinfo_92_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_92_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][95][m_type]\" id=\"ipt_fsqm_form_8_pinfo_95_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][95][type]\" id=\"ipt_fsqm_form_8_pinfo_95_type\" value=\"textinput\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_textinput\" id=\"ipt_fsqm_form_8_pinfo_95\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_question ipt_uif_question_full\"><div\nclass=\"ipt_uif_question_content\"><div\nclass=\"input-field\">\n<input\nclass=\" check_me  ipt_uif_text\"\ntype=\"text\"\nname=\"ipt_fsqm_form_8[pinfo][95][value]\"\nid=\"ipt_fsqm_form_8_pinfo_95_value\"\nmaxlength=\"\"\t\tvalue=\"\" \/>\n<label\nfor=\"ipt_fsqm_form_8_pinfo_95_value\">Write Here<\/label><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[freetype][0][m_type]\" id=\"ipt_fsqm_form_8_freetype_0_m_type\" value=\"freetype\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[freetype][0][type]\" id=\"ipt_fsqm_form_8_freetype_0_type\" value=\"upload\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_upload\" id=\"ipt_fsqm_form_8_freetype_0\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_container ipt_uif_iconbox\" data-opened=\"1\"><div\nclass=\"ipt_uif_container_head\"><h3>\t\t\t\t\t\t<i\ntitle=\"\" class=\" ipticm prefix\" data-ipt-icomoon=\"&#xe002;\"><\/i>\n<span\nclass=\"ipt_uif_container_label\">Please attach photographs or relevant documents to support your claim<\/span><\/h3><\/div><div\nclass=\"ipt_uif_container_inner\"><div\nclass=\"ipt_uif_uploader\" id=\"ipt_fsqm_file_upload_8_0__uploader_wrap\" data-settings=\"{&quot;accept_file_types&quot;:&quot;gif,jpeg,png,jpg,pdf,doc,docx&quot;,&quot;max_number_of_files&quot;:&quot;&quot;,&quot;min_number_of_files&quot;:&quot;&quot;,&quot;max_file_size&quot;:134217728,&quot;min_file_size&quot;:&quot;1&quot;,&quot;show_drop_zone&quot;:true,&quot;wp_media_integration&quot;:false,&quot;auto_upload&quot;:true,&quot;single_upload&quot;:false,&quot;drag_n_drop&quot;:true,&quot;progress_bar&quot;:true,&quot;preview_media&quot;:true,&quot;can_delete&quot;:true,&quot;required&quot;:false,&quot;minimal_ui&quot;:false,&quot;accept&quot;:&quot;all&quot;,&quot;capture&quot;:&quot;none&quot;,&quot;icon&quot;:&quot;57346&quot;,&quot;centered&quot;:false,&quot;dragdrop&quot;:&quot;Drag &#039;n Drop files here&quot;,&quot;upload_label&quot;:&quot;Select Files&quot;,&quot;recaptcha&quot;:false,&quot;site_key&quot;:&quot;&quot;,&quot;theme&quot;:&quot;light&quot;,&quot;type&quot;:&quot;image&quot;,&quot;size&quot;:&quot;normal&quot;,&quot;hl&quot;:&quot;en&quot;}\" data-configuration=\"{&quot;id&quot;:&quot;ipt_fsqm_file_upload_8_0_&quot;,&quot;upload_url&quot;:&quot;?action=ipt_fsqm_fu_upload&quot;,&quot;download_url&quot;:&quot;?action=ipt_fsqm_fu_download&quot;,&quot;do_download&quot;:false,&quot;show_ui&quot;:true,&quot;captcha_url&quot;:&quot;?action=ipt_fsqm_fu_captcha&quot;}\" data-formData=\"{&quot;data_id&quot;:null,&quot;form_id&quot;:&quot;8&quot;,&quot;nonce&quot;:&quot;490620fee6&quot;,&quot;element_key&quot;:&quot;0&quot;,&quot;files_key&quot;:&quot;ipt_fsqm_file_upload_8_0&quot;}\"><div\nclass=\"fileinput-dragdrop ui-state-active\">\n<span>Drag &#8216;n Drop files here<\/span><\/div><div\nclass=\"fileupload-meta\"><p>Max file size: 128.00 MB. | Allowed file