{"id":14,"date":"2024-04-13T05:38:38","date_gmt":"2024-04-13T05:38:38","guid":{"rendered":"https:\/\/drschoicesform.com\/?page_id=14"},"modified":"2024-05-16T14:14:19","modified_gmt":"2024-05-16T14:14:19","slug":"home-2","status":"publish","type":"page","link":"https:\/\/drschoicesform.com\/","title":{"rendered":"Home"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"14\" class=\"elementor elementor-14\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a029bd0 e-con-full e-flex e-con e-parent\" data-id=\"a029bd0\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-2bafb90 elementor-widget__width-initial elementor-widget elementor-widget-heading\" data-id=\"2bafb90\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 08-05-2024 *\/\n.elementor-heading-title{padding:0;margin:0;line-height:1}.elementor-widget-heading .elementor-heading-title[class*=elementor-size-]>a{color:inherit;font-size:inherit;line-height:inherit}.elementor-widget-heading .elementor-heading-title.elementor-size-small{font-size:15px}.elementor-widget-heading .elementor-heading-title.elementor-size-medium{font-size:19px}.elementor-widget-heading .elementor-heading-title.elementor-size-large{font-size:29px}.elementor-widget-heading .elementor-heading-title.elementor-size-xl{font-size:39px}.elementor-widget-heading .elementor-heading-title.elementor-size-xxl{font-size:59px}<\/style><h2 class=\"elementor-heading-title elementor-size-default\">PRE-APPLICATION QUESTIONNAIRE<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-6eeda4d elementor-widget__width-initial elementor-widget elementor-widget-text-editor\" data-id=\"6eeda4d\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<style>\/*! elementor - v3.21.0 - 08-05-2024 *\/\n.elementor-widget-text-editor.elementor-drop-cap-view-stacked .elementor-drop-cap{background-color:#69727d;color:#fff}.elementor-widget-text-editor.elementor-drop-cap-view-framed .elementor-drop-cap{color:#69727d;border:3px solid;background-color:transparent}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap{margin-top:8px}.elementor-widget-text-editor:not(.elementor-drop-cap-view-default) .elementor-drop-cap-letter{width:1em;height:1em}.elementor-widget-text-editor .elementor-drop-cap{float:left;text-align:center;line-height:1;font-size:50px}.elementor-widget-text-editor .elementor-drop-cap-letter{display:inline-block}<\/style>\t\t\t\tThe purpose of this form is simply to gather information to help complete an application for disability or life insurance &#8211; it is not an application. If you apply for insurance you may be asked additional or different questions. Once you have completed this form, your agent will use the information requested in this pre-application questionnaire to help prepare your formal e-Application, which requires your review and authorization before being submitted to the insurance company, a separate secure link will be sent to you when this process is complete. Your agent may contact you with questions.\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-1a26ab1 e-con-full e-flex e-con e-child\" data-id=\"1a26ab1\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4259492 elementor-widget elementor-widget-shortcode\" data-id=\"4259492\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-shortcode\"><script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_1' style='display:none'><style>#gform_wrapper_1[data-form-index=\"0\"].gform-theme,[data-parent-form=\"1_0\"]{--gf-color-primary: #204ce5;--gf-color-primary-rgb: 32, 76, 229;--gf-color-primary-contrast: #fff;--gf-color-primary-contrast-rgb: 255, 255, 255;--gf-color-primary-darker: #001AB3;--gf-color-primary-lighter: #527EFF;--gf-color-secondary: #fff;--gf-color-secondary-rgb: 255, 255, 255;--gf-color-secondary-contrast: #112337;--gf-color-secondary-contrast-rgb: 17, 35, 55;--gf-color-secondary-darker: #F5F5F5;--gf-color-secondary-lighter: #FFFFFF;--gf-color-out-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-out-ctrl-light-rgb: 17, 35, 55;--gf-color-out-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-out-ctrl-light-lighter: #F5F5F5;--gf-color-out-ctrl-dark: #585e6a;--gf-color-out-ctrl-dark-rgb: 88, 94, 106;--gf-color-out-ctrl-dark-darker: #112337;--gf-color-out-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-color-in-ctrl: #fff;--gf-color-in-ctrl-rgb: 255, 255, 255;--gf-color-in-ctrl-contrast: #112337;--gf-color-in-ctrl-contrast-rgb: 17, 35, 55;--gf-color-in-ctrl-darker: #F5F5F5;--gf-color-in-ctrl-lighter: #FFFFFF;--gf-color-in-ctrl-primary: #204ce5;--gf-color-in-ctrl-primary-rgb: 32, 76, 229;--gf-color-in-ctrl-primary-contrast: #fff;--gf-color-in-ctrl-primary-contrast-rgb: 255, 255, 255;--gf-color-in-ctrl-primary-darker: #001AB3;--gf-color-in-ctrl-primary-lighter: #527EFF;--gf-color-in-ctrl-light: rgba(17, 35, 55, 0.1);--gf-color-in-ctrl-light-rgb: 17, 35, 55;--gf-color-in-ctrl-light-darker: rgba(104, 110, 119, 0.35);--gf-color-in-ctrl-light-lighter: #F5F5F5;--gf-color-in-ctrl-dark: #585e6a;--gf-color-in-ctrl-dark-rgb: 88, 94, 106;--gf-color-in-ctrl-dark-darker: #112337;--gf-color-in-ctrl-dark-lighter: rgba(17, 35, 55, 0.65);--gf-radius: 3px;--gf-font-size-secondary: 14px;--gf-font-size-tertiary: 13px;--gf-icon-ctrl-number: url(\"data:image\/svg+xml,%3Csvg width='8' height='14' viewBox='0 0 8 14' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-select: url(\"data:image\/svg+xml,%3Csvg width='10' height='6' viewBox='0 0 10 6' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-icon-ctrl-search: url(\"data:image\/svg+xml,%3Csvg version='1.1' xmlns='http:\/\/www.w3.org\/2000\/svg' width='640' height='640'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gf-label-space-y-secondary: var(--gf-label-space-y-md-secondary);--gf-ctrl-border-color: #686e77;--gf-ctrl-size: var(--gf-ctrl-size-md);--gf-ctrl-label-color-primary: #112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_1' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/index.php\/wp-json\/wp\/v2\/pages\/14#gf_1' data-formid='1' novalidate><input id=partial_entry_id_1 class=\"partial_entry_id\" type=hidden name=\"partial_entry_id\" value=\"pending\" data-form_id=\"1\"\/>\n        <div id='gf_progressbar_wrapper_1' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>5<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_20' style='width:20%;'><span>20%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_1_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_3\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\" >Insured Information<\/div><div id=\"field_1_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_4\" ><label class='gfield_label gform-field-label' for='input_1_4'>First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_1_4' type='text' value='' class='large'   tabindex='49'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\" ><label class='gfield_label gform-field-label' for='input_1_6'>Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_1_6' type='text' value='' class='large'   tabindex='50'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_7\" ><label class='gfield_label gform-field-label' for='input_1_7'>Previous Last Name<\/label><div class='ginput_container ginput_container_text'><input name='input_7' id='input_1_7' type='text' value='' class='large'   tabindex='51'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_8\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_8\" ><label class='gfield_label gform-field-label' for='input_1_8'>Social Security Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_1_8' type='text' value='' class='large' maxlength='9'  tabindex='52'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_9\" ><legend class='gfield_label gform-field-label' >Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_9'>\n\t\t\t<div class='gchoice gchoice_1_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Male'  id='choice_1_9_0' onchange='gformToggleRadioOther( this )'  tabindex='53'  \/>\n\t\t\t\t\t<label for='choice_1_9_0' id='label_1_9_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Female'  id='choice_1_9_1' onchange='gformToggleRadioOther( this )'  tabindex='54'  \/>\n\t\t\t\t\t<label