SurveyJS Library + Next.js Template
MIT
shadcn/ui
Documentation
Source
Records
Browse and edit insurance-claim records.
4 claims
Add new
View CLM-2026-0001
Edit
Configure Form JSON
Have the claim on paper? Upload a scan, a photo or a PDF and the answers are read into the form below for review.
Fill from a document
Try the sample CMS-1500
Insurance Claim
Create or edit a claim record.
Claim
Claim number
*
Status
*
Approved
Claim type
*
Medical
Dental
Vision
Date of service
*
Amount claimed (USD)
Claimant
First name
*
Last name
*
SSN
Date of birth
Phone
Email
Injury details
Shown for medical claims.
Was this injury work-related?
No
Yes
Yes
Employer name
Affected body parts
Affected body parts
Head
Neck
Back
Arm
Leg
Other
Describe the injury
Lower-back strain while lifting cargo.
Supporting documents
Attach receipts / reports
No file selected
Select File
I authorize release of medical information for this claim
*
No
Yes
Yes