types: gif,jpeg,png,jpg,pdf,doc,docx<\/p><\/div><div\nclass=\"ipt_fsqm_fileuploader_list_wrap\"><table\nrole=\"presentation\" class=\"ipt_fsqm_fileuploader_list\"><thead><tr><td\ncolspan=\"4\"><div\nclass=\"fileupload-buttonbar\"><div\nclass=\"fileupload-buttons\">\n<span\nrole=\"button\" class=\"fileinput-button secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n<span\nclass=\"ui-button-icon-primary ui-icon ui-icon-plusthick\"><\/span>\n<span\nclass=\"ui-button-text\">\n<span\nclass=\"select secondary-button\">Select Files<\/span>\n<\/span>\n<input\nclass=\"ipt_uif_uploader_handle\" type=\"file\" multiple=\"multiple\" name=\"ipt_fsqm_file_upload_8_0[]\" id=\"ipt_fsqm_file_upload_8_0_\" \/>\n<\/span>\n<button\ntype=\"reset\" class=\"cancel secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n<span\nclass=\"ui-button-icon-primary ui-icon ui-icon-cancel\"><\/span>\n<span\nclass=\"ui-button-text\">\nCancel All Uploads\t\t\t\t\t\t\t\t\t\t<\/span>\n<\/button>\n<span\nclass=\"fileupload-process\"><\/span><\/div><div\nclass=\"fileupload-progress fade wp-eform-fileupload-globalprogress\" style=\"display: none;\"><div\nclass=\"progress ui-progressbar ui-widget ui-widget-content ui-corner-all\" role=\"progressbar\" aria-valuemin=\"0\" aria-valuemax=\"100\"><div\nclass=\"progress-bar ui-progressbar-value ui-widget-header ui-corner-left\" style=\"width: 0%;\"><\/div><\/div><div\nclass=\"progress-extended\">&nbsp;<\/div><\/div><\/div><\/td><td\nclass=\"delete_button\"><div\nclass=\"fileupload-buttonbar\"><div\nclass=\"fileupload-buttons\">\n<button\ntype=\"button\" class=\"delete secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n<span\nclass=\"ui-button-icon-primary ui-icon ui-icon-trash\"><\/span>\n<span\nclass=\"ui-button-text\">\nDelete Selected\t\t\t\t\t\t\t\t\t\t<\/span>\n<\/button><\/div><\/div><\/td><td\nclass=\"delete_toggle\"><div\nclass=\"fileupload-buttonbar\"><div\nclass=\"fileupload-buttons\"><div\nclass=\"ipt_uif_label_column\">\n<input\ntype=\"checkbox\" class=\"toggle ipt_uif_checkbox\" id=\"ipt_fsqm_file_upload_8_0__toggler\" \/>\n<label\ndata-labelcon=\"&#xe18e;\" for=\"ipt_fsqm_file_upload_8_0__toggler\"><\/label><\/div><\/div><\/div><\/td><\/tr><\/thead><tbody\nclass=\"files\"><\/tbody><\/table><\/div> <script class=\"template-upload\" id=\"ipt_fsqm_file_upload_8_0__tmpl_upload\" type=\"text\/x-tmpl\">{% for (var i=0, file; file=o.files[i]; i++) { %}\n\t<tr class=\"template-upload\">\n\t\t<td>\n\t\t\t<span class=\"preview\"><\/span>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p class=\"name\">{%=file.name%}<\/p>\n\t\t\t<strong class=\"error\"><\/strong>\n\t\t<\/td>\n\t\t<td class=\"fileupload_list_pb\">\n\t\t\t<p class=\"size\">Processing&hellip;<\/p>\n\t\t\t<div class=\"progress ui-progressbar ui-widget ui-widget-content ui-corner-all\" role=\"progressbar\" aria-valuemin=\"0\" aria-valuemax=\"100\">\n\t\t\t\t<div class=\"progress-bar ui-progressbar-value ui-widget-header ui-corner-left\" style=\"width: 0%;\"><\/div>\n\t\t\t<\/div>\n\t\t<\/td>\n\t\t<td colspan=\"3\">\n\t\t\t{% if (!i && !o.options.autoUpload) { %}\n\t\t\t\t<button class=\"start secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\" disabled>\n\t\t\t\t\t<span class=\"ui-button-icon-primary ui-icon ui-icon-circle-arrow-e\"><\/span>\n\t\t\t\t\t<span