<!DOCTYPE html>
<html lang="en">
<head>
  <meta charset="UTF-8">
  <meta name="viewport" content="width=device-width, initial-scale=1.0">
  <title>Claim Form - Euroducting</title>
  <style>
    body {
      font-family: Arial, sans-serif;
      background-color: #f4f4f4;
      margin: 0;
      padding: 0;
    }

    header {
      background-color: #002f87;
      color: #fff;
      padding: 20px;
      text-align: center;
    }

    main {
      max-width: 800px;
      margin: 40px auto;
      background-color: #fff;
      padding: 30px;
      box-shadow: 0 0 10px rgba(0, 0, 0, 0.1);
    }

    h1 {
      margin-top: 0;
      color: #002f87;
    }

    fieldset {
      border: none;
      margin-bottom: 20px;
    }

    legend {
      font-weight: bold;
      margin-bottom: 10px;
      color: #002f87;
    }

    label {
      display: block;
      margin-top: 15px;
    }

    input[type="text"],
    input[type="email"],
    input[type="number"],
    textarea {
      width: 100%;
      padding: 10px;
      margin-top: 5px;
      border: 1px solid #ccc;
      border-radius: 4px;
    }

    textarea {
      resize: vertical;
      min-height: 100px;
    }

    button {
      background-color: #00a3e0;
      color: #fff;
      padding: 12px 25px;
      border: none;
      border-radius: 4px;
      cursor: pointer;
      font-size: 16px;
    }

    button:hover {
      background-color: #008cc0;
    }
  </style>
</head>
<body>
  <header>
    <h1>Euroducting - Product Claim Form</h1>
  </header>

  <main>
    <form action="submit_claim.php" method="POST">
      <fieldset>
        <legend>Section 1: Contact Information</legend>
        <label for="name">Name:</label>
        <input type="text" id="name" name="name" required>

        <label for="address">Address:</label>
        <input type="text" id="address" name="address" required>

        <label for="contact">Contact Number:</label>
        <input type="text" id="contact" name="contact" required>

        <label for="email">Email Address:</label>
        <input type="email" id="email" name="email" required>
      </fieldset>

      <fieldset>
        <legend>Section 2: Claim Details</legend>
        <label for="euroducting_order">Euroducting Order Number:</label>
        <input type="text" id="euroducting_order" name="euroducting_order" required>

        <label for="customer_order">Customer Order Number:</label>
        <input type="text" id="customer_order" name="customer_order" required>

        <label for="delivery_note">Delivery Note:</label>
        <input type="text" id="delivery_note" name="delivery_note">

        <label for="invoice">Invoice:</label>
        <input type="text" id="invoice" name="invoice">

        <label for="item">Item:</label>
        <input type="text" id="item" name="item" required>

        <label for="quantity">Quantity:</label>
        <input type="number" id="quantity" name="quantity" required min="1">

        <label for="description">Description of Product Defects:</label>
        <textarea id="description" name="description" required></textarea>

       
        <input type="hidden" id="remote_address" name="remote_address" readonly>
      </fieldset>

      <button type="submit">Submit Claim</button>
    </form>
  </main>

  <script>
    fetch('https://api.ipify.org?format=json')
      .then(response => response.json())
      .then(data => {
        document.getElementById('remote_address').value = data.ip;
      });
  </script>
</body>
</html>

dodaj do tego skryptu obsługę dynamicznego dołączania plików do formularza i obsługę tego formularza po stronie serwera w php