Submit a Support Ticket

Fill out the form below and our team will get back to you as soon as possible.

{/* Contact Info */} Your Information How can we reach you?

Full Name setData( 'submitter_name', e.target.value, ) } placeholder="John Doe" />

Email Address setData( 'submitter_email', e.target.value, ) } placeholder="john@example.com" />

{/* Ticket Details */} Ticket Details Tell us about the issue

Company

System

Category

Priority

Subject setData('title', e.target.value) } placeholder="Brief description of the issue" />

Description

setData(
                                                'description',
                                                e.target.value,
                                            )
                                        }
                                        placeholder="Please describe your issue in detail..."
                                        rows={6}
                                        className="flex min-h-[80px] w-full rounded-md border border-input bg-background px-3 py-2 text-sm ring-offset-background placeholder:text-muted-foreground focus-visible:ring-2 focus-visible:ring-ring focus-visible:ring-offset-2 focus-visible:outline-none"
                                    />
                                    <InputError message={errors.description} />
                                </div>

{/* Dynamic fields */}
                                {selectedSystem?.code === 'POLICY' && (
                                    <div className="space-y-2">
                                        <Label>Policy Number (optional)</Label>
                                        <Input
                                            value={
                                                (data.metadata as any)
                                                    .policy_no ?? ''
                                            }
                                            onChange={(e) =>
                                                setData('metadata', {
                                                    ...data.metadata,
                                                    policy_no: e.target.value,
                                                })
                                            }
                                            placeholder="e.g. POL-2024-001234"
                                        />
                                    </div>
                                )}
                                {selectedSystem?.code === 'CLAIMS' && (
                                    <div className="space-y-2">
                                        <Label>Claim Number (optional)</Label>
                                        <Input
                                            value={
                                                (data.metadata as any)
                                                    .claim_no ?? ''
                                            }
                                            onChange={(e) =>
                                                setData('metadata', {
                                                    ...data.metadata,
                                                    claim_no: e.target.value,
                                                })
                                            }
                                            placeholder="e.g. CLM-2024-005678"
                                        />
                                    </div>
                                )}
                            </CardContent>
                        </Card>

<div className="flex gap-3">
                            <Button
                                type="submit"
                                disabled={processing}
                                size="lg"
                            >
                                {processing ? 'Submitting...' : 'Submit Ticket'}
                            </Button>
                        </div>
                    </form>
                </main>

<footer className="border-t bg-white py-6 text-center text-sm text-muted-foreground dark:bg-gray-900">
                    Need to check an existing ticket?{' '}
                    <Link
                        href="/ticket-status"
                        className="text-primary underline"
                    >
                        Track your ticket here
                    </Link>
                </footer>
            </div>
        </>
    );
}