for='choice_1_9_1' id='label_1_9_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_10\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_10' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_10_1_container' >\n                                        <label for='input_1_10_1' id='input_1_10_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_10.1' id='input_1_10_1' value='' tabindex='55'   aria-required='true'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_10_3_container' >\n                                    <label for='input_1_10_3' id='input_1_10_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_10.3' id='input_1_10_3' value='' tabindex='56'   aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_10_4_container' >\n                                        <label for='input_1_10_4' id='input_1_10_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                        <input type='text' name='input_10.4' id='input_1_10_4' value='' tabindex='58'     aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_10_5_container' >\n                                    <label for='input_1_10_5' id='input_1_10_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                    <input type='text' name='input_10.5' id='input_1_10_5' value='' tabindex='59'   aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_10.6' id='input_1_10_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_1_11\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_11\" ><legend class='gfield_label gform-field-label' >How long have you lived at this address?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_11'>\n\t\t\t<div class='gchoice gchoice_1_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Less than two years'  id='choice_1_11_0' onchange='gformToggleRadioOther( this )'  tabindex='60'  \/>\n\t\t\t\t\t<label for='choice_1_11_0' id='label_1_11_0' class='gform-field-label gform-field-label--type-inline'>Less than two years<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='More than two years'  id='choice_1_11_1' onchange='gformToggleRadioOther( this )'  tabindex='61'  \/>\n\t\t\t\t\t<label for='choice_1_11_1' id='label_1_11_1' class='gform-field-label gform-field-label--type-inline'>More than two years<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_20\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_20\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >PREVIOUS ADDRESS<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_20' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_20_1_container' >\n                                        <label for='input_1_20_1' id='input_1_20_1_label' class='gform-field-label gform-field-label--type-sub '>Previous Street Address<\/label>\n                                        <input type='text' name='input_20.1' id='input_1_20_1' value='' tabindex='62'   aria-required='true'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_20_3_container' >\n                                    <label for='input_1_20_3' id='input_1_20_3_label' class='gform-field-label gform-field-label--type-sub '>Previous City<\/label>\n                                    <input type='text' name='input_20.3' id='input_1_20_3' value='' tabindex='63'   aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_20_4_container' >\n                                        <label for='input_1_20_4' id='input_1_20_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                        <input type='text' name='input_20.4' id='input_1_20_4' value='' tabindex='65'     aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_20_5_container' >\n                                    <label for='input_1_20_5' id='input_1_20_5_label' class='gform-field-label gform-field-label--type-sub '>Previous Zip<\/label>\n                                    <input type='text' name='input_20.5' id='input_1_20_5' value='' tabindex='66'   aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_20.6' id='input_1_20_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_12\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_12\" ><label class='gfield_label gform-field-label' for='input_1_12'>Date Of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_12' id='input_1_12' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='67'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_12_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_12_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_12' class='gform_hidden' value='https:\/\/drschoicesform.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_112\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_112\" ><label class='gfield_label gform-field-label' for='input_1_112'>Place Of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_112' id='input_1_112' type='text' value='' class='large'   tabindex='68'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_14\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_14\" ><label class='gfield_label gform-field-label' for='input_1_14'>Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_14' id='input_1_14' type='email' value='' class='large' tabindex='69'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_15\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_15\" ><label class='gfield_label gform-field-label' for='input_1_15'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_1_15' type='tel' value='' class='large' tabindex='70'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_16\" ><legend class='gfield_label gform-field-label' >Are you a US Citizen or Green Card holder?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_16'>\n\t\t\t<div class='gchoice gchoice_1_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Yes'  id='choice_1_16_0' onchange='gformToggleRadioOther( this )'  tabindex='71'  \/>\n\t\t\t\t\t<label for='choice_1_16_0' id='label_1_16_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='No'  id='choice_1_16_1' onchange='gformToggleRadioOther( this )'  tabindex='72'  \/>\n\t\t\t\t\t<label for='choice_1_16_1' id='label_1_16_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_17\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_17\" ><label class='gfield_label gform-field-label' for='input_1_17'>Visa Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_1_17' class='large gfield_select' tabindex='73'   aria-required=\"true\" aria-invalid=\"false\" ><option value='A-1' >A-1<\/option><option value='A-2' >A-2<\/option><option value='A-3' >A-3<\/option><option value='B-1' >B-1<\/option><option value='C-1' >C-1<\/option><option value='C-1D' >C-1D<\/option><option value='C-2' >C-2<\/option><option value='C-3' >C-3<\/option><option value='C-4' >C-4<\/option><option value='D-1' >D-1<\/option><option value='D-2' >D-2<\/option><option value='E-1' >E-1<\/option><option value='E-2' >E-2<\/option><option value='Employment Authorization Document' >Employment Authorization Document<\/option><option value='F-1' >F-1<\/option><option value='F-2' >F-2<\/option><\/select><\/div><\/div><div id=\"field_1_19\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_19\" ><label class='gfield_label gform-field-label' for='input_1_19'>Visa Duration<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_1_19' class='large gfield_select' tabindex='74'   aria-required=\"true\" aria-invalid=\"false\" ><option value='6 months' >6 months<\/option><option value='1 Year' >1 Year<\/option><option value='1.5 Year' >1.5 Year<\/option><option value='2 Year' >2 Year<\/option><\/select><\/div><\/div><fieldset id=\"field_1_21\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_21\" ><legend class='gfield_label gform-field-label' >Has your residence in the U.S. been continuous?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_21'>\n\t\t\t<div class='gchoice gchoice_1_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_1_21_0' onchange='gformToggleRadioOther( this )'  tabindex='75'  \/>\n\t\t\t\t\t<label for='choice_1_21_0' id='label_1_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_1_21_1' onchange='gformToggleRadioOther( this )'  tabindex='76'  \/>\n\t\t\t\t\t<label for='choice_1_21_1' id='label_1_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_22\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\" ><legend class='gfield_label gform-field-label' >Do you expect to remain in the U.S. permanently?