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Subject

Description

Policy Number

Date of Birth

Claim Number

MainClientId

InternalPolicyNumber

OtherClientId

ClaimNames

Email Address

Confirm Email Address

Phone Number - Enter without international dialing code.

Which country were you travelling to?

Trip departure date

Trip return date

Date you booked the trip

Date of loss/incident (When it happened)

Reason for your claim

<div class="form-group  helpdesk_ticket_custom_field_cf_who_has_caused_the_cancellation_2321673">
    <label for="helpdesk_ticket_custom_field_cf_who_has_caused_the_cancellation_2321673" class=" form-label">
    	Who has caused the cancellation?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000833178}"}'value="Myself or another insured person">
            Myself or another insured person
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833179}"}'value="Travelling companion (not on this policy)">
            Travelling companion (not on this policy)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833180}"}'value="Close relative (not on this policy)">
            Close relative (not on this policy)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833181}"}'value="Someone you were intending to stay with">
            Someone you were intending to stay with
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_are_you_currently_still_abroad_2321673">
    <label for="helpdesk_ticket_custom_field_cf_are_you_currently_still_abroad_2321673" class=" form-label">
    	 Why did you cancel your trip?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000833183}"}'value="Illness">
            Illness
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833184}"}'value="Injury">
            Injury
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833185}"}'value="Death">
            Death
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101001127629}"}'value="Other - Select if you&#39;re sure it&#39;s not listed above">
            Other - Select if you&#39;re sure it&#39;s not listed above
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833186}"}'value="Redundancy from work">
            Redundancy from work
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833187}"}'value="Called for jury service or as a witness">
            Called for jury service or as a witness
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833188}"}'value="Your home or business premises being uninhabitable">
            Your home or business premises being uninhabitable
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833189}"}'value="Pregnancy">
            Pregnancy
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833190}"}'value="Cancellation of leave by emergency services or armed forces">
            Cancellation of leave by emergency services or armed forces
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_when_did_the_symptoms_start_2321673" class=" form-label">
			When did the symptoms start?
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_what_medical_condition_has_resulted_in_cancellation748907_2321673">
    <label for="helpdesk_ticket_custom_field_cf_what_medical_condition_has_resulted_in_cancellation748907_2321673" class=" form-label">
    	What medical condition has resulted in cancellation?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000833341}"}'value="Acid reflux">
            Acid reflux
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833364}"}'value="Allergies">
            Allergies
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833342}"}'value="Angina">
            Angina
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833385}"}'value="Anxiety / Depression / Stress">
            Anxiety / Depression / Stress
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833375}"}'value="Appendicitis">
            Appendicitis
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833343}"}'value="Arthritis">
            Arthritis
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833344}"}'value="Asthma">
            Asthma
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833345}"}'value="Atrial fibrillation">
            Atrial fibrillation
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833372}"}'value="Bladder infection">
            Bladder infection
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833381}"}'value="Bowel Obstruction">
            Bowel Obstruction
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833346}"}'value="Cancer">
            Cancer
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833347}"}'value="Cardiac arrhythmia">
            Cardiac arrhythmia
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833379}"}'value="Chest Infection">
            Chest Infection
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833388}"}'value="Chicken Pox">
            Chicken Pox
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833348}"}'value="Cholesterol">
            Cholesterol
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833351}"}'value="Chronic obstructive pulmonary disease (COPD)">
            Chronic obstructive pulmonary disease (COPD)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833362}"}'value="Cold/Flu">
            Cold/Flu
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833349}"}'value="Colitis">
            Colitis
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833367}"}'value="Conjunctivitis">
            Conjunctivitis
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833363}"}'value="Coronavirus">
            Coronavirus
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833389}"}'value="Coronavirus - Long Covid">
            Coronavirus - Long Covid
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833350}"}'value="Crohn&#39;s disease">
            Crohn&#39;s disease
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833352}"}'value="Diabetes">
            Diabetes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833386}"}'value="Ear Infection">
            Ear Infection
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833373}"}'value="Eczema">
            Eczema
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833353}"}'value="Epilepsy">
            Epilepsy
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833368}"}'value="Food poisoning">
            Food poisoning
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833369}"}'value="Gastroenteritis">
            Gastroenteritis
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833371}"}'value="Headache">
            Headache
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833358}"}'value="Heart attack">
            Heart attack
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833376}"}'value="Heart Block">
            Heart Block
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833380}"}'value="Hernia">
            Hernia
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833355}"}'value="Hyper/Hypo thyroidism">
            Hyper/Hypo thyroidism
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833354}"}'value="Hypertension">
            Hypertension
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833366}"}'value="laryngitis">
            laryngitis
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833370}"}'value="Migrane">
            Migrane
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833374}"}'value="Ongoing Test &amp; Investigations">
            Ongoing Test &amp; Investigations
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833357}"}'value="Osteoporosis">
            Osteoporosis
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833361}"}'value="Other">
            Other
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833356}"}'value="Rheumatoid arthritis">
            Rheumatoid arthritis
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833382}"}'value="Sciatica">
            Sciatica
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833377}"}'value="Seizures">
            Seizures
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833384}"}'value="Sickness / Diarrhoea">
            Sickness / Diarrhoea
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833360}"}'value="Stroke">
            Stroke
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833365}"}'value="Tonsillitis">
            Tonsillitis
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833359}"}'value="Transient ischaemic attack (TIA)">
            Transient ischaemic attack (TIA)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833387}"}'value="Vertigo">
            Vertigo
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833378}"}'value="Viral Infection">
            Viral Infection
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_on_what_date_did_the_incident_causing_the_injury_happen_2321673" class=" form-label">
			On what date did the incident causing the injury happen?
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_who_advised_to_cancel_2321673">
    <label for="helpdesk_ticket_custom_field_cf_who_advised_to_cancel_2321673" class=" form-label">
    	Who advised to cancel?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834654}"}'value="Medical professional (Doctor or Nurse)">
            Medical professional (Doctor or Nurse)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834655}"}'value="Medical facility (Hospital or Physio)">
            Medical facility (Hospital or Physio)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834657}"}'value="Was not advised to Cancel">
            Was not advised to Cancel
          </option>

</select>

<div class="form-group ">
  
		<label for="helpdesk_ticket_custom_field_cf_please_give_us_further_details352533_2321673" class="form-label">
			Please give us further details
			
			
		</label>

<textarea
  	class="form-control section-field"
  	id="helpdesk_ticket_custom_field_cf_please_give_us_further_details352533_2321673"
  	name="helpdesk_ticket[custom_field][cf_please_give_us_further_details352533_2321673]"
    rows="6"
    cols=""
  	
  	
		placeholder=""
    
  >&lt/textarea&gt

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_on_what_date_were_you_advised_of_the_redundancy_2321673" class=" form-label">
			On what date were you advised of the redundancy
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_do_you_qualify_for_redundancy_payment_under_current_legislation_2321673">
    <label for="helpdesk_ticket_custom_field_cf_do_you_qualify_for_redundancy_payment_under_current_legislation_2321673" class=" form-label">
    	Do you qualify for redundancy payment under current legislation
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834658}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834659}"}'value="No">
            No
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_on_what_date_were_you_advised_of_the_jury_service_or_court_date_2321673" class=" form-label">
			On what date were you advised of the jury service or court date
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_please_confirm_the_date_of_death_2321673" class=" form-label">
			Please confirm the date of death
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_please_confirm_the_cause_of_death_2321673" class=" form-label">
			Please confirm the cause of death
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_to_the_best_of_your_knowledge_were_you_or_this_person_considered_stable_at_the_time_of_booking_the_trip_2321673">
    <label for="helpdesk_ticket_custom_field_cf_to_the_best_of_your_knowledge_were_you_or_this_person_considered_stable_at_the_time_of_booking_the_trip_2321673" class=" form-label">
    	To the best of your knowledge, were you or this person considered stable at the time of booking the trip
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834660}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834661}"}'value="No">
            No
          </option>

</select>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834662}"}'value="Package booking (e.g. flights and accommodation or flights and cruise)">
            Package booking (e.g. flights and accommodation or flights and cruise)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834663}"}'value="Independent booking (travel and accommodation booked separately">
            Independent booking (travel and accommodation booked separately
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834664}"}'value="Accommodation ONLY (no travel costs)">
            Accommodation ONLY (no travel costs)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834665}"}'value="Travel ONLY (e.g flights or ferry)">
            Travel ONLY (e.g flights or ferry)
          </option>

