<% (1..12).each do |n| %>
    <div class="pl-1 pt-2 w-full">
        <%= provider_fields.text_field "claim_to_#{n}".to_sym, label: { text: "Claim To Line #{n}" }, data: { general_form_target: "providerField"}, class: "w-full" %>
    </div>
<% end %>