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_22'>\n\t\t\t<div class='gchoice gchoice_1_22_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='Yes'  id='choice_1_22_0' onchange='gformToggleRadioOther( this )'  tabindex='77'  \/>\n\t\t\t\t\t<label for='choice_1_22_0' id='label_1_22_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_22_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_22' type='radio' value='No'  id='choice_1_22_1' onchange='gformToggleRadioOther( this )'  tabindex='78'  \/>\n\t\t\t\t\t<label for='choice_1_22_1' id='label_1_22_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_23\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_23\" ><label class='gfield_label gform-field-label' for='input_1_23'>Please Provide Details<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_23' id='input_1_23' type='text' value='' class='large'   tabindex='79'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_24\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\" ><legend class='gfield_label gform-field-label' >Do you plan to reside in another country besides the US in the next 2 years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_24'>\n\t\t\t<div class='gchoice gchoice_1_24_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='Yes'  id='choice_1_24_0' onchange='gformToggleRadioOther( this )'  tabindex='80'  \/>\n\t\t\t\t\t<label for='choice_1_24_0' id='label_1_24_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_24_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_24' type='radio' value='No'  id='choice_1_24_1' onchange='gformToggleRadioOther( this )'  tabindex='81'  \/>\n\t\t\t\t\t<label for='choice_1_24_1' id='label_1_24_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_25\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_25\" ><label class='gfield_label gform-field-label' for='input_1_25'>Please Provide Details<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_25' id='input_1_25' type='text' value='' class='large'   tabindex='82'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_26\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_26\" ><label class='gfield_label gform-field-label' for='input_1_26'>When do you expect to obtain US citizenship or permanent residency (green Card)? Provide Details<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_1_26' type='text' value='' class='large'   tabindex='83'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_27\" ><label class='gfield_label gform-field-label' for='input_1_27'>Employer Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_1_27' type='text' value='' class='large'   tabindex='84'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_28\" ><legend class='gfield_label gform-field-label' >Number of years with current employer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_28'>\n\t\t\t<div class='gchoice gchoice_1_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='More than two years'  id='choice_1_28_0' onchange='gformToggleRadioOther( this )'  tabindex='85'  \/>\n\t\t\t\t\t<label for='choice_1_28_0' id='label_1_28_0' class='gform-field-label gform-field-label--type-inline'>More than two years<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Less than two years'  id='choice_1_28_1' onchange='gformToggleRadioOther( this )'  tabindex='86'  \/>\n\t\t\t\t\t<label for='choice_1_28_1' id='label_1_28_1' class='gform-field-label gform-field-label--type-inline'>Less than two years<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_31\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_31\" ><label class='gfield_label gform-field-label' for='input_1_31'>Months with current employer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_1_31' type='text' value='' class='large'   tabindex='87'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_29\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_29\" ><label class='gfield_label gform-field-label' for='input_1_29'>Previous employer name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_1_29' type='text' value='' class='large'   tabindex='88'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_30\" ><label class='gfield_label gform-field-label' for='input_1_30'>Nature of current Business<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_1_30' type='text' value='' class='large'   tabindex='89'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_32\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_32\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >CURRENT EMPLOYER ADDRESS<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_32' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_32_1_container' >\n                                        <label for='input_1_32_1' id='input_1_32_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_32.1' id='input_1_32_1' value='' tabindex='90'   aria-required='true'    \/>\n                                   <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_32_3_container' >\n                                    <label for='input_1_32_3' id='input_1_32_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_32.3' id='input_1_32_3' value='' tabindex='91'   aria-required='true'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_32_4_container' >\n                                        <label for='input_1_32_4' id='input_1_32_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                        <input type='text' name='input_32.4' id='input_1_32_4' value='' tabindex='93'     aria-required='true'    \/>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_32_5_container' >\n                                    <label for='input_1_32_5' id='input_1_32_5_label' class='gform-field-label gform-field-label--type-sub '>Zip<\/label>\n                                    <input type='text' name='input_32.5' id='input_1_32_5' value='' tabindex='94'   aria-required='true'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_32.6' id='input_1_32_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_33\" ><label class='gfield_label gform-field-label' for='input_1_33'>Approximately how many people are employed by your current business\/organization?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_1_33' type='text' value='' class='large'   tabindex='95'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_1' class='gform_next_button gform-theme-button button' value='Next' tabindex='96' onclick='jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_2' class='gform_page' data-js='page-field-id-1' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_5\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\" >Occupation Information<\/div><div id=\"field_1_34\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_34\" ><label class='gfield_label gform-field-label' for='input_1_34'>Your Occupation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_1_34' type='text' value='' class='large'   tabindex='97'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_35\" ><label class='gfield_label gform-field-label' for='input_1_35'>Number of Years in Occupation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_1_35' type='text' value='' class='large'   tabindex='98'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\" ><label class='gfield_label gform-field-label' for='input_1_36'>How many hours per week are you at work in this occupation?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_1_36' type='text' value='' class='large'   tabindex='99'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_37\" ><label class='gfield_label gform-field-label' for='input_1_37'>Job Title (If medical or dental occupation, state specialty)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_1_37' type='text' value='' class='large'   tabindex='100'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_38\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_38\" ><label class='gfield_label gform-field-label' for='input_1_38'>Academic degrees, professional licenses and\/or designations held (if none, so state)<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_1_38' type='text' value='' class='large'   tabindex='101'   aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_39\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_39\" ><legend class='gfield_label gform-field-label' >Are you any of the following?