</select>

<div class="form-group ">
  
		<label for="helpdesk_ticket_custom_field_cf_please_confirm_the_name_of_the_trip_providers_and_the_booking_references342856_2321673" class="form-label">
			Please confirm the name of the trip provider(s) and the booking reference(s)
			
			
		</label>

<textarea
  	class="form-control section-field"
  	id="helpdesk_ticket_custom_field_cf_please_confirm_the_name_of_the_trip_providers_and_the_booking_references342856_2321673"
  	name="helpdesk_ticket[custom_field][cf_please_confirm_the_name_of_the_trip_providers_and_the_booking_references342856_2321673]"
    rows="6"
    cols=""
  	
  	
		placeholder=""
    
  >&lt/textarea&gt

<div class="form-group  helpdesk_ticket_custom_field_cf_currency_type637939_2321673">
    <label for="helpdesk_ticket_custom_field_cf_currency_type637939_2321673" class=" form-label">
    	Currency type
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000830858}"}'value="United States Dollar">
            United States Dollar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830859}"}'value="Euro">
            Euro
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830860}"}'value="British Pound">
            British Pound
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830861}"}'value="Australian Dollar">
            Australian Dollar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830862}"}'value="Canadian Dollar">
            Canadian Dollar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830863}"}'value="Afghan Afghani">
            Afghan Afghani
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830864}"}'value="Albanian Lek">
            Albanian Lek
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830865}"}'value="Algerian Dinar">
            Algerian Dinar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830866}"}'value="Arab Emirates Dirham">
            Arab Emirates Dirham
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830867}"}'value="Argentine Peso">
            Argentine Peso
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830868}"}'value="Armenian Dram">
            Armenian Dram
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830869}"}'value="Azerbaijani Manat">
            Azerbaijani Manat
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830870}"}'value="Bahamian Dollar">
            Bahamian Dollar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830871}"}'value="Bahraini Dinar">
            Bahraini Dinar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830872}"}'value="Bangladeshi Taka">
            Bangladeshi Taka
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830873}"}'value="Barbados Dollar">
            Barbados Dollar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830874}"}'value="Belarusian Ruble">
            Belarusian Ruble
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830875}"}'value="Belize Dollar">
            Belize Dollar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830876}"}'value="Bermudan Dollar">
            Bermudan Dollar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830877}"}'value="Bolivian Boliviano">
            Bolivian Boliviano
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830878}"}'value="Bosnia-Herzegovina Convertible Mark">
            Bosnia-Herzegovina Convertible Mark
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830879}"}'value="Botswanan Pula">
            Botswanan Pula
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830880}"}'value="Brazilian Real">
            Brazilian Real
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830881}"}'value="Brunei Dollar">
            Brunei Dollar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830882}"}'value="Bulgarian Lev">
            Bulgarian Lev
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830883}"}'value="Cambodian riel">
            Cambodian riel
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830884}"}'value="Cape Verdean Escudo">
            Cape Verdean Escudo
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830885}"}'value="Central African CFA franc">
            Central African CFA franc
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830886}"}'value="CFP franc">
            CFP franc
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830887}"}'value="Chilean Peso">
            Chilean Peso
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830888}"}'value="Chinese Yuan">
            Chinese Yuan
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830889}"}'value="Colombian Peso">
            Colombian Peso
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830890}"}'value="Congolese Franc">
            Congolese Franc
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830891}"}'value="Costa Rican Colón">
            Costa Rican Colón
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830892}"}'value="Croatian Kuna">
            Croatian Kuna
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830893}"}'value="Cuban Convertible Peso">
            Cuban Convertible Peso
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830894}"}'value="Czech Koruna">
            Czech Koruna
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830895}"}'value="Danish Krone">
            Danish Krone
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830896}"}'value="Dominican Peso">
            Dominican Peso
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830897}"}'value="Eastern Caribbean dollar">
            Eastern Caribbean dollar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830898}"}'value="Egyptian Pound">
            Egyptian Pound
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830899}"}'value="Ethiopian Birr">
            Ethiopian Birr
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830900}"}'value="Fijian Dollar">
            Fijian Dollar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830901}"}'value="Gambian dalasi">
            Gambian dalasi
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830902}"}'value="Georgian Lari">
            Georgian Lari
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830903}"}'value="Ghanaian Cedi">
            Ghanaian Cedi
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830904}"}'value="Gibraltar pound">
            Gibraltar pound
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830905}"}'value="Guatemalan Quetzal">
            Guatemalan Quetzal
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830906}"}'value="Guinean Franc">
            Guinean Franc
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830907}"}'value="Guyanaese Dollar">
            Guyanaese Dollar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830908}"}'value="Haitian Gourde">
            Haitian Gourde
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830909}"}'value="Honduran Lempira">
            Honduran Lempira
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830910}"}'value="Hong Kong Dollar">
            Hong Kong Dollar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830911}"}'value="Hungarian Forint">
            Hungarian Forint
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830912}"}'value="Icelandic Króna">
            Icelandic Króna
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830913}"}'value="Indian Rupee">
            Indian Rupee
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830914}"}'value="Indonesian Rupiah">
            Indonesian Rupiah
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830915}"}'value="Iranian Rial">
            Iranian Rial
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830916}"}'value="Iraqi Dinar">
            Iraqi Dinar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830917}"}'value="Israeli New Shekel">
            Israeli New Shekel
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830918}"}'value="Jamaican Dollar">
            Jamaican Dollar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830919}"}'value="Japanese Yen">
            Japanese Yen
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830920}"}'value="Jordanian Dinar">
            Jordanian Dinar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830921}"}'value="Kazakhstani Tenge">
            Kazakhstani Tenge
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830922}"}'value="Kenyan Shilling">
            Kenyan Shilling
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830923}"}'value="Kuwaiti Dinar">
            Kuwaiti Dinar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830924}"}'value="Lebanese pound">
            Lebanese pound
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830925}"}'value="Liberian Dollar">
            Liberian Dollar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830926}"}'value="Libyan dinar">
            Libyan dinar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830927}"}'value="Macedonian Denar">
            Macedonian Denar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830928}"}'value="Malagasy ariary">
            Malagasy ariary
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830929}"}'value="Malawian kwacha">
            Malawian kwacha
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830930}"}'value="Malaysian ringgit">
            Malaysian ringgit
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830931}"}'value="Maldivian rufiyaa">
            Maldivian rufiyaa
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830932}"}'value="Mauritian Rupee">
            Mauritian Rupee
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830933}"}'value="Mexican peso">
            Mexican peso
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830934}"}'value="Moldovan leu">
            Moldovan leu
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830935}"}'value="Mongolian tögrög">
            Mongolian tögrög
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830936}"}'value="Moroccan dirham">
            Moroccan dirham
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830937}"}'value="Mozambican metical">
            Mozambican metical
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830938}"}'value="Namibian dollar">
            Namibian dollar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830939}"}'value="Nepalese Rupee">
            Nepalese Rupee
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830940}"}'value="New Taiwan dollar">
            New Taiwan dollar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830941}"}'value="New Zealand Dollar">
            New Zealand Dollar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830942}"}'value="Nigerian Naira">
            Nigerian Naira
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830943}"}'value="North Korean won">
            North Korean won
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830944}"}'value="Norwegian Krone">
            Norwegian Krone
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830945}"}'value="Omani Rial">
            Omani Rial
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830946}"}'value="Pakistani Rupee">
            Pakistani Rupee
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830947}"}'value="Panamanian Balboa">
            Panamanian Balboa
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830948}"}'value="Papua New Guinean Kina">
            Papua New Guinean Kina
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830949}"}'value="Paraguayan Guarani">
            Paraguayan Guarani
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830950}"}'value="Peru Sol">
            Peru Sol
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830951}"}'value="Philippine peso">
            Philippine peso
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830952}"}'value="Poland zloty">
            Poland zloty
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830953}"}'value="Qatari Rial">
            Qatari Rial
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830954}"}'value="Romanian Leu">
            Romanian Leu
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830955}"}'value="Russian Ruble">
            Russian Ruble
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830956}"}'value="Rwandan franc">
            Rwandan franc
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830957}"}'value="Samoan tala">
            Samoan tala
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830958}"}'value="Saudi Riyal">
            Saudi Riyal
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830959}"}'value="Serbian Dinar">
            Serbian Dinar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830960}"}'value="Seychellois Rupee">
            Seychellois Rupee
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830961}"}'value="Sierra Leonean Leone">
            Sierra Leonean Leone
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830962}"}'value="Singapore Dollar">
            Singapore Dollar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830963}"}'value="South African Rand">
            South African Rand
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830964}"}'value="South Korean won">
            South Korean won
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830965}"}'value="Sri Lankan Rupee">
            Sri Lankan Rupee
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830966}"}'value="Sudanese pound">
            Sudanese pound
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830967}"}'value="Swazi lilangeni">
            Swazi lilangeni
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830968}"}'value="Swedish Krona">
            Swedish Krona
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830969}"}'value="Swiss Franc">
            Swiss Franc
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830970}"}'value="Syrian pound">
            Syrian pound
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830971}"}'value="Tajikistani somoni">
            Tajikistani somoni
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830972}"}'value="Tanzanian Shilling">
            Tanzanian Shilling
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830973}"}'value="Thai baht">
            Thai baht
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830974}"}'value="Trinidad &amp; Tobago Dollar">
            Trinidad &amp; Tobago Dollar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830975}"}'value="Tunisian Dinar">
            Tunisian Dinar
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830976}"}'value="Turkish lira">
            Turkish lira
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830977}"}'value="Turkmenistan manat">
            Turkmenistan manat
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830978}"}'value="Ugandan shilling">
            Ugandan shilling
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830979}"}'value="Ukrainian hryvnia">
            Ukrainian hryvnia
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830980}"}'value="Uruguayan Peso">
            Uruguayan Peso
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830981}"}'value="Uzbekistani Som">
            Uzbekistani Som
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830982}"}'value="Venezuelan soberano">
            Venezuelan soberano
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830983}"}'value="Vietnamese dong">
            Vietnamese dong
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830984}"}'value="Zambian kwacha">
            Zambian kwacha
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830985}"}'value="Zimbabwean dollar">
            Zimbabwean dollar
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_total_trip_cost_the_amount_you_paid_2321673" class=" form-label">
			Enter amount you paid for the trip (e.g. 100.00)
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_have_you_received_any_refunds_or_compensation702973_2321673" class=" form-label">
			Enter any refunds you have received for this trip (e.g. 50.00)
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_please_enter_the_date_you_asked_your_tour_operatortravel_provider_to_cancel_the_trip_2321673" class=" form-label">
			Please enter the date you asked your tour operator/travel provider to cancel the trip
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_do_you_have_any_other_travel_insurance_policy400572_2321673">
    <label for="helpdesk_ticket_custom_field_cf_do_you_have_any_other_travel_insurance_policy400572_2321673" class=" form-label">
    	Other than this policy, do you have any other insurance policy that may cover this event?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000833131}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833132}"}'value="No">
            No
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_name_of_your_policy_provider895583_2321673" class=" form-label">
			Name of your policy provider
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_policy_number964552_2321673" class=" form-label">
			Policy number
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_when_did_the_symptoms_start437132_2321673" class=" form-label">
			When did the symptoms start?
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_are_you_claiming_for_an_injury_or_illness644442_2321673">
    <label for="helpdesk_ticket_custom_field_cf_are_you_claiming_for_an_injury_or_illness644442_2321673" class=" form-label">
    	Are you claiming for an injury or illness?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000832759}"}'value="Illness">
            Illness
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832760}"}'value="Injury">
            Injury
          </option>

