glu-claim-form-template

System Generated Field Panel
Author Entered Field Panel
Form Title Panel
End-user Entered Field Panel
Thank You and Error Message Panel
Hidden Panel

System Generated Field Panel
Author Entered Field Panel
Form Title Panel
End-user Entered Field Panel
Thank You and Error Message Panel
Hidden Panel

System Generated Panel

Market Region

User Date

Enable Captcha

SendUserEmail

Email Template for Recipient

Acknowledgement Email Template

Attachment Information

Glu Recaptcha Token

Locale

Secret Key

Author Input Panel

Author Input Panel - Required fields

Analytics form type

Email address to which form data will be sent

CC Email address to which form data will be sent

Subject line of the email

Subject line of the Acknowledgement

File Upload Messages Configuration

Virus Scan in Progress

File Size Limit Error

Virus Found Message

Invalid File Type Error message

File Count

Upload More

Service Down

Form Title Panel

Online Claims Intimation Form

User Input Panel

All fields marked with * are required

*Policy Holder’s Name

*Policy Number

*Insured’s Name

*Beneficiary’s Name

*Claim Type

*Contact Number

*Email Address

File Attachment

Only PDF Files Under 8 MB can be uploaded

By clicking submit, you are agreeing to the Privacy Statement and Terms and Conditions of MetLife Nepal

Call 5555166 Ext. 226/227/228

Thank You/Error Panel Configuration

Settings for same page thank you/error message

Message Delay

Sorry, there was a problem with your submisson.

Sorry for inconvinence. Please try again after some time.

Thank You !!!

Thank You for submitting your claim. Our claims department will revert in 48 hours.

Settings for separate page thank you/error message

Error Page

Thank You Page

Page Target

Hidden Panel

Name Of The Template