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1 forms found in the DOM

Name: fileupload — POST /

<form action="/" enctype="multipart/form-data" id="fileupload" method="POST" name="fileupload" autocomplete="on" role="form" aria-label="Document Upload">
  <input type="hidden" id="sourceSystem" name="sourceSystem" value="standalone">
  <div>
    <label class="headings" style="font-size:xx-large">Welcome to EZDrop™</label>
    <br>
    <label class="headings">Tell us about your claim and upload documents in seconds.</label>
    <br>
    <label class="headings">Please note all fields are required.</label>
    <br>
    <br>
  </div>
  <div class="form-group">
    <label class="headings" for="accidentNumber">Claim Number</label>
    <input type="text" id="accidentNumber" name="accidentNumber" placeholder="e.g. AB123456789, P 123456789, WC123456789" required="" class="form-control" maxlength="20"
      pattern="^(?=[A-Za-z0-9- ]{0,20}$)(([A-Za-z0-9]+[- ]?[A-Za-z0-9]+[- ]?[A-Za-z0-9]+$)|([A-Za-z0-9]$))$" value="">
    <div id="accidentNumber-error" style="display:none"></div>
  </div>
  <div class="form-group">
    <label class="headings" for="lossLocationOptions">Loss State</label>
    <select id="lossLocationOptions" required="" class="form-control">
      <option value="" selected="" hidden="" id="lossLocationDefaultText">The State in which the loss occurred...</option>
      <optgroup label="----- US States -----">
        <option value="AK">Alaska</option>
        <option value="AL">Alabama</option>
        <option value="AR">Arkansas</option>
        <option value="AZ">Arizona</option>
        <option value="CA">California</option>
        <option value="CO">Colorado</option>
        <option value="CT">Connecticut</option>
        <option value="DC">District of Columbia</option>
        <option value="DE">Delaware</option>
        <option value="FL">Florida</option>
        <option value="GA">Georgia</option>
        <option value="HI">Hawaii</option>
        <option value="IA">Iowa</option>
        <option value="ID">Idaho</option>
        <option value="IL">Illinois</option>
        <option value="IN">Indiana</option>
        <option value="KS">Kansas</option>
        <option value="KY">Kentucky</option>
        <option value="LA">Louisiana</option>
        <option value="MA">Massachusetts</option>
        <option value="MD">Maryland</option>
        <option value="ME">Maine</option>
        <option value="MI">Michigan</option>
        <option value="MN">Minnesota</option>
        <option value="MO">Missouri</option>
        <option value="MS">Mississippi</option>
        <option value="MT">Montana</option>
        <option value="NC">North Carolina</option>
        <option value="ND">North Dakota</option>
        <option value="NE">Nebraska</option>
        <option value="NH">New Hampshire</option>
        <option value="NJ">New Jersey</option>
        <option value="NM">New Mexico</option>
        <option value="NV">Nevada</option>
        <option value="NY">New York</option>
        <option value="OH">Ohio</option>
        <option value="OK">Oklahoma</option>
        <option value="OR">Oregon</option>
        <option value="PA">Pennsylvania</option>
        <option value="RI">Rhode Island</option>
        <option value="SC">South Carolina</option>
        <option value="SD">South Dakota</option>
        <option value="TN">Tennessee</option>
        <option value="TX">Texas</option>
        <option value="UT">Utah</option>
        <option value="VA">Virginia</option>
        <option value="VT">Vermont</option>
        <option value="WA">Washington</option>
        <option value="WI">Wisconsin</option>
        <option value="WV">West Virginia</option>
        <option value="WY">Wyoming</option>
      </optgroup>
      <optgroup label="----- Canadian Provinces -----">
        <option value="AB">Alberta</option>
        <option value="BC">British Columbia</option>
        <option value="MB">Manitoba</option>
        <option value="NB">New Brunswick</option>
        <option value="NL">Newfoundland and Labrador</option>
        <option value="NS">Nova Scotia</option>
        <option value="NT">Northwest Territories</option>
        <option value="NU">Nunavut</option>
        <option value="ON">Ontario</option>
        <option value="PE">Prince Edward Island</option>
        <option value="QC">Quebec</option>
        <option value="SK">Saskatchewan</option>
        <option value="YT">Yukon Territories</option>
      </optgroup>
      <optgroup label="----- US Other -----">
        <option value="AA">Armed Forces Americas</option>
        <option value="AE">Armed Forces Europe</option>
        <option value="AP">Armed Forces Pacific</option>