class=\"ui-button-text\">\n\t\t\t\t\t\tStart\t\t\t\t\t<\/span>\n\t\t\t\t<\/button>\n\t\t\t{% } %}\n\t\t\t{% if (!i) { %}\n\t\t\t\t<button class=\"cancel secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\">\n\t\t\t\t\t<span class=\"ui-button-icon-primary ui-icon ui-icon-cancel\"><\/span>\n\t\t\t\t\t<span class=\"ui-button-text\">\n\t\t\t\t\t\tCancel\t\t\t\t\t<\/span>\n\t\t\t\t<\/button>\n\t\t\t{% } %}\n\t\t<\/td>\n\t<\/tr>\n{% } %}<\/script>  <script class=\"template-download\" id=\"ipt_fsqm_file_upload_8_0__tmpl_download\" type=\"text\/x-tmpl\">{%\n\twindow.ipt_fsqm_upload_count_global;\n\tif ( window.ipt_fsqm_upload_count_global == undefined ) {\n\t\twindow.ipt_fsqm_upload_count_global = 0;\n\t}\n%}\n{% for (var i=0, file; file=o.files[i]; i++) { %}\n{% var toggler_check_id = window.ipt_fsqm_upload_count_global++; %}\n\t<tr class=\"template-download\">\n\t\t<td class=\"preview_td\" colspan=\"2\">\n\t\t\t<span class=\"preview\">\n\t\t\t\t{% if (file.thumbnailUrl) { %}\n\t\t\t\t\t<a href=\"{%=file.url%}\" title=\"{%=file.name%}\" download=\"{%=file.name%}\" data-gallery><img decoding=\"async\" src=\"{%=file.thumbnailUrl%}\" \/><\/a>\n\t\t\t\t{% } else if ( file.validAudio ) { %}\n\t\t\t\t\t\t\t\t\t\t<audio controls=\"controls\">\n\t\t\t\t\t\t<source src=\"{%=file.url%}\" type=\"{%=file.type%}\" \/>\n\t\t\t\t\t\tYour browser does not support audio element.\t\t\t\t\t<\/audio>\n\t\t\t\t\t\t\t\t\t{% } else if ( file.validVideo ) { %}\n\t\t\t\t\t\t\t\t\t\t<video controls=\"controls\" height=\"100\" width=\"200\">\n\t\t\t\t\t\t<source src=\"{%=file.url%}\" type=\"{%=file.type%}\" \/>\n\t\t\t\t\t\tYour browser does not support video element.\t\t\t\t\t<\/video>\n\t\t\t\t\t\t\t\t\t{% } %}\n\t\t\t<\/span>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<p class=\"name\">\n\t\t\t\t<a href=\"{%=file.url%}\" title=\"{%=file.name%}\" download=\"{%=file.name%}\" {%=file.thumbnailUrl?'data-gallery':''%}>{%=file.name%}<\/a>\n\t\t\t<\/p>\n\t\t\t{% if (file.error) { %}\n\t\t\t\t<div><span class=\"error\">Error<\/span> {%=file.error%}<\/div>\n\t\t\t{% } %}\n\t\t\t<input type=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[freetype][0][id][]\" value=\"{%=file.id%}\" \/>\n\t\t<\/td>\n\t\t<td>\n\t\t\t<span class=\"size\">{%=o.formatFileSize(file.size)%}<\/span>\n\t\t<\/td>\n\t\t\t\t<td class=\"delete_button\">\n\t\t\t<button class=\"delete secondary-button small ui-button ui-widget ui-state-default ui-corner-all ui-button-text-icon-primary\" data-type=\"{%=file.deleteType%}\" data-url=\"{%=file.deleteUrl%}\"{% if (file.deleteWithCredentials) { %} data-xhr-fields='{\"withCredentials\":true}'{% } %}>\n\t\t\t\t<span class=\"ui-button-icon-primary ui-icon ui-icon-trash\"><\/span>\n\t\t\t\t<span class=\"ui-button-text\">\n\t\t\t\t\tDelete\t\t\t\t<\/span>\n\t\t\t<\/button>\n\t\t<\/td>\n\t\t\t\t\t<td class=\"delete_toggle\">\n\t\t\t\t<div class=\"ipt_uif_label_column\">\n\t\t\t\t\t<input type=\"checkbox\" name=\"delete\" value=\"1\" class=\"toggle ipt_uif_checkbox\" id=\"ipt_fsqm_file_upload_8_0__toggler_files_{%=toggler_check_id%}\" \/>\n\t\t\t\t\t<label data-labelcon=\"&#xe18e;\" for=\"ipt_fsqm_file_upload_8_0__toggler_files_{%=toggler_check_id%}\"><\/label>\n\t\t\t\t<\/div>\n\t\t\t<\/td>\n\t\t\t\t\t<\/tr>\n{% } %}<\/script> <\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><div\nid=\"ipt_fsqm_form_8_tab_4\" class=\"ipt_fsqm_form_tab_panel\"><div\nid=\"ipt_fsqm_form_8_layout_4_inner\" class=\"ipt-eform-layout-wrapper\"><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_main_heading_column\"><div\nclass=\"ipt_uif_column_inner\"><h3 