<div class="row">
   <div class="col-md-6">
	<div>[text* name placeholder "Your Name"]</div>
   </div>
   <div class="col-md-6">
        <div>[email* email placeholder "Email Address"]</div>
  </div>
  <div class="col-md-6">
        <div>[text* username placeholder "Username"]</div>
  </div>
  <div class="col-md-6">
        <div>[text* subject placeholder "Listing URL"]</div>
  </div>
</div>

<div>[textarea* textarea-265 40x7 placeholder "Please provide additional details for your claim here"]</div>
[submit "Send"]