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_39'>\n\t\t\t<div class='gchoice gchoice_1_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Student'  id='choice_1_39_0' onchange='gformToggleRadioOther( this )'  tabindex='102'  \/>\n\t\t\t\t\t<label for='choice_1_39_0' id='label_1_39_0' class='gform-field-label gform-field-label--type-inline'>Student<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Resident'  id='choice_1_39_1' onchange='gformToggleRadioOther( this )'  tabindex='103'  \/>\n\t\t\t\t\t<label for='choice_1_39_1' id='label_1_39_1' class='gform-field-label gform-field-label--type-inline'>Resident<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_39_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Fellow'  id='choice_1_39_2' onchange='gformToggleRadioOther( this )'  tabindex='104'  \/>\n\t\t\t\t\t<label for='choice_1_39_2' id='label_1_39_2' class='gform-field-label gform-field-label--type-inline'>Fellow<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_39_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='None'  id='choice_1_39_3' onchange='gformToggleRadioOther( this )'  tabindex='105'  \/>\n\t\t\t\t\t<label for='choice_1_39_3' id='label_1_39_3' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_138\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_138\" ><label class='gfield_label gform-field-label' for='input_1_138'>What is your expected graduation date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_138' id='input_1_138' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='106'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_138_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_138_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_138' class='gform_hidden' value='https:\/\/drschoicesform.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_41\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_41\" >DESCRIPTION OF SPECIFIC DUTIES<\/div><div id=\"field_1_43\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_43\" ><label class='gfield_label gform-field-label' for='input_1_43'>Duty<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_1_43' type='text' value='' class='large'   tabindex='107' placeholder='i.e: travel, meeting with clients or patients, etc..' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_44\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_44\" ><label class='gfield_label gform-field-label' for='input_1_44'>Percentage of Time Devoted<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_1_44' type='text' value='' class='large'   tabindex='108' placeholder='%' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_45\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_45\" ><legend class='gfield_label gform-field-label' >Do you ever perform any manual duties such as operating machinery, carrying or lifting objects in excess of 30 lbs., climbing ladders, or driving a delivery vehicle?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_45'>\n\t\t\t<div class='gchoice gchoice_1_45_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='Yes'  id='choice_1_45_0' onchange='gformToggleRadioOther( this )'  tabindex='109'  \/>\n\t\t\t\t\t<label for='choice_1_45_0' id='label_1_45_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_45_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_45' type='radio' value='No'  id='choice_1_45_1' onchange='gformToggleRadioOther( this )'  tabindex='110'  \/>\n\t\t\t\t\t<label for='choice_1_45_1' id='label_1_45_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_46\" ><label class='gfield_label gform-field-label' for='input_1_46'>Details<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_1_46' type='text' value='' class='large'   tabindex='111'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_47\" ><legend class='gfield_label gform-field-label' >Do you ever wear any protective gear or attire?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_47'>\n\t\t\t<div class='gchoice gchoice_1_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Yes'  id='choice_1_47_0' onchange='gformToggleRadioOther( this )'  tabindex='112'  \/>\n\t\t\t\t\t<label for='choice_1_47_0' id='label_1_47_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='No'  id='choice_1_47_1' onchange='gformToggleRadioOther( this )'  tabindex='113'  \/>\n\t\t\t\t\t<label for='choice_1_47_1' id='label_1_47_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_48\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_48\" ><label class='gfield_label gform-field-label' for='input_1_48'>Details<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_1_48' type='text' value='' class='large'   tabindex='114'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_49\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_49\" ><label class='gfield_label gform-field-label' for='input_1_49'>If you are a medical professional please provide your certifications below.<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_1_49' type='text' value='' class='large'   tabindex='115' placeholder='Medical Board Specialty Certification'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_50\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_50\" ><label class='gfield_label gform-field-label' for='input_1_50'>*<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_1_50' type='text' value='' class='large'   tabindex='116' placeholder='Medical Board Sub-specialty Certification'  aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_54\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_54\" ><legend class='gfield_label gform-field-label' >Is this a home-based occupation?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_54'>\n\t\t\t<div class='gchoice gchoice_1_54_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='Yes'  id='choice_1_54_0' onchange='gformToggleRadioOther( this )'  tabindex='117'  \/>\n\t\t\t\t\t<label for='choice_1_54_0' id='label_1_54_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_54_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_54' type='radio' value='No'  id='choice_1_54_1' onchange='gformToggleRadioOther( this )'  tabindex='118'  \/>\n\t\t\t\t\t<label for='choice_1_54_1' id='label_1_54_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_57\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_57\" ><label class='gfield_label gform-field-label' for='input_1_57'>What percentage of time are you working out of the home?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_1_57' type='text' value='' class='large'   tabindex='119'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_59\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_59\" ><label class='gfield_label gform-field-label' for='input_1_59'>How many hours per week in this occupation?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_1_59' type='text' value='' class='large'   tabindex='120'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_60\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_60\" ><legend class='gfield_label gform-field-label' >Have you been continuously at work full time performing the usual duties of your occupation for the past six months?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_60'>\n\t\t\t<div class='gchoice gchoice_1_60_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='Yes'  id='choice_1_60_0' onchange='gformToggleRadioOther( this )'  tabindex='121'  \/>\n\t\t\t\t\t<label for='choice_1_60_0' id='label_1_60_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_60_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_60' type='radio' value='No'  id='choice_1_60_1' onchange='gformToggleRadioOther( this )'  tabindex='122'  \/>\n\t\t\t\t\t<label for='choice_1_60_1' id='label_1_60_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_61\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_61\" ><label class='gfield_label gform-field-label' for='input_1_61'>Please Explain<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_1_61' type='text' value='' class='large'   tabindex='123'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_62\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_62\" ><legend class='gfield_label gform-field-label' >Do you supervise any employees?