class=\"ipt_fsqm_main_heading ipt_uif_heading ipt_uif_divider ipt_uif_align_left ipt_uif_divider_no_icon ipt_uif_divider_icon_no_bg\">\n<span\nclass=\"ipt_uif_divider_text\">\n<span\nclass=\"ipt_uif_divider_text_inner\">\nSubmit your Claim<span\nclass=\"subtitle\"><\/span>\t\t\t\t<\/span>\n<\/span><\/h3><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][23][m_type]\" id=\"ipt_fsqm_form_8_design_23_m_type\" value=\"design\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[design][23][type]\" id=\"ipt_fsqm_form_8_design_23_type\" value=\"richtext\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional\" id=\"ipt_fsqm_form_8_design_23\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_richtext\"><p>You\u2019re are almost done: Please complete the Declaration below and just click \u201cSubmit these claim details\u201d and we\u2019ll take it from there.<\/p><p\nclass=\"MsoNormal\" style=\"margin-bottom: 7.5pt; color: #222222; font-family: arial, sans-serif; font-size: small; text-align: justify; line-height: 13.5pt; vertical-align: baseline;\"><span\nstyle=\"font-size: 12pt;\">I hereby declare that to the best of my knowledge and belief that the information I have provided is correct and request you to deal on my behalf with any claims which may arise out of the accident in accordance with the terms and conditions of the Policy.<\/span><\/p><p\nclass=\"MsoNormal\" style=\"margin-bottom: 7.5pt; color: #222222; font-family: arial, sans-serif; font-size: small; text-align: justify; line-height: 13.5pt; vertical-align: baseline;\"><span\nstyle=\"font-size: 12pt;\">I authorize you and your attorneys-at-law on my behalf to make such admissions and settlements and give such consents as you consider necessary for the disposal of such claims and any litigation arising therefrom.<\/span><\/p><div\nclass=\"clear-both\"><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][62][m_type]\" id=\"ipt_fsqm_form_8_pinfo_62_m_type\" value=\"pinfo\" class=\"ipt_fsqm_hf_m_type\" \/>\n<input\ntype=\"hidden\" data-sayt-exclude name=\"ipt_fsqm_form_8[pinfo][62][type]\" id=\"ipt_fsqm_form_8_pinfo_62_type\" value=\"s_checkbox\" class=\"ipt_fsqm_hf_type\" \/><div\nclass=\"ipt_uif_column ipt_uif_column_full ipt_uif_conditional ipt_fsqm_container_s_checkbox column-centered\" id=\"ipt_fsqm_form_8_pinfo_62\"><div\nclass=\"ipt_uif_column_inner side_margin\"><div\nclass=\"ipt_uif_label_column column_1\">\n<input\ntype=\"checkbox\"\nclass=\"check_me validate[required] ipt_uif_checkbox filled-in  ipt_uif_s_checkbox\"\nname=\"ipt_fsqm_form_8[pinfo][62][value]\" id=\"ipt_fsqm_form_8_pinfo_62_value_1\"\nvalue=\"1\" \/>\n<label\nclass=\"eform-label-with-tabindex\" tabindex=\"0\" for=\"ipt_fsqm_form_8_pinfo_62_value_1\" data-labelcon=\"&#xf022;\">\nI agree\t\t\t\t<\/label><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><div\nclass=\"clear\"><\/div><div\nid=\"ipt_fsqm_form_8_button_container\" class=\"ipt_fsqm_form_button_container ipt_fsqm_form_button_container--classic ipt-eform-material-button-container\"><div\nclass=\"eform-button-container-inner\">\n<button\ntype=\"button\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_prev