Insurance Service

Application Type * {{dictionary.required}}

Service * {{dictionary.required}}

Tracking Number * {{dictionary.required}} {{verificationTrackingError}}

Type of problem * {{dictionary.required}}

{{ticketOption[dictionary.fullName]}} * {{dictionary.required}} {{ticketOption[dictionary.fullName]}} * {{dictionary.required}}

Customer Type * {{dictionary.required}}

Identity Residence Number * {{dictionary.required}} Invalid Data

Commercial Record Number * {{dictionary.required}} Invalid Data

Full Name * {{dictionary.required}}

Mobile * {{dictionary.required}} {{dictionary.inValidMobile}}

Email * {{dictionary.required}}

Complaint Description * {{dictionary.required}}

Attachments Attach

You can add up to 5 attachments of 2 MB

You can attach following extensions : pdf,jpg,png

#	{{dictionary.fName}}	{{dictionary.fType}}	{{dictionary.fSize}}	{{dictionary.fAction}}
{{index + 1}}	{{file.name}}	{{file.type}}	{{file.size \| size}}

Your ticket has been received. Ticket Number is {{ticketNumber}}