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_62'>\n\t\t\t<div class='gchoice gchoice_1_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Yes'  id='choice_1_62_0' onchange='gformToggleRadioOther( this )'  tabindex='124'  \/>\n\t\t\t\t\t<label for='choice_1_62_0' id='label_1_62_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='No'  id='choice_1_62_1' onchange='gformToggleRadioOther( this )'  tabindex='125'  \/>\n\t\t\t\t\t<label for='choice_1_62_1' id='label_1_62_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_63\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_63\" ><label class='gfield_label gform-field-label' for='input_1_63'>How many employees?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_1_63' type='text' value='' class='large'   tabindex='126'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_64\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_64\" ><legend class='gfield_label gform-field-label' >Employment Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_64'>\n\t\t\t<div class='gchoice gchoice_1_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Owner or Partner'  id='choice_1_64_0' onchange='gformToggleRadioOther( this )'  tabindex='127'  \/>\n\t\t\t\t\t<label for='choice_1_64_0' id='label_1_64_0' class='gform-field-label gform-field-label--type-inline'>Owner or Partner<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Employee'  id='choice_1_64_1' onchange='gformToggleRadioOther( this )'  tabindex='128'  \/>\n\t\t\t\t\t<label for='choice_1_64_1' id='label_1_64_1' class='gform-field-label gform-field-label--type-inline'>Employee<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_65\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_65\" ><legend class='gfield_label gform-field-label' >Owner or Partner Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_65'>\n\t\t\t<div class='gchoice gchoice_1_65_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Sole Proprietor'  id='choice_1_65_0' onchange='gformToggleRadioOther( this )'  tabindex='129'  \/>\n\t\t\t\t\t<label for='choice_1_65_0' id='label_1_65_0' class='gform-field-label gform-field-label--type-inline'>Sole Proprietor<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_65_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='Partner'  id='choice_1_65_1' onchange='gformToggleRadioOther( this )'  tabindex='130'  \/>\n\t\t\t\t\t<label for='choice_1_65_1' id='label_1_65_1' class='gform-field-label gform-field-label--type-inline'>Partner<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_65_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='S-Corporation Shareholder'  id='choice_1_65_2' onchange='gformToggleRadioOther( this )'  tabindex='131'  \/>\n\t\t\t\t\t<label for='choice_1_65_2' id='label_1_65_2' class='gform-field-label gform-field-label--type-inline'>S-Corporation Shareholder<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_65_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_65' type='radio' value='C-Corporation Shareholder'  id='choice_1_65_3' onchange='gformToggleRadioOther( this )'  tabindex='132'  \/>\n\t\t\t\t\t<label for='choice_1_65_3' id='label_1_65_3' class='gform-field-label gform-field-label--type-inline'>C-Corporation Shareholder<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_66\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_66\" ><label class='gfield_label gform-field-label' for='input_1_66'>Percent partnership<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_1_66' type='text' value='' class='large'   tabindex='133'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_68\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_68\" ><legend class='gfield_label gform-field-label' >Do you plan to change your occupation, job or employment within the next six months?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_68'>\n\t\t\t<div class='gchoice gchoice_1_68_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='Yes'  id='choice_1_68_0' onchange='gformToggleRadioOther( this )'  tabindex='134'  \/>\n\t\t\t\t\t<label for='choice_1_68_0' id='label_1_68_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_68_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_68' type='radio' value='No'  id='choice_1_68_1' onchange='gformToggleRadioOther( this )'  tabindex='135'  \/>\n\t\t\t\t\t<label for='choice_1_68_1' id='label_1_68_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_69\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_69\" ><label class='gfield_label gform-field-label' for='input_1_69'>Please Explain<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_1_69' type='text' value='' class='large'   tabindex='136'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_71\" ><legend class='gfield_label gform-field-label' >Do you have any other part or full time occupation, job or employment?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_71'>\n\t\t\t<div class='gchoice gchoice_1_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Yes'  id='choice_1_71_0' onchange='gformToggleRadioOther( this )'  tabindex='137'  \/>\n\t\t\t\t\t<label for='choice_1_71_0' id='label_1_71_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='No'  id='choice_1_71_1' onchange='gformToggleRadioOther( this )'  tabindex='138'  \/>\n\t\t\t\t\t<label for='choice_1_71_1' id='label_1_71_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_70\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_70\" ><label class='gfield_label gform-field-label screen-reader-text' for='input_1_70'><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_1_70' type='text' value='' class='large'   tabindex='139'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_55' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous' tabindex='140' onclick='jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"1\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_55' class='gform_next_button gform-theme-button button' value='Next' tabindex='141' onclick='jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_3' class='gform_page' data-js='page-field-id-55' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_58\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_58\" >Financial Information<\/div><div id=\"field_1_72\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_72\" ><label class='gfield_label gform-field-label' for='input_1_72'>Are you applying for Disability Insurance, Life Insurance, or Both?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_72' id='input_1_72' class='large gfield_select' tabindex='142'   aria-required=\"true\" aria-invalid=\"false\" ><option value='Are you applying for:' >Are you applying for:<\/option><option value='Disability Insurance' >Disability Insurance<\/option><option value='Life Insurance' >Life Insurance<\/option><option value='Both' >Both<\/option><\/select><\/div><\/div><div id=\"field_1_139\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_139\" ><label class='gfield_label gform-field-label' for='input_1_139'>Net Worth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_1_139' type='text' value='' class='large'   tabindex='143'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_74\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_74\" >For purposes of this section only, Earned Income means the income you are required to report to the Internal Revenue Service (\u201cIRS\u201d) for income tax purposes. This includes W-2 wages, salary, bonuses, your share of net business income, and all other compensation you received for work or services.<\/div><div id=\"field_1_75\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_75\" ><label class='gfield_label gform-field-label screen-reader-text' for='input_1_75'>Current Income This Calendar\u00a0Year<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_1_75' type='text' value='' class='large'   tabindex='144' placeholder='Current Income This Calendar\u00a0Year' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_76\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_76\" ><label class='gfield_label gform-field-label screen-reader-text' for='input_1_76'>Earned Income Actually filed with the IRS last Year.