{"id":9078,"date":"2020-09-11T10:39:59","date_gmt":"2020-09-11T10:39:59","guid":{"rendered":"https:\/\/263host.co.zw\/projects\/firstmutual\/?page_id=9078"},"modified":"2020-09-14T09:54:02","modified_gmt":"2020-09-14T09:54:02","slug":"employee-benefits-claims","status":"publish","type":"page","link":"https:\/\/263host.co.zw\/projects\/firstmutual\/employee-benefits-claims\/","title":{"rendered":"Employee Benefits Claims"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"9078\" class=\"elementor elementor-9078\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;,&quot;element_pack_global_tooltip_width&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;element_pack_global_tooltip_width_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;element_pack_global_tooltip_width_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;element_pack_global_tooltip_padding&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_padding_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_padding_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_border_radius&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_border_radius_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_border_radius_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true}}\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-e5c4d50 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"e5c4d50\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-38de1be\" data-id=\"38de1be\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-d5e179d elementor-widget elementor-widget-spacer\" data-id=\"d5e179d\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-1358368 elementor-widget elementor-widget-heading\" data-id=\"1358368\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Employee Benefits Claims<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2a327b7 elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"2a327b7\" data-element_type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-divider\">\n\t\t\t<span class=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-abeead2\" data-id=\"abeead2\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-6a280f4 elementor-section-stretched elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"6a280f4\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-7c123f1\" data-id=\"7c123f1\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-144c97f elementor-widget elementor-widget-text-editor\" data-id=\"144c97f\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-9097\"><form id=\"wpforms-form-9097\" class=\"wpforms-validate wpforms-form\" data-formid=\"9097\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/projects\/firstmutual\/wp-json\/wp\/v2\/pages\/9078?wpforms_form_id=9097\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-page-indicator progress\" data-indicator=\"progress\" data-indicator-color=\"#fa0000\" data-scroll=\"1\"><span class=\"wpforms-page-indicator-page-title\" ><\/span><span class=\"wpforms-page-indicator-page-title-sep\" style=\"display:none;\"> &#8211; <\/span><span class=\"wpforms-page-indicator-steps\">Step <span class=\"wpforms-page-indicator-steps-current\">1<\/span> of 2<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:50%;background-color:#fa0000;\"><\/div><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \"><div id=\"wpforms-9097-field_13-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"13\"><\/div><div id=\"wpforms-9097-field_1-container\" class=\"wpforms-field wpforms-field-number wpforms-one-half wpforms-first\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_1\">Policy Number\/ Card Reference Number<\/label><input type=\"number\" pattern=\"\\d*\" id=\"wpforms-9097-field_1\" class=\"wpforms-field-large\" name=\"wpforms[fields][1]\" ><div class=\"wpforms-field-description\">if you forgot your policy number please proceed to the next section<\/div><\/div><div id=\"wpforms-9097-field_2-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_2\">Policy Holder\/ Premium Payer\/ Beneficiary Name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-9097-field_2\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][2]\" required><div class=\"wpforms-field-description\">Please enter your full name<\/div><\/div><div id=\"wpforms-9097-field_3-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_3\">Claimant&#039;s National ID Number  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-9097-field_3\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][3]\" required><div class=\"wpforms-field-description\">Please state your National ID Number in the format 00-000000N00<\/div><\/div><div id=\"wpforms-9097-field_4-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-half\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_4\">Claimant&#039;s Date of Birth <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-9097-field_4\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-input=\"true\" name=\"wpforms[fields][4][date]\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-9097-field_5-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_5\">Physical Address <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-9097-field_5\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][5]\" required><div class=\"wpforms-field-description\">Please state your current physical address<\/div><\/div><div id=\"wpforms-9097-field_6-container\" class=\"wpforms-field wpforms-field-phone wpforms-one-half\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_6\">Mobile Number (s) <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"tel\" id=\"wpforms-9097-field_6\" class=\"wpforms-field-large wpforms-field-required wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][6]\" required><div class=\"wpforms-field-description\">Please enter your mobile number<\/div><\/div><div id=\"wpforms-9097-field_7-container\" class=\"wpforms-field wpforms-field-email wpforms-one-half wpforms-first\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_7\">Email Address<\/label><input type=\"email\" id=\"wpforms-9097-field_7\" class=\"wpforms-field-large\" name=\"wpforms[fields][7]\" ><div class=\"wpforms-field-description\">Please state your email address (s)<\/div><\/div><div id=\"wpforms-9097-field_8-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half wpforms-first\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_8\">Claim Type <span class=\"wpforms-required-label\">*<\/span><\/label><select id=\"wpforms-9097-field_8\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][8]\" required=\"required\"><option value=\"Choose\" >Choose<\/option><option value=\"Funeral Death Claim(FCP or efml)\" >Funeral Death Claim(FCP or efml)<\/option><option value=\"Death Ordinary(All Other Life Claims\" >Death Ordinary(All Other Life Claims<\/option><\/select><div class=\"wpforms-field-description\">Please choose the applicable claim type<\/div><\/div><div id=\"wpforms-9097-field_9-container\" class=\"wpforms-field wpforms-field-select wpforms-one-half\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_9\">Are you receiving First Mutual Funeral Services<\/label><select id=\"wpforms-9097-field_9\" class=\"wpforms-field-medium\" name=\"wpforms[fields][9]\"><option value=\"Yes\" >Yes<\/option><option value=\"No\" >No<\/option><\/select><\/div><div id=\"wpforms-9097-field_10-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_10\">Name of claimant&#039;s employer and phone number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-9097-field_10\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][10]\" required><div class=\"wpforms-field-description\">Please state your employer&#8217;s name, physical