medium primary-button\" name=\"ipt_fsqm_form_8_button_prev\" id=\"ipt_fsqm_form_8_button_prev\"> Previous<\/button>\n<button\ntype=\"submit\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_submit medium primary-button\" name=\"ipt_fsqm_form_8_button_submit\" id=\"ipt_fsqm_form_8_button_submit\"> Submit<\/button>\n<button\ntype=\"button\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_next medium primary-button\" name=\"ipt_fsqm_form_8_button_next\" id=\"ipt_fsqm_form_8_button_next\"> Next<\/button>\n<button\ntype=\"reset\" title=\"Reset\" class=\"ipt_uif_button eform-material-button eform-ripple ipt_fsqm_form_button_reset ipt_uif_tooltip medium primary-button\" name=\"ipt_fsqm_form_8_button_reset\" id=\"ipt_fsqm_form_8_button_reset\"> <i\nclass=\"ipticm ipt-icomoon-refresh\"><\/i><\/button><\/div><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"ipt_fsqm_main_pb eform-mainpb-bottom ipt_uif_progress_bar\" data-start=\"0\" data-decimals=\"2\" id=\"ipt_fsqm_form_8_progressbar\"><div\nclass=\"ipt_uif_progress_value\"><span\nclass=\"eform-progress-value-span\"><\/span><\/div><\/div><div\nclass=\"clear-both\"><\/div><div\nclass=\"clear-both\"><\/div><\/div><\/div><\/form><\/div><div\nstyle=\"display: none;\" class=\"ipt_fsqm_form_message_success ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><h3><i\ntitle=\"\" class=\" ipt-icomoon-checkmark-circle ipticm prefix\"><\/i>\nYour claim has been submitted<\/h3><\/div><div\nclass=\"ui-widget-content ui-corner-all ipt_fsqm_success_wrap\"><p>Thank you for submitting your claim. This is to acknowledge receipt and advise you that we will contact you before the end of the next business day.<\/p><\/div><\/div><div\nstyle=\"display: none;\" class=\"ipt_fsqm_form_message_error ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><div><i\ntitle=\"\" class=\" ipt-icomoon-laptop ipticm prefix\"><\/i>\nServer Side Error<\/div><\/div><div\nclass=\"ui-widget-content ui-corner-all\"><p>We faced problems while connecting to the server or receiving data from the server. Please wait for a few seconds and try again.<\/p><p>If the problem persists, then check your internet connectivity. If all other sites open fine, then please contact the administrator of this website with the following information.<\/p><p\nclass=\"jqXHR\">\n<strong>TextStatus: <\/strong><span\nclass=\"textStatus\">undefined<\/span><br\n\/>\n<strong>HTTP Error: <\/strong><span\nclass=\"errorThrown\">undefined<\/span><\/p><\/div><\/div><div\nstyle=\"display: none\" class=\"ipt_uif_widget_box ipt_fsqm_form_message_process\"><div\nclass=\"ui-widget ui-widget-header ui-corner-all\"><style type=\"text\/css\">.ipt_uif_ajax_loader,\n\t\t\t.ipt_uif_ajax_loader *,\n\t\t\tipt_uif_ajax_loader *::before,\n\t\t\tipt_uif_ajax_loader *::after {\n\t\t\t\tbox-sizing: border-box;\n\t\t\t}<\/style><div\nclass=\"ipt-eform-preloader-inline ipt_uif_ajax_loader\"><div\nclass=\"ipt-eform-preloader-inner\"><div\nclass=\"ipt-eform-preloader-circle\"><div\nclass=\"preloader-wrapper active\"><div\nclass=\"spinner-layer spinner-blue\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-red\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-yellow\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><div\nclass=\"spinner-layer spinner-green\"><div\nclass=\"circle-clipper