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_1_76' type='text' value='' class='large'   tabindex='145' placeholder='Earned Income Actually filed with the IRS last Year.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_77\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_77\" ><label class='gfield_label gform-field-label screen-reader-text' for='input_1_77'>Earned Income Actually Filed with the IRS two calendar years ago.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_77' id='input_1_77' type='text' value='' class='large'   tabindex='146' placeholder='Earned Income Actually Filed with the IRS two calendar years ago.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_78\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_78\" ><legend class='gfield_label gform-field-label' >Do you have any unearned income that is more than 10% or your earned income?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_78'>\n\t\t\t<div class='gchoice gchoice_1_78_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Yes'  id='choice_1_78_0' onchange='gformToggleRadioOther( this )'  tabindex='147'  \/>\n\t\t\t\t\t<label for='choice_1_78_0' id='label_1_78_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_78_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='No'  id='choice_1_78_1' onchange='gformToggleRadioOther( this )'  tabindex='148'  \/>\n\t\t\t\t\t<label for='choice_1_78_1' id='label_1_78_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_79\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_79\" ><label class='gfield_label gform-field-label' for='input_1_79'>Last year&#039;s actual income filed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_1_79' type='text' value='' class='large'   tabindex='149'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_80\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_80\" ><label class='gfield_label gform-field-label' for='input_1_80'>2 Year&#039;s Ago actual income filed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_1_80' type='text' value='' class='large'   tabindex='150'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_81\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_81\" ><label class='gfield_label gform-field-label' for='input_1_81'>Source<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_1_81' type='text' value='' class='large'   tabindex='151'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_84\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_84\" ><legend class='gfield_label gform-field-label' >Have you or a business you\u2019ve owned ever filed, or plan to file, for bankruptcy?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_84'>\n\t\t\t<div class='gchoice gchoice_1_84_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='Yes'  id='choice_1_84_0' onchange='gformToggleRadioOther( this )'  tabindex='152'  \/>\n\t\t\t\t\t<label for='choice_1_84_0' id='label_1_84_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_84_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_84' type='radio' value='No'  id='choice_1_84_1' onchange='gformToggleRadioOther( this )'  tabindex='153'  \/>\n\t\t\t\t\t<label for='choice_1_84_1' id='label_1_84_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_85\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_85\" ><legend class='gfield_label gform-field-label' >Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_85'>\n\t\t\t<div class='gchoice gchoice_1_85_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='Personal'  id='choice_1_85_0' onchange='gformToggleRadioOther( this )'  tabindex='154'  \/>\n\t\t\t\t\t<label for='choice_1_85_0' id='label_1_85_0' class='gform-field-label gform-field-label--type-inline'>Personal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_85_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='Business'  id='choice_1_85_1' onchange='gformToggleRadioOther( this )'  tabindex='155'  \/>\n\t\t\t\t\t<label for='choice_1_85_1' id='label_1_85_1' class='gform-field-label gform-field-label--type-inline'>Business<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_86\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_86\" ><label class='gfield_label gform-field-label' for='input_1_86'>Date Filed<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_86' id='input_1_86' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='156'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_86_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_86_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_86' class='gform_hidden' value='https:\/\/drschoicesform.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_87\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_87\" ><label class='gfield_label gform-field-label' for='input_1_87'>Date Discharged<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_87' id='input_1_87' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='157'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_87_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_87_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_87' class='gform_hidden' value='https:\/\/drschoicesform.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_93' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous' tabindex='158' onclick='jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"2\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_93' class='gform_next_button gform-theme-button button' value='Next' tabindex='159' onclick='jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"4\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_4' class='gform_page' data-js='page-field-id-93' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_90\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_90\" >Additional Information<\/div><div id=\"field_1_160\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_160\" ><label class='gfield_label gform-field-label' for='input_1_160'>Driver&#039;s License Number<\/label><div class='ginput_container ginput_container_text'><input name='input_160' id='input_1_160' type='text' value='' class='large'   tabindex='160'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_140\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_140\" ><label class='gfield_label gform-field-label' for='input_1_140'>Driver&#039;s License State<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_1_140' type='text' value='' class='large'   tabindex='161'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_143\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_143\" >BENEFICIARY<\/div><div id=\"field_1_144\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_144\" ><label class='gfield_label gform-field-label' for='input_1_144'>Full Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_144' id='input_1_144' type='text' value='' class='large'   tabindex='162'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_147\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_147\" ><label class='gfield_label gform-field-label' for='input_1_147'>Date Of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_147' id='input_1_147' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='163'  placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_147_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_1_147_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_147' class='gform_hidden' value='https:\/\/drschoicesform.