</select>

<div class="form-group ">
  
		<label for="helpdesk_ticket_custom_field_cf_please_provide_any_further_information_about_the_condition_2321673" class="form-label">
			In your own words, tell us what happened
			
			
		</label>

<textarea
  	class="form-control section-field"
  	id="helpdesk_ticket_custom_field_cf_please_provide_any_further_information_about_the_condition_2321673"
  	name="helpdesk_ticket[custom_field][cf_please_provide_any_further_information_about_the_condition_2321673]"
    rows="6"
    cols=""
  	
  	
		placeholder=""
    
  >&lt/textarea&gt

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_please_confirm_the_first_date_of_diagnosis_for_this_condition_2321673" class=" form-label">
			Please confirm the first date of diagnosis for this condition
			
			
		</label>

<div class="form-group ">
  
		<label for="helpdesk_ticket_custom_field_cf_please_list_the_expenses_incurred_including_the_type_of_expense_and_the_name_of_the_dentist_or_company_that_provided_this_expense90799_2321673" class="form-label">
			Please list the expenses incurred, include the type of expense with the name of the doctor/company:
			
			
		</label>

<textarea
  	class="form-control section-field"
  	id="helpdesk_ticket_custom_field_cf_please_list_the_expenses_incurred_including_the_type_of_expense_and_the_name_of_the_dentist_or_company_that_provided_this_expense90799_2321673"
  	name="helpdesk_ticket[custom_field][cf_please_list_the_expenses_incurred_including_the_type_of_expense_and_the_name_of_the_dentist_or_company_that_provided_this_expense90799_2321673]"
    rows="6"
    cols=""
  	
  	
		placeholder=""
    
  >&lt/textarea&gt

<option value>Choose...</option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_amount_paid_in_local_currency527297_2321673" class=" form-label">
			Total amount paid: Enter numbers only - 100.00
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_date_of_payment778903_2321673" class=" form-label">
			Date of payment
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_do_any_of_the_costs_relate_to_covid_tests_2321673">
    <label for="helpdesk_ticket_custom_field_cf_do_any_of_the_costs_relate_to_covid_tests_2321673" class=" form-label">
    	Do any of the costs relate to Covid Test(s)?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000859803}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000859804}"}'value="No">
            No
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_do_any_of_the_costs_relate_to_physiotherapy_or_chiropracter_2321673">
    <label for="helpdesk_ticket_custom_field_cf_do_any_of_the_costs_relate_to_physiotherapy_or_chiropracter_2321673" class=" form-label">
    	Do any of the costs relate to Physiotherapy or Chiropracter?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000859811}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000859812}"}'value="No">
            No
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_do_any_of_the_costs_relate_to_accommodation555447_2321673">
    <label for="helpdesk_ticket_custom_field_cf_do_any_of_the_costs_relate_to_accommodation555447_2321673" class=" form-label">
    	Do any of the costs relate to accommodation?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000859833}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000859834}"}'value="No">
            No
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_do_any_of_the_costs_relate_to_travel_not_including_the_ambulance_or_taxi_to_the_hospital_2321673">
    <label for="helpdesk_ticket_custom_field_cf_do_any_of_the_costs_relate_to_travel_not_including_the_ambulance_or_taxi_to_the_hospital_2321673" class=" form-label">
    	Do any of the costs relate to travel (not including the ambulance or taxi to the hospital?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000859835}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000859836}"}'value="No">
            No
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_do_you_have_any_other_travel_insurance_policy206683_2321673">
    <label for="helpdesk_ticket_custom_field_cf_do_you_have_any_other_travel_insurance_policy206683_2321673" class=" form-label">
    	Other than this policy, do you have any other insurance policy that may cover this event?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000832955}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832956}"}'value="No">
            No
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_name_of_your_policy_provider_2321673" class=" form-label">
			Name of your policy provider
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_policy_number533894_2321673" class=" form-label">
			Policy number
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_name_of_your_policy_provider618179_2321673" class=" form-label">
			Name of your policy provider
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_policy_number701021_2321673" class=" form-label">
			Policy number
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_what_transport_was_delayed_2321673">
    <label for="helpdesk_ticket_custom_field_cf_what_transport_was_delayed_2321673" class=" form-label">
    	What transport was delayed?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000830647}"}'value="Aeroplane">
            Aeroplane
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830648}"}'value="Ferry">
            Ferry
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830649}"}'value="Coach">
            Coach
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830650}"}'value="Train">
            Train
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000836590}"}'value="Cruise">
            Cruise
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_what_was_the_reason_for_the_delay_2321673">
    <label for="helpdesk_ticket_custom_field_cf_what_was_the_reason_for_the_delay_2321673" class=" form-label">
    	What was the reason for the delay?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000836605}"}'value="Bad Weather">
            Bad Weather
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000836606}"}'value="Strike or Industrial Action">
            Strike or Industrial Action
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000836608}"}'value="Fault or Mechanical Breakdown of Transport">
            Fault or Mechanical Breakdown of Transport
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000836609}"}'value="Failure of Air Traffic Control">
            Failure of Air Traffic Control
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000836610}"}'value="Crew Shortage - Lack of Transport Staff">
            Crew Shortage - Lack of Transport Staff
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_how_many_hours_were_you_delayed_2321673" class=" form-label">
			Full hours delayed? Enter numbers only. 4 hours = 4
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_on_which_part_of_the_journey_were_you_delayed_2321673">
    <label for="helpdesk_ticket_custom_field_cf_on_which_part_of_the_journey_were_you_delayed_2321673" class=" form-label">
    	On which part of the journey were you delayed?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000836647}"}'value="On the return journey back home">
            On the return journey back home
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000836648}"}'value="On the outward journey to my destination">
            On the outward journey to my destination
          </option>