left\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"gap-patch\"><div\nclass=\"circle\"><\/div><\/div><div\nclass=\"circle-clipper right\"><div\nclass=\"circle\"><\/div><\/div><\/div><\/div><\/div><div\nclass=\"ipt-eform-preloader-text\"><div\nclass=\"ipt-eform-preloader-text-inner ipt_uif_ajax_loader_text\">Processing you request<\/div><\/div><div\nclass=\"clear\"><\/div><\/div><\/div><\/div><\/div><div\nstyle=\"display: none;\" class=\"ipt_fsqm_form_validation_error ui-widget ui-widget-content ui-corner-all ipt_uif_widget_box\"><div\nclass=\"ui-helper-reset ui-helper-clearfix ui-widget-header ui-corner-all\"><div><i\ntitle=\"\" class=\" ipt-icomoon-warning2 ipticm prefix\"><\/i>\n<span\nclass=\"fsqm_ve_text\">Error<\/span><\/div><\/div><div\nclass=\"ui-widget-content ui-corner-all\"><p\nclass=\"fsqm_ve_msg\">Some error has occured.<\/p><\/div><\/div><\/div><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-toggle-item\">\n\t\t\t\t\t<div id=\"elementor-tab-title-1375\" class=\"elementor-tab-title\" data-tab=\"5\" role=\"button\" aria-controls=\"elementor-tab-content-1375\" aria-expanded=\"false\">\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon elementor-toggle-icon-left\" aria-hidden=\"true\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon-closed\"><i class=\"fas fa-caret-right\"><\/i><\/span>\n\t\t\t\t\t\t\t\t<span class=\"elementor-toggle-icon-opened\"><i class=\"elementor-toggle-icon-opened fas fa-caret-up\"><\/i><\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t<a class=\"elementor-toggle-title\" tabindex=\"0\">Glass Only<\/a>\n\t\t\t\t\t<\/div>\n\n\t\t\t\t\t<div id=\"elementor-tab-content-1375\" class=\"elementor-tab-content elementor-clearfix\" data-tab=\"5\" role=\"region\" aria-labelledby=\"elementor-tab-title-1375\"><p>\t\t<div data-elementor-type=\"section\" data-elementor-id=\"3146\" class=\"elementor elementor-3146\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;}\" data-elementor-post-type=\"elementor_library\">\n\t\t\t\t\t<section class=\"has_eae_slider elementor-section elementor-top-section elementor-element elementor-element-a1ee19b premium-equal-height-yes elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-eae-slider=\"2938\" data-pa-eq-height=\"{&quot;targetType&quot;:&quot;widget&quot;,&quot;target&quot;:&quot;&quot;,&quot;trigger&quot;:&quot;load&quot;,&quot;enableOn&quot;:[&quot;desktop&quot;,&quot;tablet&quot;,&quot;mobile&quot;]}\" data-id=\"a1ee19b\" data-element_type=\"section\" data-e-type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;premium_eq_height_switcher&quot;:&quot;yes&quot;,&quot;_ha_eqh_enable&quot;:&quot;yes&quot;,&quot;_ha_eqh_to&quot;:&quot;widget&quot;,&quot;_ha_eqh_disable_on_tablet&quot;:&quot;no&quot;,&quot;_ha_eqh_disable_on_mobile&quot;:&quot;yes&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-narrow\">\n\t\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-4fe2dfa\" data-eae-slider=\"83378\" data-id=\"4fe2dfa\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-8586a9f\" data-eae-slider=\"54772\" data-id=\"8586a9f\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-1faeaf7 ekit-equal-height-disable elementor-widget elementor-widget-elementskit-image-box\" data-id=\"1faeaf7\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"elementskit-image-box.