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_148\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_148\" ><label class='gfield_label gform-field-label' for='input_1_148'>Type<\/label><div class='ginput_container ginput_container_select'><select name='input_148' id='input_1_148' class='large gfield_select' tabindex='164'    aria-invalid=\"false\" ><option value='Primary' >Primary<\/option><option value='Contingent' >Contingent<\/option><option value='Tertiary' >Tertiary<\/option><\/select><\/div><\/div><fieldset id=\"field_1_149\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_149\" ><legend class='gfield_label gform-field-label' >Per Stripes<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_149'>\n\t\t\t<div class='gchoice gchoice_1_149_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_149' type='radio' value='Yes'  id='choice_1_149_0' onchange='gformToggleRadioOther( this )'  tabindex='165'  \/>\n\t\t\t\t\t<label for='choice_1_149_0' id='label_1_149_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_149_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_149' type='radio' value='No'  id='choice_1_149_1' onchange='gformToggleRadioOther( this )'  tabindex='166'  \/>\n\t\t\t\t\t<label for='choice_1_149_1' id='label_1_149_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_146\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_146\" ><label class='gfield_label gform-field-label' for='input_1_146'>Relationship to Proposed Insured<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_146' id='input_1_146' type='text' value='' class='large'   tabindex='167'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_150\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_150\" ><label class='gfield_label gform-field-label' for='input_1_150'>Percentage %<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_150' id='input_1_150' type='text' value='' class='large'   tabindex='168'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_151\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_151\" ><label class='gfield_label gform-field-label' for='input_1_151'>Social Security Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_151' id='input_1_151' type='number' step='any'   value='' class='large' tabindex='169'    aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_152\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_152\" ><label class='gfield_label gform-field-label' for='input_1_152'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_152' id='input_1_152' type='number' step='any'   value='' class='large' tabindex='170'    aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_1_153\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_153\" ><legend class='gfield_label gform-field-label' >Is Address same as Owner<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_153'>\n\t\t\t<div class='gchoice gchoice_1_153_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_153' type='radio' value='Yes'  id='choice_1_153_0' onchange='gformToggleRadioOther( this )'  tabindex='171'  \/>\n\t\t\t\t\t<label for='choice_1_153_0' id='label_1_153_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_153_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_153' type='radio' value='No'  id='choice_1_153_1' onchange='gformToggleRadioOther( this )'  tabindex='172'  \/>\n\t\t\t\t\t<label for='choice_1_153_1' id='label_1_153_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_155\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_155\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_1_155' >\n                        <span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_155_2_container' >\n                                        <input type='text' name='input_155.2' id='input_1_155_2' value='' tabindex='174'  placeholder='Mailing Address'  aria-required='false'   \/>\n                                        <label for='input_1_155_2' id='input_1_155_2_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_155_3_container' >\n                                    <input type='text' name='input_155.3' id='input_1_155_3' value='' tabindex='175'  placeholder='City' aria-required='true'    \/>\n                                    <label for='input_1_155_3' id='input_1_155_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_1_155_4_container' >\n                                        <input type='text' name='input_155.4' id='input_1_155_4' value='' tabindex='177'    placeholder='State' aria-required='true'    \/>\n                                        <label for='input_1_155_4' id='input_1_155_4_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_155_5_container' >\n                                    <input type='text' name='input_155.5' id='input_1_155_5' value='' tabindex='178'  placeholder='Zip' aria-required='true'    \/>\n                                    <label for='input_1_155_5' id='input_1_155_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_155.6' id='input_1_155_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_156\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_156\" >EXISTING INSURANCE\/REPLACEMENT<\/div><fieldset id=\"field_1_158\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_158\" ><legend class='gfield_label gform-field-label' >1) Does the Applicant\/Owner have any existing individual life insurance policies or annuity contracts (including those that may have recently been lapsed or surrendered)?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_158'>\n\t\t\t<div class='gchoice gchoice_1_158_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_158' type='radio' value='Yes'  id='choice_1_158_0' onchange='gformToggleRadioOther( this )'  tabindex='179'  \/>\n\t\t\t\t\t<label for='choice_1_158_0' id='label_1_158_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_158_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_158' type='radio' value='No'  id='choice_1_158_1' onchange='gformToggleRadioOther( this )'  tabindex='180'  \/>\n\t\t\t\t\t<label for='choice_1_158_1' id='label_1_158_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_159\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_159\" ><legend class='gfield_label gform-field-label' >2) As a result of the proposed purchase of life insurance, have you (the Applicant\/Owner) done, or are you considering doing, any of the following to any existing life insurance policy or annuity contract that you own: lapse, partial lapse, surrender, forfeit, assignment to an insurer, termination of existing insurance; taking loans, withdrawals, or any other use of funds from your existing insurance ( including a stoppage or reduction in premium payments) to pay the premiums on the new life insurance policy?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_159'>\n\t\t\t<div class='gchoice gchoice_1_159_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_159' type='radio' value='Yes'  id='choice_1_159_0' onchange='gformToggleRadioOther( this )'  tabindex='181'  \/>\n\t\t\t\t\t<label for='choice_1_159_0' id='label_1_159_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_159_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_159' type='radio' value='No'  id='choice_1_159_1' onchange='gformToggleRadioOther( this )'  tabindex='182'  \/>\n\t\t\t\t\t<label for='choice_1_159_1' id='label_1_159_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_91\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_91\" ><legend class='gfield_label gform-field-label' >Do you plan to reside or travel outside of the U.S.?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_91'>\n\t\t\t<div class='gchoice gchoice_1_91_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='Yes'  id='choice_1_91_0' onchange='gformToggleRadioOther( this )'  tabindex='183'  \/>\n\t\t\t\t\t<label for='choice_1_91_0' id='label_1_91_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_91_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='No'  id='choice_1_91_1' onchange='gformToggleRadioOther( this )'  tabindex='184'  \/>\n\t\t\t\t\t<label for='choice_1_91_1' id='label_1_91_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_92\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_92\" ><label class='gfield_label gform-field-label' for='input_1_92'>Untitled<\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_1_92' type='text' value='' class='large'   tabindex='185' placeholder='Please indicate location, frequency, for work or pleasure, date of departure, length of stay'  aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_95\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_95\" ><legend class='gfield_label gform-field-label' >Within the past five years, have you been charged with or convicted of any motor vehicle violations or had your driver&#039;s license suspended or revoked?