</select>

<div class="form-group ">
  
		<label for="helpdesk_ticket_custom_field_cf_give_us_more_information_2321673" class="form-label">
			Please provide any additional details about your travel delay
			
			
		</label>

<textarea
  	class="form-control section-field"
  	id="helpdesk_ticket_custom_field_cf_give_us_more_information_2321673"
  	name="helpdesk_ticket[custom_field][cf_give_us_more_information_2321673]"
    rows="6"
    cols=""
  	
  	
		placeholder=""
    
  >&lt/textarea&gt

<label for="helpdesk_ticket_custom_field_cf_please_tick_this_box_if_your_travel_delay_was_related_to_the_recent_cyber_attack_2321673" class="form-check-label ">
			Please tick this box if your travel delay was related to the recent cyber attack.
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_are_you_claiming_for_a_loss_or_theft_2321673">
    <label for="helpdesk_ticket_custom_field_cf_are_you_claiming_for_a_loss_or_theft_2321673" class=" form-label">
    	Are you claiming for a loss or theft?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834813}"}'value="Theft">
            Theft
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834814}"}'value="Loss">
            Loss
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_where_did_the_loss_or_theft_take_place_2321673">
    <label for="helpdesk_ticket_custom_field_cf_where_did_the_loss_or_theft_take_place_2321673" class=" form-label">
    	Where did the loss or theft take place
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834816}"}'value="From your own or a rental vehicle">
            From your own or a rental vehicle
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834817}"}'value="Checked-in luggage (In my suitcase)">
            Checked-in luggage (In my suitcase)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834818}"}'value="Pickpocketed or Stolen whilst in your possession">
            Pickpocketed or Stolen whilst in your possession
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834819}"}'value="At the beach">
            At the beach
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834820}"}'value="By the pool side">
            By the pool side
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834821}"}'value="Left on public transport (Flight, Bus, Train or Taxi)">
            Left on public transport (Flight, Bus, Train or Taxi)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834822}"}'value="Other">
            Other
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834823}"}'value="Hotel room">
            Hotel room
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834824}"}'value="Safety deposit box">
            Safety deposit box
          </option>

</select>

<div class="form-group ">
  
		<label for="helpdesk_ticket_custom_field_cf_in_your_own_words_tell_us_what_happened994308_2321673" class="form-label">
			In a few words, tell us what happened:
			
			
		</label>

<textarea
  	class="form-control section-field"
  	id="helpdesk_ticket_custom_field_cf_in_your_own_words_tell_us_what_happened994308_2321673"
  	name="helpdesk_ticket[custom_field][cf_in_your_own_words_tell_us_what_happened994308_2321673]"
    rows="6"
    cols=""
  	
  	
		placeholder=""
    
  >&lt/textarea&gt

<div class="form-group ">
  
		<label for="helpdesk_ticket_custom_field_cf_in_your_own_words_tell_us_what_happened511569_2321673" class="form-label">
			In a few words, tell us what happened:
			
			
		</label>

<textarea
  	class="form-control section-field"
  	id="helpdesk_ticket_custom_field_cf_in_your_own_words_tell_us_what_happened511569_2321673"
  	name="helpdesk_ticket[custom_field][cf_in_your_own_words_tell_us_what_happened511569_2321673]"
    rows="6"
    cols=""
  	
  	
		placeholder=""
    
  >&lt/textarea&gt

<div class="form-group  helpdesk_ticket_custom_field_cf_were_you_in_the_vehicle_at_the_time_of_the_theft_2321673">
    <label for="helpdesk_ticket_custom_field_cf_were_you_in_the_vehicle_at_the_time_of_the_theft_2321673" class=" form-label">
    	Were you in the vehicle at the time of the theft
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834845}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834846}"}'value="No">
            No
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_whereabouts_in_the_vehicle_was_the_items_when_stolen_2321673">
    <label for="helpdesk_ticket_custom_field_cf_whereabouts_in_the_vehicle_was_the_items_when_stolen_2321673" class=" form-label">
    	Whereabouts in the vehicle was the item(s) when stolen?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834847}"}'value="Back Seat">
            Back Seat
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834848}"}'value="Foot Well">
            Foot Well
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834849}"}'value="Glove Box">
            Glove Box
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834850}"}'value="Front Seat">
            Front Seat
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834851}"}'value="Boot">
            Boot
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_was_there_physical_damage_to_the_vehicle_2321673">
    <label for="helpdesk_ticket_custom_field_cf_was_there_physical_damage_to_the_vehicle_2321673" class=" form-label">
    	Was there physical damage to the vehicle?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834852}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834853}"}'value="No">
            No
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_are_any_of_the_items_lost_defined_as_a_valuable_gadgetelectrical_as_shown_within_your_policy_wording_2321673">
    <label for="helpdesk_ticket_custom_field_cf_are_any_of_the_items_lost_defined_as_a_valuable_gadgetelectrical_as_shown_within_your_policy_wording_2321673" class=" form-label">
    	Are any of the items a valuable or Gadget (e.g. Watches, jewellery, tablets, mobile phones)
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834860}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834861}"}'value="No">
            No
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_are_you_claiming_for_more_than_1_item_2321673">
    <label for="helpdesk_ticket_custom_field_cf_are_you_claiming_for_more_than_1_item_2321673" class=" form-label">
    	Are you claiming for more than 1 item?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834863}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834864}"}'value="No">
            No
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_did_you_report_the_loss_or_theft_2321673">
    <label for="helpdesk_ticket_custom_field_cf_did_you_report_the_loss_or_theft_2321673" class=" form-label">
    	Did you report the loss or theft?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834865}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834866}"}'value="No">
            No
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_who_did_you_report_it_to_2321673">
    <label for="helpdesk_ticket_custom_field_cf_who_did_you_report_it_to_2321673" class=" form-label">
    	Who did you report it to
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834867}"}'value="Hotel (Duty manager, receptionist etc)">
            Hotel (Duty manager, receptionist etc)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834868}"}'value="Airline (Baggage desk, flight attendant etc)">
            Airline (Baggage desk, flight attendant etc)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834869}"}'value="Police">
            Police
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834870}"}'value="Tour Operator (Travel representative etc)">
            Tour Operator (Travel representative etc)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834871}"}'value="Other">
            Other
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_please_give_us_further_details341695_2321673" class=" form-label">
			Please give us further details
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_please_confirm_why_you_did_not_report_the_loss_or_theft6975_2321673">
    <label for="helpdesk_ticket_custom_field_cf_please_confirm_why_you_did_not_report_the_loss_or_theft6975_2321673" class=" form-label">
    	Please confirm why you did not report the loss or theft
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834877}"}'value="Loss occurred in a remote location">
            Loss occurred in a remote location
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834878}"}'value="Insufficient time to report loss">
            Insufficient time to report loss
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834879}"}'value="Unaware loss report was required">
            Unaware loss report was required
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834880}"}'value="Item was lost at sea/overboard">
            Item was lost at sea/overboard
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834881}"}'value="Other reason">
            Other reason
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_how_many_items_are_you_claiming_for_2321673">
    <label for="helpdesk_ticket_custom_field_cf_how_many_items_are_you_claiming_for_2321673" class=" form-label">
    	How many items are you claiming for?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834882}"}'value="1">
            1
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834883}"}'value="2">
            2
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834884}"}'value="3">
            3
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834885}"}'value="4">
            4
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834886}"}'value="5">
            5
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834887}"}'value="6">
            6
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834888}"}'value="7">
            7
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834889}"}'value="8">
            8
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834890}"}'value="9">
            9
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_what_is_the_total_amount_youre_claiming_2321673" class=" form-label">
			Total amount being claimed. Enter numbers only - 100.00
			
