\r\n"; $headers .= "Reply-To: $emailAddress\r\n"; $headers .= "MIME-Version: 1.0\r\n"; $headers .= "Content-Type: multipart/mixed; boundary=\"$boundary\"\r\n"; $emailBody = "--$boundary\r\n"; $emailBody .= "Content-Type: text/plain; charset=UTF-8\r\n"; $emailBody .= "Content-Transfer-Encoding: 7bit\r\n\r\n"; $emailBody .= $message . "\r\n\r\n"; if (isset($_FILES['photograph']) && $_FILES['photograph']['error'] == 0) { $fileName = $_FILES['photograph']['name']; $fileType = $_FILES['photograph']['type']; $fileData = file_get_contents($_FILES['photograph']['tmp_name']); $fileEncoded = chunk_split(base64_encode($fileData)); $emailBody .= "--$boundary\r\n"; $emailBody .= "Content-Type: $fileType; name=\"$fileName\"\r\n"; $emailBody .= "Content-Disposition: attachment; filename=\"$fileName\"\r\n"; $emailBody .= "Content-Transfer-Encoding: base64\r\n\r\n"; $emailBody .= $fileEncoded . "\r\n\r\n"; } $emailBody .= "--$boundary--"; // Send email if (mail($to, $subject, $emailBody, $headers)) { $_SESSION['certificate'] = nl2br($message); header("Location: success.php"); exit(); } else { echo "There was an error sending your claim. Please try again."; } } if (isset($_FILES['photograph']) && $_FILES['photograph']['error'] == 0) { $fileName = $_FILES['photograph']['name']; $fileType = $_FILES['photograph']['type']; $fileData = file_get_contents($_FILES['photograph']['tmp_name']); $fileEncoded = chunk_split(base64_encode($fileData)); $emailBody .= "--$boundary\r\n"; $emailBody .= "Content-Type: $fileType; name=\"$fileName\"\r\n"; $emailBody .= "Content-Disposition: attachment; filename=\"$fileName\"\r\n"; $emailBody .= "Content-Transfer-Encoding: base64\r\n\r\n"; $emailBody .= $fileEncoded . "\r\n\r\n"; } // Handle optional additional document if (isset($_FILES['additionalDocument']) && $_FILES['additionalDocument']['error'] == 0) { $fileName = $_FILES['additionalDocument']['name']; $fileType = $_FILES['additionalDocument']['type']; $fileData = file_get_contents($_FILES['additionalDocument']['tmp_name']); $fileEncoded = chunk_split(base64_encode($fileData)); $emailBody .= "--$boundary\r\n"; $emailBody .= "Content-Type: $fileType; name=\"$fileName\"\r\n"; $emailBody .= "Content-Disposition: attachment; filename=\"$fileName\"\r\n"; $emailBody .= "Content-Transfer-Encoding: base64\r\n\r\n"; $emailBody .= $fileEncoded . "\r\n\r\n"; } ?> Claim Intimation Form

Claim Intimation Form

Name of Insured:

Mobile No:

Email Address:

Type of Insurance:

Policy / Certificate No:

Date of Loss:

Accident Location:

Accident Time: Details of Accident: Estimated Claim Amount of Tk.:

Photograph of the Damaged Property:

Additional Document (if any):