        <option value="GU">Guam</option>
        <option value="PR">Puerto Rico</option>
        <option value="VI">Virgin Islands</option>
      </optgroup>
    </select>
    <input type="hidden" id="lossLocation" name="lossLocation" value="">
    <div id="lossLocationOptions-error" style="display:none">Please select a loss state</div>
  </div>
  <label class="headings" for="WCradio">Claim Type</label>
  <div class="form-group">
    <div class="form-check form-check-inline radio-inline">
      <input class="form-check-input" id="WCradio" value="WC" type="radio" name="lob">
      <label class="form-check-label" for="WCradio">Workers Compensation</label>
    </div>
    <div class="form-check form-check-inline radio-inline">
      <input class="form-check-input" id="AUTOLIABILITYradio" value="AUTOLIABILITY" type="radio" name="lob">
      <label class="form-check-label" for="AUTOLIABILITYradio">Auto &amp; General Liability</label>
    </div>
    <div class="form-check form-check-inline radio-inline">
      <input class="form-check-input" id="PROPERTYradio" value="PROPERTY" type="radio" name="lob">
      <label class="form-check-label" for="PROPERTYradio">Property</label>
    </div>
    <div id="claimType-error" style="display:none">Please select a LOB</div>
  </div>
  <div class="row rowBreak"></div>
  <br>
  <div id="innerErrorMessage" class="hasErrors" style="display:none"></div>
  <br>
  <div class="breakout col-xs-12" id="AGLFileSpecs" style="visibility: hidden">
    <div class="well-sm">
      <label name="maxAllowedFiles" class="headings">Select up to 10 files of the following types: </label>
      <br>
      <div class="well-sm">
        <p>
          <strong>Media:</strong> mp3, wav, wma, wmv <br><strong>Image:</strong> bmp, dic, exc, gif, htm, html, jpeg, jpg, pdf, tif, tiff <br><strong>Text:</strong> doc, docx, log, msg, ppt, pptx, rtf, scp, txt, xls, xlsx
        </p>
      </div>
      <label class="headings">Files should be no greater than 10MB. </label>
      <label class="headings">If your file type is not supported, please advise your case handler. </label>
      <br><label class="headings">For Document Type selection, here are some guidelines: </label>
      <br>
      <div class="well-sm">
        <p>
          <strong>Damage and Injury Documents:</strong> Documents that will help us assess the property damage or injury, such as: medical bills or records, wage records, photos of damages or injury and appraisals related to the loss
          <br><strong>Legal:</strong> Documents or correspondence pertaining to a litigated or attorney represented claim <br><strong>Loss Details:</strong> Documents that will help us determine who was at fault for the incident, such as incident
          reports, party involved statements, scene photos or correspondence that will help us review the loss <br><strong>Other:</strong> All other documents or correspondence relating to the claim
        </p>
      </div>
    </div>
  </div>
  <div class="breakout col-xs-12" id="PFileSpecs" style="visibility: hidden">
    <div class="well-sm">
      <label name="maxAllowedFiles" class="headings">Select up to 10 files of the following types: </label>
      <br>
      <div class="well-sm">
        <p>
          <strong>Media:</strong> mp3, wav, wma, wmv <br><strong>Image:</strong> bmp, dic, exc, gif, htm, html, jpeg, jpg, pdf, tif, tiff <br><strong>Text:</strong> doc, docx, log, msg, ppt, pptx, rtf, scp, txt, xls, xlsx
        </p>
      </div>
      <label class="headings">Files should be no greater than 10MB. </label>
      <label class="headings">If your file type is not supported, please advise your case handler. </label>
      <br><label class="headings">For Document Type selection, here are some guidelines: </label>
      <br>
      <div class="well-sm">
        <p>
          <strong>Legal:</strong> Documents or correspondence pertaining to a litigated or attorney represented claim <br><strong>Loss Details:</strong> Documents that will help us determine who was at fault for the incident, such as any reports,
          statements, photos, estimates, contracts or correspondence that will help us review the loss <br><strong>Other:</strong> All other documents or correspondence relating to the claim
        </p>
      </div>
    </div>
  </div>
  <div class="breakout col-xs-12" id="WCFileSpecs" style="visibility: hidden">
    <div class="well-sm">
      <label name="maxAllowedFiles" class="headings">Select up to 10 files of the following types: </label>
      <br>
      <div class="well-sm">
        <p>
          <strong>Media:</strong> mp3, wav, wma <br><strong>Image:</strong> bmp, dic, exc, gif, htm, html, jpeg, jpg, pdf, tif, tiff <br><strong>Text:</strong> doc, docx, log, msg, ppt, pptx, rtf, scp, txt, xls, xlsx