			
		</label>

<div class="form-group ">
  
		<label for="helpdesk_ticket_custom_field_cf_please_provide_a_description_the_owner_the_purchase_date_and_purchase_price_of_each_item910226_2321673" class="form-label">
			Please provide a description, the owner, and the purchase date/price of each item. We will also ask you to provide specific details of the most expensive item you're claiming for
			
			
		</label>

<textarea
  	class="form-control section-field"
  	id="helpdesk_ticket_custom_field_cf_please_provide_a_description_the_owner_the_purchase_date_and_purchase_price_of_each_item910226_2321673"
  	name="helpdesk_ticket[custom_field][cf_please_provide_a_description_the_owner_the_purchase_date_and_purchase_price_of_each_item910226_2321673]"
    rows="6"
    cols=""
  	
  	
		placeholder=""
    
  >&lt/textarea&gt

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834899}"}'value="Mobile Phone">
            Mobile Phone
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834896}"}'value="Gadgets">
            Gadgets
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834900}"}'value="Personal Possessions">
            Personal Possessions
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834897}"}'value="Jewellery">
            Jewellery
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834902}"}'value="Personal Money/Currency">
            Personal Money/Currency
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834903}"}'value="Passport (Old)">
            Passport (Old)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834905}"}'value="Golf Equipment">
            Golf Equipment
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834906}"}'value="Winter Sports Equipment">
            Winter Sports Equipment
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_have_you_blocked_imei_with_your_provider_2321673">
    <label for="helpdesk_ticket_custom_field_cf_have_you_blocked_imei_with_your_provider_2321673" class=" form-label">
    	Have you blocked IMEI with your provider
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834908}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834909}"}'value="No">
            No
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_imei_number_2321673" class=" form-label">
			IMEI number
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_item_description369043_2321673" class=" form-label">
			Item Description
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_what_was_its_cost_when_you_bought_it_2321673" class=" form-label">
			How much was the item? Enter numbers only - 100.00
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_when_did_you_purchase_the_item_2321673" class=" form-label">
			When did you purchase the item
			
			
		</label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834910}"}'value="Myself">
            Myself
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834911}"}'value="Other Person Named on my insurance">
            Other Person Named on my insurance
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_do_you_have_home_contents_insurance_2321673">
    <label for="helpdesk_ticket_custom_field_cf_do_you_have_home_contents_insurance_2321673" class=" form-label">
    	Do you have Home Contents Insurance?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834801}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834802}"}'value="No">
            No
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_name_of_your_policy_provider267746_2321673" class=" form-label">
			Name of your policy provider
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_policy_number818860_2321673" class=" form-label">
			Policy number
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_do_you_have_any_other_travel_insurance_policy_2321673">
    <label for="helpdesk_ticket_custom_field_cf_do_you_have_any_other_travel_insurance_policy_2321673" class=" form-label">
    	Other than this policy, do you have any other insurance policy that may cover this event?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834803}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834804}"}'value="No">
            No
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_name_of_your_policy_provider610133_2321673" class=" form-label">
			Name of your policy provider
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_policy_number832231_2321673" class=" form-label">
			Policy number
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_which_part_of_the_journey_did_your_baggage_arrive_late_2321673">
    <label for="helpdesk_ticket_custom_field_cf_which_part_of_the_journey_did_your_baggage_arrive_late_2321673" class=" form-label">
    	Which part of the journey did your baggage arrive late?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000830987}"}'value="Outbound">
            Outbound
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830988}"}'value="Inbound">
            Inbound
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_how_many_hours_was_your_baggage_delayed_2321673" class=" form-label">
			Full hours baggage delayed? Enter numbers only. 4 hours = 4
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_has_your_baggage_been_returned_to_you_2321673">
    <label for="helpdesk_ticket_custom_field_cf_has_your_baggage_been_returned_to_you_2321673" class=" form-label">
    	Has your baggage been returned to you?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000836167}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000836168}"}'value="No">
            No
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_what_transport_type_was_your_baggage_delayed_on_2321673">
    <label for="helpdesk_ticket_custom_field_cf_what_transport_type_was_your_baggage_delayed_on_2321673" class=" form-label">
    	What transport type was your baggage delayed on?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000830992}"}'value="Aeroplane">
            Aeroplane
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830993}"}'value="Ferry">
            Ferry
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830994}"}'value="Coach">
            Coach
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830995}"}'value="Train">
            Train
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_did_you_notify_your_transport_provider_about_the_delay_and_get_a_report_pir_2321673">
    <label for="helpdesk_ticket_custom_field_cf_did_you_notify_your_transport_provider_about_the_delay_and_get_a_report_pir_2321673" class=" form-label">
    	Did you notify your transport provider about the delay and get a report (PIR)?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000831092}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000831093}"}'value="No">
            No
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_enter_the_report_reference_pir_2321673" class=" form-label">
			Enter the report reference (PIR)
			
			
		</label>

<div class="form-group ">
  
		<label for="helpdesk_ticket_custom_field_cf_please_list_all_replacement_items_purchased339565_2321673" class="form-label">
			Please list all replacement items purchased
			
			
		</label>

<textarea
  	class="form-control section-field"
  	id="helpdesk_ticket_custom_field_cf_please_list_all_replacement_items_purchased339565_2321673"
  	name="helpdesk_ticket[custom_field][cf_please_list_all_replacement_items_purchased339565_2321673]"
    rows="6"
    cols=""
  	
  	
		placeholder=""
    
  >&lt/textarea&gt

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_on_what_date_did_you_purchase_the_replacement_items_2321673" class=" form-label">
			On what date did you purchase the replacement item(s)?
			
			
		</label>

<option value>Choose...</option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_have_you_received_any_refund_from_your_transport_provider_2321673">
    <label for="helpdesk_ticket_custom_field_cf_have_you_received_any_refund_from_your_transport_provider_2321673" class=" form-label">
    	Have you received any refund from your transport provider?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000833420}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000833421}"}'value="No">
            No
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_total_refund_vouchers_amount_the_amount_you_have_received_back594804_2321673" class=" form-label">
			Enter any refunds you have received for this trip (e.g. 50.00)
			
			
		</label>

<div class="form-group ">
  
		<label for="helpdesk_ticket_custom_field_cf_how_did_the_damage_happen_well_need_as_much_information_as_you_can_give_please_2321673" class="form-label">
			How did the damage happen? We'll need as much information as you can give please:
			
			
		</label>

<textarea
  	class="form-control section-field"
  	id="helpdesk_ticket_custom_field_cf_how_did_the_damage_happen_well_need_as_much_information_as_you_can_give_please_2321673"
  	name="helpdesk_ticket[custom_field][cf_how_did_the_damage_happen_well_need_as_much_information_as_you_can_give_please_2321673]"
    rows="6"
    cols=""
  	
  	
		placeholder=""
    
  >&lt/textarea&gt

<div class="form-group  helpdesk_ticket_custom_field_cf_was_the_items_with_you_when_it_was_damaged_2321673">
    <label for="helpdesk_ticket_custom_field_cf_was_the_items_with_you_when_it_was_damaged_2321673" class=" form-label">
    	Was the item(s) with you when it was damaged?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834725}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834726}"}'value="No">
            No
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_was_the_items_with_your_transport_provider_when_damaged_eg_airline_checkedin_luggage_2321673">
    <label for="helpdesk_ticket_custom_field_cf_was_the_items_with_your_transport_provider_when_damaged_eg_airline_checkedin_luggage_2321673" class=" form-label">
    	Was the item(s) with your transport provider when damaged (e.g. Airline: checked-in luggage)?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834727}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834728}"}'value="No">
            No
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_is_the_damaged_items_listed_as_valuable_gadgetelectrical_in_your_policy_wording_2321673">
    <label for="helpdesk_ticket_custom_field_cf_is_the_damaged_items_listed_as_valuable_gadgetelectrical_in_your_policy_wording_2321673" class=" form-label">
    	Are any of the items a valuable or Gadget (e.g. Watches, jewellery, tablets, mobile phones)
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834731}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834732}"}'value="No">
            No
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_did_you_tell_your_transport_provider_about_the_damage_2321673">
    <label for="helpdesk_ticket_custom_field_cf_did_you_tell_your_transport_provider_about_the_damage_2321673" class=" form-label">
    	Did you tell your transport provider about the damage?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834733}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834734}"}'value="No">
            No
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_please_enter_the_report_reference_given_by_your_transport_provider_pir_reference_if_applicable_2321673" class=" form-label">
			Please enter the report reference given by your transport provider (PIR reference if applicable)
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_how_many_items_are_you_claiming_for411795_2321673">
    <label for="helpdesk_ticket_custom_field_cf_how_many_items_are_you_claiming_for411795_2321673" class=" form-label">
    	How many items are you claiming for?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834744}"}'value="1">
            1
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834745}"}'value="2">
            2
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834746}"}'value="3">
            3
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834747}"}'value="4">
            4
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834748}"}'value="5">
            5
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834749}"}'value="6">
            6
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834750}"}'value="7">
            7
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834751}"}'value="8">
            8
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834752}"}'value="9">
            9
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_whats_the_total_amount_youre_claiming_2321673" class=" form-label">
			What's the total amount you're claiming? 
			