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"ekit-wid-con\" >\n            <div class=\"elementskit-info-image-box ekit-image-box text-center hover_from_left hover-border-bottom\" >\n\n                <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/windscreen\/about-you\" target=\"_blank\">\n                <div class=\"elementskit-box-header image-box-img-center\">\n\n                    <img loading=\"lazy\" decoding=\"async\" width=\"1024\" height=\"683\" src=\"https:\/\/bciconline.com\/ba\/wp-content\/uploads\/sites\/6\/2022\/07\/fmf-D1l9o8a-1024x683-1.jpeg\" class=\"attachment-full size-full wp-image-3153\" alt=\"\" \/>\n                <\/div>\n                <\/a>\n                <div class=\"elementskit-box-body ekit-image-box-body\">\n                    <div class=\"elementskit-box-content ekit-image-box-body-inner\">\n                                                <h3 class=\"elementskit-info-box-title\">\n\n                        Glass Only\n                        \n                    <\/h3>\n                                                        <\/div>\n\n                                <div class=\"elementskit-box-footer\">\n                    <div class=\"box-footer\">\n                        <div class=\"btn-wraper\">\n                                                            <a href=\"https:\/\/myclaims.bciconline.com\/report-a-claim\/bb\/motor\/windscreen\/about-you\" class=\"elementskit-btn whitespace--normal\">\n                                    \n                                    \n                                    Report Claim Here                                <\/a>\n                                                        <\/div>\n                    <\/div>\n                <\/div>\n                            <\/div>\n            <\/div>\n    <\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"has_eae_slider elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-1d458d1\" data-eae-slider=\"71786\" data-id=\"1d458d1\" data-element_type=\"column\" data-e-type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t<\/p><\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>How to Make A Claim. We know you need us the most when making a claim, our priority is to make it\u00a0 hassle free. Report a Claim or Call us 246-621-7340 Email us info@bcicbarbados.com scroll for more Report your Claim below: In an accident? Call BCIC ASSIST and we will handle everything for you. From [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"_monsterinsights_skip_tracking":false,"footnotes":""},"class_list":["post-1636","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/bciconline.com\/ba\/wp-json\/wp\/v2\/pages\/1636","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/bciconline.com\/ba\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/bciconline.com\/ba\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/bciconline.com\/ba\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/bciconline.com\/ba\/wp-json\/wp\/v2\/comments?post=1636"}],"version-history":[{"count":110,"href":"https:\/\/bciconline.com\/ba\/wp-json\/wp\/v2\/pages\/1636\/revisions"}],"predecessor-version":[{"id":5255,"href":"https:\/\/bciconline.com\/ba\/wp-json\/wp\/v2\/pages\/1636\/revisions\/5255"}],"wp:attachment":[{"href":"https:\/\/bciconline.com\/ba\/wp-json\/wp\/v2\/media?parent=1636"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}