address and phone number<\/div><\/div><div id=\"wpforms-9097-field_11-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_11\">If No Please state the name of the name and contact of the Funeral Service Provider<\/label><input type=\"text\" id=\"wpforms-9097-field_11\" class=\"wpforms-field-large\" name=\"wpforms[fields][11]\" ><\/div><div id=\"wpforms-9097-field_12-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"12\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"1\" data-formid=\"9097\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2 last \" style=\"display:none;\"><div id=\"wpforms-9097-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_15\">Full Name of the deceased <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-9097-field_15\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][15]\" required><div class=\"wpforms-field-description\">Please state the full name as it appears on the National I.D or Birth Certificate\r\n<\/div><\/div><div id=\"wpforms-9097-field_16-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-half wpforms-first\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_16\">Date of Birth of the Deceased <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-9097-field_16\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-input=\"true\" name=\"wpforms[fields][16][date]\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><div class=\"wpforms-field-description\">Please state the Date of Birth in the format (DD\/MM\/YYYY)<\/div><\/div><div id=\"wpforms-9097-field_17-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-half\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_17\">Date of Death <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-9097-field_17\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"m\/d\/Y\" data-input=\"true\" name=\"wpforms[fields][17][date]\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><div class=\"wpforms-field-description\">Please indicate the date of Birth in the format MM\/DD\/YYYY)<\/div><\/div><div id=\"wpforms-9097-field_18-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"18\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_18\">Deceased&#039;s National Identity Number <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-9097-field_18\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][18]\" required><div class=\"wpforms-field-description\">Please state in the formart 00-000000N00<\/div><\/div><div id=\"wpforms-9097-field_19-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_19\">Occupation at date of death<\/label><input type=\"text\" id=\"wpforms-9097-field_19\" class=\"wpforms-field-large\" name=\"wpforms[fields][19]\" ><div class=\"wpforms-field-description\">Please enter the deceased&#8217;s occupation at the time of death<\/div><\/div><div id=\"wpforms-9097-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_20\">Principal cause of death <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-9097-field_20\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][20]\" required><div class=\"wpforms-field-description\">Please state the main cause of death\r\n<\/div><\/div><div id=\"wpforms-9097-field_21-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-half wpforms-first\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_21\">When did the health of the Deceased first begin to be affected by disease or injury? <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-9097-field_21\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-required wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-input=\"true\" name=\"wpforms[fields][21][date]\" required><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-9097-field_22-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_22\">Duration of last illness<\/label><input type=\"text\" id=\"wpforms-9097-field_22\" class=\"wpforms-field-large\" name=\"wpforms[fields][22]\" ><div class=\"wpforms-field-description\">Please indicate the duration in months of years<\/div><\/div><div id=\"wpforms-9097-field_24-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_24\">Names and addresses of all doctors who attended or prescribed treatment, drugs, etc. for the Deceased during the two years preceding death. <span class=\"wpforms-required-label\">*<\/span><\/label><textarea id=\"wpforms-9097-field_24\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][24]\" required><\/textarea><\/div><div id=\"wpforms-9097-field_25-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"25\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_25\">Did the deceased commit suicide or did he die as a result of violation of any law? <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-9097-field_25\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][25]\" required><\/div><div id=\"wpforms-9097-field_26-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_26\">Name &amp; contact details of 3 witnesses of death (other than self): <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-9097-field_26\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][26]\" required><\/div><div id=\"wpforms-9097-field_27-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_27\">Please state the Address where mourners are gathered <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-9097-field_27\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][27]\" required><\/div><div id=\"wpforms-9097-field_28-container\" class=\"wpforms-field wpforms-field-file-upload wpforms-one-half\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_28\">Claims attachments<\/label><div class=\"wpforms-uploader\"\n\tdata-field-id=\"28\"\n\tdata-form-id=\"9097\"\n\tdata-input-name=\"wpforms_9097_28\"\n\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages,json,svg\"\n\tdata-max-size=\"20971520\"\n\tdata-max-file-number=\"1\"\n\tdata-post-max-size=\"20971520\">\n\t<div class=\"dz-message\">\n\t\t<svg viewBox=\"0 0 1024 1024\" focusable=\"false\" class=\"\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"#B1B1B1\" aria-hidden=\"true\"><path d=\"M885.2 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id=\"wpforms-9097-field_29-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_29\">Account Number or Ecocash Number to whom payment is made <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-9097-field_29\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][29]\" required><div class=\"wpforms-field-description\">For account Numbers please state your Bank Name, Bank branch code, Account Holder Name and Account Number<\/div><\/div><div id=\"wpforms-9097-field_30-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-9097-field_30\">Signature of the Claimant <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-9097-field_30\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][30]\" required><div class=\"wpforms-field-description\">Please insert your signature in form of first Name initials and Surname<\/div><\/div><div id=\"wpforms-9097-field_14-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"14\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><\/div><\/div><\/div><\/div><div class=\"wpforms-field wpforms-field-hp\"><label for=\"wpforms-9097-field-hp\" class=\"wpforms-field-label\">Name<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-9097-field-hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"9097\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"3\"><button type=\"submit\" name=\"wpforms[submit]\" class=\"wpforms-submit \" id=\"wpforms-submit-9097\" value=\"wpforms-submit\" aria-live=\"assertive\" data-alt-text=\"Sending...\" 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