			
		</label>

<div class="form-group ">
  
		<label for="helpdesk_ticket_custom_field_cf_please_provide_a_description_the_owner_the_purchase_date_and_purchase_price_of_each_item_2321673" class="form-label">
			Please provide a description, the owner, the purchase date and purchase price of each item
			
			
		</label>

<textarea
  	class="form-control section-field"
  	id="helpdesk_ticket_custom_field_cf_please_provide_a_description_the_owner_the_purchase_date_and_purchase_price_of_each_item_2321673"
  	name="helpdesk_ticket[custom_field][cf_please_provide_a_description_the_owner_the_purchase_date_and_purchase_price_of_each_item_2321673]"
    rows="6"
    cols=""
  	
  	
		placeholder=""
    
  >&lt/textarea&gt

<div class="form-group  helpdesk_ticket_custom_field_cf_did_you_get_a_repair_estimate_2321673">
    <label for="helpdesk_ticket_custom_field_cf_did_you_get_a_repair_estimate_2321673" class=" form-label">
    	Did you get a repair estimate
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834756}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834757}"}'value="No">
            No
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_can_the_item_be_repaired_2321673">
    <label for="helpdesk_ticket_custom_field_cf_can_the_item_be_repaired_2321673" class=" form-label">
    	Can the item be repaired
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834770}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834771}"}'value="No">
            No
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_total_refund_vouchers_amount_the_amount_you_have_received_back_2321673" class=" form-label">
			Repair cost. Enter numbers only - 100.00
			
			
		</label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834788}"}'value="Mobile Phone">
            Mobile Phone
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834785}"}'value="Gadgets">
            Gadgets
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834789}"}'value="Personal Possessions">
            Personal Possessions
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834786}"}'value="Jewellery">
            Jewellery
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834791}"}'value="Personal Money/Currency">
            Personal Money/Currency
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834792}"}'value="Passport (Old)">
            Passport (Old)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834794}"}'value="Golf Equipment">
            Golf Equipment
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834795}"}'value="Winter Sports Equipment">
            Winter Sports Equipment
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_item_description_2321673" class=" form-label">
			Item description
			
			
		</label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834797}"}'value="Myself">
            Myself
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834798}"}'value="Other Person Named on my insurance">
            Other Person Named on my insurance
          </option>

</select>

<option value>Choose...</option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_name_of_your_policy_provider267746_2321673" class=" form-label">
			Name of your policy provider
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_policy_number818860_2321673" class=" form-label">
			Policy number
			
			
		</label>

<option value>Choose...</option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_name_of_your_policy_provider610133_2321673" class=" form-label">
			Name of your policy provider
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_policy_number832231_2321673" class=" form-label">
			Policy number
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_what_caused_you_to_miss_your_departure_2321673">
    <label for="helpdesk_ticket_custom_field_cf_what_caused_you_to_miss_your_departure_2321673" class=" form-label">
    	What caused you to miss your departure?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834623}"}'value="Public transport delay/cancellation">
            Public transport delay/cancellation
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834624}"}'value="Delay to a connecting flight">
            Delay to a connecting flight
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834625}"}'value="Vehicle you were travelling in was in an accident">
            Vehicle you were travelling in was in an accident
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834626}"}'value="Vehicle you were travelling in broke down">
            Vehicle you were travelling in broke down
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834627}"}'value="Other">
            Other
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834628}"}'value="Denied boarding">
            Denied boarding
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834629}"}'value="Queues at departure point">
            Queues at departure point
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834630}"}'value="Passport/visa/document issue">
            Passport/visa/document issue
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834631}"}'value="Failed health screening">
            Failed health screening
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834632}"}'value="Delayed test results">
            Delayed test results
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834633}"}'value="Traffic or road closure">
            Traffic or road closure
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_was_someone_else_a_third_party_involved_in_the_accident_2321673">
    <label for="helpdesk_ticket_custom_field_cf_was_someone_else_a_third_party_involved_in_the_accident_2321673" class=" form-label">
    	Was someone else (a third party) involved in the accident?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000839196}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000839197}"}'value="No">
            No
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_please_confirm_the_reason_for_delay_2321673">
    <label for="helpdesk_ticket_custom_field_cf_please_confirm_the_reason_for_delay_2321673" class=" form-label">
    	Please confirm the reason for delay
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000830844}"}'value="Adverse Weather">
            Adverse Weather
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830845}"}'value="Strike">
            Strike
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830846}"}'value="Industrial Action">
            Industrial Action
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830847}"}'value="Mechanical Breakdown">
            Mechanical Breakdown
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830848}"}'value="Failure Air Traffic Control">
            Failure Air Traffic Control
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830849}"}'value="Crew or Staff shortage">
            Crew or Staff shortage
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830850}"}'value="Other">
            Other
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_do_you_have_a_report_confirming_the_reason_for_the_delay_2321673">
    <label for="helpdesk_ticket_custom_field_cf_do_you_have_a_report_confirming_the_reason_for_the_delay_2321673" class=" form-label">
    	Do you have a report confirming the reason for the delay?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000838294}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000838295}"}'value="No">
            No
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_on_which_part_of_the_journey_did_you_miss_your_departure_2321673">
    <label for="helpdesk_ticket_custom_field_cf_on_which_part_of_the_journey_did_you_miss_your_departure_2321673" class=" form-label">
    	On which part of the journey did you miss your departure?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000830853}"}'value="First Outbound from your Home Country">
            First Outbound from your Home Country
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830854}"}'value="Final Inbound to your Home Country">
            Final Inbound to your Home Country
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_did_you_allow_yourself_sufficient_time_to_reach_your_international_departure_point_2321673">
    <label for="helpdesk_ticket_custom_field_cf_did_you_allow_yourself_sufficient_time_to_reach_your_international_departure_point_2321673" class=" form-label">
    	Did you allow yourself sufficient time to reach your international departure point?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000834634}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000834635}"}'value="No">
            No
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_what_type_of_additional_expenses_are_you_claiming_for_2321673">
    <label for="helpdesk_ticket_custom_field_cf_what_type_of_additional_expenses_are_you_claiming_for_2321673" class=" form-label">
    	What type of additional expense(s) are you claiming for?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000839204}"}'value="Accommodation">
            Accommodation
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000839205}"}'value="Travel and Accommodation">
            Travel and Accommodation
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000839206}"}'value="Travel">
            Travel
          </option>

</select>

<div class="form-group ">
  
		<label for="helpdesk_ticket_custom_field_cf_name_of_provider_please_list_all_2321673" class="form-label">
			Name of provider (please list all)
			
			
		</label>

<textarea
  	class="form-control section-field"
  	id="helpdesk_ticket_custom_field_cf_name_of_provider_please_list_all_2321673"
  	name="helpdesk_ticket[custom_field][cf_name_of_provider_please_list_all_2321673]"
    rows="6"
    cols=""
  	
  	
		placeholder=""
    