        </p>
      </div>
      <label class="headings">Text and image files should be no greater than 5MB and audio no greater than 10MB. </label>
      <label class="headings">If your file type is not supported, please advise your case handler. </label>
      <br><label class="headings">For Document Type selection, here are some guidelines: </label>
      <br>
      <div class="well-sm">
        <p>
          <strong>Bills:</strong> Bills, invoices, or employee reimbursements for a claim <br><strong>Managed Care Provider:</strong> Documents pertaining to long term injury or managed care of an injured worker <br><strong>Legal:</strong> Documents
          or correspondence pertaining to a litigated or attorney represented claim <br><strong>Medical:</strong> Medical Records or reviews related to an injured worker <br><strong>Other:</strong> All other documents or correspondence relating to
          the claim
        </p>
      </div>
    </div>
  </div>
  <div class="row hidden-lg hidden-md hidden-s visible-xs" display="none"></div>
  <div id="fileUploader" style="display:none">
    <label id="fileHeader" class="headings" for="fine-uploader-manual-trigger">Files selected for upload (please note file names should not contain personal information)</label>
    <div id="fine-uploader-manual-trigger">
      <div>
        <div class="qq-uploader-selector qq-uploader" qq-drop-area-text="Drop file here">
          <div class="qq-upload-drop-area-selector qq-upload-drop-area" qq-hide-dropzone="" style="display: none;">
          </div>
          <div class="buttons">
            <div id="fileInputBtn" name="fileInputBtn" class="btn btn-primary qq-upload-button-selector" style="position: relative; overflow: hidden; direction: ltr;">
              <span class="glyphicon glyphicon-plus"></span> Select Files <input qq-button-id="1a153dba-fe9e-4c21-b062-3acf7723b311" title="file input" multiple=""
                accept="image/bmp,application/octet-stream,application/msword,application/vnd.openxmlformats,text/plain,image/gif,text/html,image/jpeg,audio/mpeg,application/x-msg,application/pdf,application/mspowerpoint,application/rtf,application/octet-stream,image/tiff,audio/x-wav,audio/x-ms-wma,video/x-ms-wmv,application/vnd.ms-excel"
                type="file" name="file" style="position: absolute; right: 0px; top: 0px; font-family: Arial; font-size: 118px; margin: 0px; padding: 0px; cursor: pointer; opacity: 0; height: 100%;">
            </div>
          </div>
          <span class="qq-drop-processing-selector qq-drop-processing qq-hide">
            <span>Processing dropped file...</span>
            <span class="qq-drop-processing-spinner-selector qq-drop-processing-spinner"></span>
          </span>
          <ul class="qq-upload-list-selector qq-upload-list" aria-live="polite" aria-relevant="additions removals"></ul>
          <dialog class="qq-alert-dialog-selector">
            <div class="qq-dialog-message-selector"></div>
            <div class="qq-dialog-buttons">
              <button type="button" class="qq-cancel-button-selector">Close</button>
            </div>
          </dialog>
          <dialog class="qq-confirm-dialog-selector">
            <div class="qq-dialog-message-selector"></div>
            <div class="qq-dialog-buttons">
              <button type="button" class="qq-cancel-button-selector">No</button>
              <button type="button" class="qq-ok-button-selector">Yes</button>
            </div>
          </dialog>
          <dialog class="qq-prompt-dialog-selector">
            <div class="qq-dialog-message-selector"></div>
            <input type="text">
            <div class="qq-dialog-buttons">
              <button type="button" class="qq-cancel-button-selector">Cancel</button>
              <button type="button" class="qq-ok-button-selector">Ok</button>
            </div>
          </dialog>
        </div>
      </div>
    </div>
    <br>
    <div class="form-group">
      <label for="email" class="headings">Email</label>
      <input type="email" class="form-control" id="email" name="email" required="" placeholder="Please enter your Email Address..." autocomplete="email">
      <div id="customerEmail-error" style="display:none"></div>
    </div>
    <br>
    <label class="headings" style="width: 80%">By using EZDrop™, you acknowledge that you have read, understand, and agree to our <a href="/ezdropTermsAndConditions" target="_blank">Terms and Conditions</a> for <label>Helmsman Management Services
        LLC</label> EZDrop™.</label>
    <button id="submitBtn" name="submitBtn" class="btn btn-primary start submit">
      <i class="glyphicon glyphicon-upload"></i> Submit </button>
  </div>
  <br>
  <br>
  <br>
</form>

