<div class="control-group ticket_section"> <label class=" control-label cf_insurance_company_838493-label " for="helpdesk_ticket_cf_insurance_company_838493">Your insurer:</label> <div class="controls "> <select class=" dropdown_blank section_field" data-placeholder="..." name="helpdesk_ticket[custom_field][cf_insurance_company_838493]" id="helpdesk_ticket_custom_field_cf_insurance_company_838493"><option value="">...</option> <option data-id="36000730823" value="Bolttech/Backmarket">Bolttech/Backmarket</option> <option data-id="36000730820" value="Likewize">Likewize</option> <option data-id="36000730821" value="Pier Insurance">Pier Insurance</option> <option data-id="36000730822" value="Protect Your Bubble by Assurant">Protect Your Bubble by Assurant</option> <option data-id="36000904330" value="Square Trade">Square Trade</option> <option data-id="36000904331" value="SPB">SPB</option></select> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_claim_number_838493-label " for="helpdesk_ticket_cf_claim_number_838493">Do you have claim number? If yes please write it below</label> <div class="controls "> <input class=" text section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_claim_number_838493]" id="helpdesk_ticket_custom_field_cf_claim_number_838493" /> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_order_number_838493-label " for="helpdesk_ticket_cf_order_number_838493">Order Number</label> <div class="controls "> <input class=" number section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_order_number_838493]" id="helpdesk_ticket_custom_field_cf_order_number_838493" /> </div> </div> <div class="control-group ticket_section"> <div class="controls"> <label class="checkbox "> <input name="helpdesk_ticket[custom_field][cf_website_checked_838493]" type="hidden" value="0" /><input class=" checkbox section_field" id="helpdesk_ticket_custom_field_cf_website_checked_838493_36000730813" type="checkbox" value="1" name="helpdesk_ticket[custom_field][cf_website_checked_838493]" /> You can find a list of all devices, models and prices on our website! </label> </div> </div> <div class="control-group ticket_section"> <div class="controls"> <label class="checkbox required"> <input type="checkbox" name="helpdesk_ticket[custom_field][cf_yes_838493]" id="helpdesk_ticket_custom_field_cf_yes_838493_36000730808" value="1" class=" required checkbox section_field" /> Have you tried to contact the store directly? </label> </div> </div> <div class="control-group ticket_section"> <label class=" control-label cf_job_number_838493-label " for="helpdesk_ticket_cf_job_number_838493">Can you please provide the 6 digit job number from your receipt ?</label> <div class="controls "> <input class=" number section_field span12" placeholder="" type="text" name="helpdesk_ticket[custom_field][cf_job_number_838493]" id="helpdesk_ticket_custom_field_cf_job_number_838493" /> </div> </div>