  >&lt/textarea&gt

<option value>Choose...</option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_amount_paid_in_local_currency_2321673" class=" form-label">
			Total amount paid for all expenses
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_why_did_you_cancel_your_trip_2321673">
    <label for="helpdesk_ticket_custom_field_cf_why_did_you_cancel_your_trip_2321673" class=" form-label">
    	Why did you cancel your trip?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000832967}"}'value="FCDO/DFA restricted travel to my destination">
            FCDO/DFA restricted travel to my destination
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832968}"}'value="Doctor advised as a precaution not to travel">
            Doctor advised as a precaution not to travel
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832969}"}'value="A POSITIVE Coronavirus test result">
            A POSITIVE Coronavirus test result
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832971}"}'value="Unable to obtain COVID travel documents (test results, vaccine pass)">
            Unable to obtain COVID travel documents (test results, vaccine pass)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832972}"}'value="Diagnosed with Long Covid">
            Diagnosed with Long Covid
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_who_has_tested_positive_for_coronavirus_2321673">
    <label for="helpdesk_ticket_custom_field_cf_who_has_tested_positive_for_coronavirus_2321673" class=" form-label">
    	Who has tested positive for Coronavirus?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000832975}"}'value="Myself or another travelling insured">
            Myself or another travelling insured
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832976}"}'value="A close relative (not travelling)">
            A close relative (not travelling)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832977}"}'value="Someone else (travelling)">
            Someone else (travelling)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832978}"}'value="Someone else (not travelling)">
            Someone else (not travelling)
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_when_did_the_symptoms_start939174_2321673" class=" form-label">
			When did the symptoms start?
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_what_type_of_test_was_taken_2321673">
    <label for="helpdesk_ticket_custom_field_cf_what_type_of_test_was_taken_2321673" class=" form-label">
    	What type of test was taken?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000832979}"}'value="NHS/HSE PCR">
            NHS/HSE PCR
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832980}"}'value="NHS/HSE Lateral flow">
            NHS/HSE Lateral flow
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832981}"}'value="Privately booked PCR">
            Privately booked PCR
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832982}"}'value="Privately booked Lateral flow">
            Privately booked Lateral flow
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_do_you_have_evidence_from_either_the_nhshse_private_testing_company_or_your_doctor_confirming_the_positive_covid_test_email_letter_sms_2321673">
    <label for="helpdesk_ticket_custom_field_cf_do_you_have_evidence_from_either_the_nhshse_private_testing_company_or_your_doctor_confirming_the_positive_covid_test_email_letter_sms_2321673" class=" form-label">
    	Do you have evidence of a positive covid test
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000832983}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832984}"}'value="No">
            No
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_when_did_the_test_results_confirming_coronavirus_infection_arrive_2321673" class=" form-label">
			When did the test results confirming Coronavirus infection arrive?
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_when_were_you_initially_aware_that_you_needed_to_cancel_your_trip635242_2321673" class=" form-label">
			When were you initially aware that you needed to cancel your trip?
			
			
		</label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000832985}"}'value="Package booking (e.g. flights and accommodation or flights and cruise)">
            Package booking (e.g. flights and accommodation or flights and cruise)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832986}"}'value="Independent booking (travel and accommodation booked separately)">
            Independent booking (travel and accommodation booked separately)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832987}"}'value="Accommodation ONLY (no travel costs)">
            Accommodation ONLY (no travel costs)
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832988}"}'value="Travel ONLY (e.g flights or ferry)">
            Travel ONLY (e.g flights or ferry)
          </option>

</select>

<option value>Choose...</option>

</select>

<option value>Choose...</option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_name_of_your_policy_provider895583_2321673" class=" form-label">
			Name of your policy provider
			
			
		</label>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_policy_number964552_2321673" class=" form-label">
			Policy number
			
			
		</label>

<div class="nested_field">
<div class="form-group ">
  <label for="helpdesk_ticket_custom_field_cf_why_did_you_shorten_your_trip_2321673" class="form-label">
  	Why did you shorten your trip?
		
    
  </label>

<select
  	class="form-control parent_field nested_select_field choices "
  	id="helpdesk_ticket_custom_field_cf_why_did_you_shorten_your_trip_2321673"
  	name="helpdesk_ticket[custom_field][cf_why_did_you_shorten_your_trip_2321673]"
  	
  	
    
    	data-nested-choices = "[[&quot;Cancellation of leave by emergency services or armed forces&quot;,&quot;Cancellation of leave by emergency services or armed forces&quot;,[]],[&quot;Your compulsory quarantine&quot;,&quot;Your compulsory quarantine&quot;,[]],[&quot;Your home or business premises being uninhabitable&quot;,&quot;Your home or business premises being uninhabitable&quot;,[]],[&quot;Redundancy from work&quot;,&quot;Redundancy from work&quot;,[]],[&quot;Being called as a witness&quot;,&quot;Being called as a witness&quot;,[]],[&quot;Jury Service&quot;,&quot;Jury Service&quot;,[]],[&quot;Illness, Injury or Death of a Close Relative&quot;,&quot;Illness, Injury or Death of a Close Relative&quot;,[]],[&quot;Injury, Illness or Death of a Travelling Companion&quot;,&quot;Injury, Illness or Death of a Travelling Companion&quot;,[]],[&quot;Injury or Illness of yourself&quot;,&quot;Injury or Illness of yourself&quot;,[[&quot;Yes&quot;,&quot;Yes&quot;,[]],[&quot;No&quot;,&quot;No&quot;,[]]]],[&quot;Other&quot;,&quot;Other&quot;,[]],[&quot;Coronavirus (COVID-19)&quot;,&quot;Coronavirus (COVID-19)&quot;,[[&quot;Yes&quot;,&quot;Yes&quot;,[]],[&quot;No&quot;,&quot;No&quot;,[]]]],[&quot;FCO Advice against travel&quot;,&quot;FCO Advice against travel&quot;,[]]]"
  	
    	data-selected-choices = "null"
  	
    	data-nested-levels = "[{&quot;id&quot;:101000002993,&quot;label&quot;:&quot;Were you admitted to hospital as an inpatient?&quot;,&quot;label_in_portal&quot;:&quot;Were you admitted to hospital as an inpatient?&quot;,&quot;name&quot;:&quot;cf_were_you_admitted_to_hospital_as_an_inpatient_2321673&quot;,&quot;level&quot;:2,&quot;field_type&quot;:&quot;nested_child&quot;}]"
  	
    	data-placeholder = ""
  	
    	data-required-field = "false"
  	
  >
   
     <option value>Choose...</option>

<option  data-custom-properties='{"id": ""}' value="Cancellation of leave by emergency services or armed forces">
          Cancellation of leave by emergency services or armed forces
         </option>
       
         <option  data-custom-properties='{"id": ""}' value="Your compulsory quarantine">
          Your compulsory quarantine
         </option>
       
         <option  data-custom-properties='{"id": ""}' value="Your home or business premises being uninhabitable">
          Your home or business premises being uninhabitable
         </option>
       
         <option  data-custom-properties='{"id": ""}' value="Redundancy from work">
          Redundancy from work
         </option>
       
         <option  data-custom-properties='{"id": ""}' value="Being called as a witness">
          Being called as a witness
         </option>
       
         <option  data-custom-properties='{"id": ""}' value="Jury Service">
          Jury Service
         </option>
       
         <option  data-custom-properties='{"id": ""}' value="Illness, Injury or Death of a Close Relative">
          Illness, Injury or Death of a Close Relative
         </option>
       
         <option  data-custom-properties='{"id": ""}' value="Injury, Illness or Death of a Travelling Companion">
          Injury, Illness or Death of a Travelling Companion
         </option>
       
         <option  data-custom-properties='{"id": ""}' value="Injury or Illness of yourself">
          Injury or Illness of yourself
         </option>
       
         <option  data-custom-properties='{"id": ""}' value="Other">
          Other
         </option>
       
         <option  data-custom-properties='{"id": ""}' value="Coronavirus (COVID-19)">
          Coronavirus (COVID-19)
         </option>
       
         <option  data-custom-properties='{"id": ""}' value="FCO Advice against travel">
          FCO Advice against travel
         </option>

</select>

<div class="form-group ">
  
		<label for="helpdesk_ticket_custom_field_cf_please_provide_a_detailed_description_of_the_reason_you_curtailed_your_trip272601_2321673" class="form-label">
			In a few words, tell us what happened:
			
			
		</label>

<textarea
  	class="form-control section-field"
  	id="helpdesk_ticket_custom_field_cf_please_provide_a_detailed_description_of_the_reason_you_curtailed_your_trip272601_2321673"
  	name="helpdesk_ticket[custom_field][cf_please_provide_a_detailed_description_of_the_reason_you_curtailed_your_trip272601_2321673]"
    rows="6"
    cols=""
  	
  	
		placeholder=""
    