Text Content

 * 



Welcome to EZDrop™
Tell us about your claim and upload documents in seconds.
Please note all fields are required.


Claim Number

Loss State The State in which the loss occurred... Alaska Alabama Arkansas
Arizona California Colorado Connecticut District of Columbia Delaware Florida
Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana
Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana
North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada
New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South
Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia
Wyoming Alberta British Columbia Manitoba New Brunswick Newfoundland and
Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island
Quebec Saskatchewan Yukon Territories Armed Forces Americas Armed Forces Europe
Armed Forces Pacific Guam Puerto Rico Virgin Islands
Please select a loss state
Claim Type
Workers Compensation
Auto & General Liability
Property
Please select a LOB




Select up to 10 files of the following types:


Media: mp3, wav, wma, wmv
Image: bmp, dic, exc, gif, htm, html, jpeg, jpg, pdf, tif, tiff
Text: doc, docx, log, msg, ppt, pptx, rtf, scp, txt, xls, xlsx

Files should be no greater than 10MB. If your file type is not supported, please
advise your case handler.
For Document Type selection, here are some guidelines:


Damage and Injury Documents: Documents that will help us assess the property
damage or injury, such as: medical bills or records, wage records, photos of
damages or injury and appraisals related to the loss
Legal: Documents or correspondence pertaining to a litigated or attorney
represented claim
Loss Details: Documents that will help us determine who was at fault for the
incident, such as incident reports, party involved statements, scene photos or
correspondence that will help us review the loss
Other: All other documents or correspondence relating to the claim

Select up to 10 files of the following types:


Media: mp3, wav, wma, wmv
Image: bmp, dic, exc, gif, htm, html, jpeg, jpg, pdf, tif, tiff
Text: doc, docx, log, msg, ppt, pptx, rtf, scp, txt, xls, xlsx

Files should be no greater than 10MB. If your file type is not supported, please
advise your case handler.
For Document Type selection, here are some guidelines:


Legal: Documents or correspondence pertaining to a litigated or attorney
represented claim
Loss Details: Documents that will help us determine who was at fault for the
incident, such as any reports, statements, photos, estimates, contracts or
correspondence that will help us review the loss
Other: All other documents or correspondence relating to the claim

Select up to 10 files of the following types:


Media: mp3, wav, wma
Image: bmp, dic, exc, gif, htm, html, jpeg, jpg, pdf, tif, tiff
Text: doc, docx, log, msg, ppt, pptx, rtf, scp, txt, xls, xlsx

Text and image files should be no greater than 5MB and audio no greater than
10MB. If your file type is not supported, please advise your case handler.
For Document Type selection, here are some guidelines:


Bills: Bills, invoices, or employee reimbursements for a claim
Managed Care Provider: Documents pertaining to long term injury or managed care
of an injured worker
Legal: Documents or correspondence pertaining to a litigated or attorney
represented claim
Medical: Medical Records or reviews related to an injured worker
Other: All other documents or correspondence relating to the claim


Files selected for upload (please note file names should not contain personal
information)
Select Files
Processing dropped file...

Close

No Yes

Cancel Ok

Email


By using EZDrop™, you acknowledge that you have read, understand, and agree to
our Terms and Conditions for Helmsman Management Services LLC EZDrop™. Submit




If you are experiencing difficulties using this document upload tool, please
contact our dedicated support team by email: ezdropsupport@helmsmantpa.com or
call: +1-800-989-7854

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© 2019 Helmsman Management Services LLC, 175 Berkeley Street, Boston, MA 02116