  >&lt/textarea&gt

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_explain_when_you_were_aware_that_you_needed_to_return_home_please_confirm_the_date_2321673" class=" form-label">
			Explain when you were aware that you needed to return home. Please confirm the date.
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_did_you_notify_us_of_the_need_to_curtail_before_making_arrangements_2321673">
    <label for="helpdesk_ticket_custom_field_cf_did_you_notify_us_of_the_need_to_curtail_before_making_arrangements_2321673" class=" form-label">
    	Did you notify us of the need to curtail before making arrangements?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000832621}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832622}"}'value="No">
            No
          </option>

</select>

<div class="form-group ">
  
		<label for="helpdesk_ticket_custom_field_cf_please_give_a_full_and_detailed_explanation_of_why_you_did_not_contact_to_contact_our_emergency_service582069_2321673" class="form-label">
			Please give a full and detailed explanation of why you did not contact to contact our emergency service
			
			
		</label>

<textarea
  	class="form-control section-field"
  	id="helpdesk_ticket_custom_field_cf_please_give_a_full_and_detailed_explanation_of_why_you_did_not_contact_to_contact_our_emergency_service582069_2321673"
  	name="helpdesk_ticket[custom_field][cf_please_give_a_full_and_detailed_explanation_of_why_you_did_not_contact_to_contact_our_emergency_service582069_2321673]"
    rows="6"
    cols=""
  	
  	
		placeholder=""
    
  >&lt/textarea&gt

<div class="form-group ">
  
		<label for="helpdesk_ticket_custom_field_cf_detail_how_you_got_home_and_on_what_date_2321673" class="form-label">
			On what date did you return home?
			
			
		</label>

<textarea
  	class="form-control section-field"
  	id="helpdesk_ticket_custom_field_cf_detail_how_you_got_home_and_on_what_date_2321673"
  	name="helpdesk_ticket[custom_field][cf_detail_how_you_got_home_and_on_what_date_2321673]"
    rows="6"
    cols=""
  	
  	
		placeholder=""
    
  >&lt/textarea&gt

<option value>Choose...</option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_what_is_the_estimated_value_of_your_claim_2321673" class=" form-label">
			Total amount being claimed. Enter numbers only - 100.00
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_who_incurred_dental_expenses930485_2321673">
    <label for="helpdesk_ticket_custom_field_cf_who_incurred_dental_expenses930485_2321673" class=" form-label">
    	Who incurred dental expenses
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000830671}"}'value="Myself">
            Myself
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830672}"}'value="Another travelling insured">
            Another travelling insured
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830673}"}'value="Other">
            Other
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_what_type_of_dental_treatment_did_you_need_2321673">
    <label for="helpdesk_ticket_custom_field_cf_what_type_of_dental_treatment_did_you_need_2321673" class=" form-label">
    	What type of dental treatment did you need?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000830674}"}'value="Emergency Dental Treatment For Pain/Discomfort">
            Emergency Dental Treatment For Pain/Discomfort
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830675}"}'value="Emergency Repairs to Dentures">
            Emergency Repairs to Dentures
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830676}"}'value="Emergency Repairs to Orthodontic Appliances">
            Emergency Repairs to Orthodontic Appliances
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000830677}"}'value="Other">
            Other
          </option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_when_did_the_symptoms_start939174_2321673" class=" form-label">
			When did the symptoms start?
			
			
		</label>

<div class="form-group ">
  
		<label for="helpdesk_ticket_custom_field_cf_please_list_the_expenses_incurred_including_the_type_of_expense_and_the_name_of_the_dentist_or_company_that_provided_this_expense_2321673" class="form-label">
			Please list the expenses incurred, include the type of expense with the name of the dentist/company:
			
			
		</label>

<textarea
  	class="form-control section-field"
  	id="helpdesk_ticket_custom_field_cf_please_list_the_expenses_incurred_including_the_type_of_expense_and_the_name_of_the_dentist_or_company_that_provided_this_expense_2321673"
  	name="helpdesk_ticket[custom_field][cf_please_list_the_expenses_incurred_including_the_type_of_expense_and_the_name_of_the_dentist_or_company_that_provided_this_expense_2321673]"
    rows="6"
    cols=""
  	
  	
		placeholder=""
    
  >&lt/textarea&gt

<option value>Choose...</option>

</select>

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_on_what_date_did_you_pay_the_dental_expenses_2321673" class=" form-label">
			Date of Payment
			
			
		</label>

<div class="form-group  helpdesk_ticket_custom_field_cf_what_caused_you_to_leave_your_original_accommodation_2321673">
    <label for="helpdesk_ticket_custom_field_cf_what_caused_you_to_leave_your_original_accommodation_2321673" class=" form-label">
    	What caused you to leave your original accommodation?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000832435}"}'value="Fire">
            Fire
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832436}"}'value="Flood">
            Flood
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832437}"}'value="Storm">
            Storm
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832438}"}'value="Natural Catastrophe">
            Natural Catastrophe
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832439}"}'value="Outbreak of infectious disease">
            Outbreak of infectious disease
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832440}"}'value="Industrial Action">
            Industrial Action
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832441}"}'value="Other">
            Other
          </option>

</select>

<div class="form-group ">
  
		<label for="helpdesk_ticket_custom_field_cf_please_provide_a_detailed_description_of_the_reason_you_left_your_accommodation_2321673" class="form-label">
			In a few words, tell us what happened:
			
			
		</label>

<textarea
  	class="form-control section-field"
  	id="helpdesk_ticket_custom_field_cf_please_provide_a_detailed_description_of_the_reason_you_left_your_accommodation_2321673"
  	name="helpdesk_ticket[custom_field][cf_please_provide_a_detailed_description_of_the_reason_you_left_your_accommodation_2321673]"
    rows="6"
    cols=""
  	
  	
		placeholder=""
    
  >&lt/textarea&gt

<div class="form-group ">
	
		<label for="helpdesk_ticket_custom_field_cf_on_what_date_did_you_leave_your_original_accommodation_2321673" class=" form-label">
			On what date did you leave your original accommodation?
			
			
		</label>

<option value>Choose...</option>

</select>

<div class="form-group ">
  
		<label for="helpdesk_ticket_custom_field_cf_please_provide_a_detailed_description_of_the_reason_youre_making_a_claim_today_2321673" class="form-label">
			Please provide a detailed description of the reason you’re making a claim today
			
			
		</label>

<textarea
  	class="form-control section-field"
  	id="helpdesk_ticket_custom_field_cf_please_provide_a_detailed_description_of_the_reason_youre_making_a_claim_today_2321673"
  	name="helpdesk_ticket[custom_field][cf_please_provide_a_detailed_description_of_the_reason_youre_making_a_claim_today_2321673]"
    rows="6"
    cols=""
  	
  	
		placeholder=""
    
  >&lt/textarea&gt

<div class="form-group  helpdesk_ticket_custom_field_cf_which_winter_sports_item_are_you_claiming_for_2321673">
    <label for="helpdesk_ticket_custom_field_cf_which_winter_sports_item_are_you_claiming_for_2321673" class=" form-label">
    	Which winter sports item are you claiming for?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000832301}"}'value="Closure of Piste">
            Closure of Piste
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832302}"}'value="Cancellation of Lessons or Lift Pass - Ski Pack">
            Cancellation of Lessons or Lift Pass - Ski Pack
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832303}"}'value="Equipment - Lost, Stolen or Damaged">
            Equipment - Lost, Stolen or Damaged
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832304}"}'value="More than one item listed">
            More than one item listed
          </option>

</select>

<div class="form-group  helpdesk_ticket_custom_field_cf_have_you_obtained_a_report_or_invoices_for_the_items_you_are_claiming_2321673">
    <label for="helpdesk_ticket_custom_field_cf_have_you_obtained_a_report_or_invoices_for_the_items_you_are_claiming_2321673" class=" form-label">
    	Have you obtained a report or invoices for the item(s) you are claiming?
	  	
      
    </label>

<option value>Choose...</option>

<option  data-custom-properties='{"id": "{"data-id"=>101000832305}"}'value="Yes">
            Yes
          </option>
       
          <option  data-custom-properties='{"id": "{"data-id"=>101000832306}"}'value="No">
            No
          </option>

</select>

<option value>Choose...</option>

</select>

Name of account holder (Exactly as it appears on your Debit card)

Your 8-Digit Bank Account Number (e.g. 12345678)

Your 6-Digit numerical Sort Code (e.g.434343 not 43-43-43)

COP Pass

Requester *

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