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_95'>\n\t\t\t<div class='gchoice gchoice_1_95_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_95' type='radio' value='Yes'  id='choice_1_95_0' onchange='gformToggleRadioOther( this )'  tabindex='186'  \/>\n\t\t\t\t\t<label for='choice_1_95_0' id='label_1_95_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_95_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_95' type='radio' value='No'  id='choice_1_95_1' onchange='gformToggleRadioOther( this )'  tabindex='187'  \/>\n\t\t\t\t\t<label for='choice_1_95_1' id='label_1_95_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_96\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_96\" ><label class='gfield_label gform-field-label' for='input_1_96'>Untitled<\/label><div class='ginput_container ginput_container_text'><input name='input_96' id='input_1_96' type='text' value='' class='large'   tabindex='188' placeholder='Please provide details of the violation and\/or penalty'  aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_98\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_98\" ><legend class='gfield_label gform-field-label' >In the past 10 years, have you ever pled guilty to, pled no contest to, or been convicted of a felony or misdemeanor?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_98'>\n\t\t\t<div class='gchoice gchoice_1_98_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='Yes'  id='choice_1_98_0' onchange='gformToggleRadioOther( this )'  tabindex='189'  \/>\n\t\t\t\t\t<label for='choice_1_98_0' id='label_1_98_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_98_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_98' type='radio' value='No'  id='choice_1_98_1' onchange='gformToggleRadioOther( this )'  tabindex='190'  \/>\n\t\t\t\t\t<label for='choice_1_98_1' id='label_1_98_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_97\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_97\" ><label class='gfield_label gform-field-label' for='input_1_97'>Untitled<\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_1_97' type='text' value='' class='large'   tabindex='191' placeholder='Please provide details'  aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_100\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_100\" ><legend class='gfield_label gform-field-label' >Within the last three years, have you participated, or do you plan to participate in piloting any type of aircraft or hang gliding?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_100'>\n\t\t\t<div class='gchoice gchoice_1_100_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='Yes'  id='choice_1_100_0' onchange='gformToggleRadioOther( this )'  tabindex='192'  \/>\n\t\t\t\t\t<label for='choice_1_100_0' id='label_1_100_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_100_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_100' type='radio' value='No'  id='choice_1_100_1' onchange='gformToggleRadioOther( this )'  tabindex='193'  \/>\n\t\t\t\t\t<label for='choice_1_100_1' id='label_1_100_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_99\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_99\" ><label class='gfield_label gform-field-label' for='input_1_99'>Untitled<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_1_99' type='text' value='' class='large'   tabindex='194' placeholder='Please provide details'  aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_102\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_102\" ><legend class='gfield_label gform-field-label' >Within the last three years, have you participated, or do you plan to participate in mountain or rock climbing, scuba diving, contact martial arts, motor vehicle racing, parachuting or skydiving or other hazardous activities?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_102'>\n\t\t\t<div class='gchoice gchoice_1_102_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_102' type='radio' value='Yes'  id='choice_1_102_0' onchange='gformToggleRadioOther( this )'  tabindex='195'  \/>\n\t\t\t\t\t<label for='choice_1_102_0' id='label_1_102_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_102_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_102' type='radio' value='No'  id='choice_1_102_1' onchange='gformToggleRadioOther( this )'  tabindex='196'  \/>\n\t\t\t\t\t<label for='choice_1_102_1' id='label_1_102_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_101\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_101\" ><label class='gfield_label gform-field-label' for='input_1_101'>Untitled<\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_1_101' type='text' value='' class='large'   tabindex='197' placeholder='Please provide details'  aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_104\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_104\" ><legend class='gfield_label gform-field-label' >Have you used tobacco, nicotine, or any nicotine delivery system in any form in the last 12 months?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_104'>\n\t\t\t<div class='gchoice gchoice_1_104_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='Yes'  id='choice_1_104_0' onchange='gformToggleRadioOther( this )'  tabindex='198'  \/>\n\t\t\t\t\t<label for='choice_1_104_0' id='label_1_104_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_104_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='No'  id='choice_1_104_1' onchange='gformToggleRadioOther( this )'  tabindex='199'  \/>\n\t\t\t\t\t<label for='choice_1_104_1' id='label_1_104_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_103\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_103\" ><label class='gfield_label gform-field-label' for='input_1_103'>Untitled<\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_1_103' type='text' value='' class='large'   tabindex='200' placeholder='Please provide details'  aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_106\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_106\" ><legend class='gfield_label gform-field-label' >Did you quit?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_106'>\n\t\t\t<div class='gchoice gchoice_1_106_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_106' type='radio' value='Yes'  id='choice_1_106_0' onchange='gformToggleRadioOther( this )'  tabindex='201'  \/>\n\t\t\t\t\t<label for='choice_1_106_0' id='label_1_106_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_106_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_106' type='radio' value='No'  id='choice_1_106_1' onchange='gformToggleRadioOther( this )'  tabindex='202'  \/>\n\t\t\t\t\t<label for='choice_1_106_1' id='label_1_106_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_105\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_105\" ><label class='gfield_label gform-field-label' for='input_1_105'>Untitled<\/label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_1_105' type='text' value='' class='large'   tabindex='203' placeholder='When did you quit?'  aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_108\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_108\" ><legend class='gfield_label gform-field-label' >Are you now, or do you intend to become a member of the U.S. Armed Forces or have you received military orders or been placed on alert?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_108'>\n\t\t\t<div class='gchoice gchoice_1_108_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='Yes'  id='choice_1_108_0' onchange='gformToggleRadioOther( this )'  tabindex='204'  \/>\n\t\t\t\t\t<label for='choice_1_108_0' id='label_1_108_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_108_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='No'  id='choice_1_108_1' onchange='gformToggleRadioOther( this )'  tabindex='205'  \/>\n\t\t\t\t\t<label for='choice_1_108_1' id='label_1_108_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_107\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_107\" ><label class='gfield_label gform-field-label' for='input_1_107'>Untitled<\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_1_107' type='text' value='' class='large'   tabindex='206' placeholder='Please provide details'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_128\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_128\" >Do any of the following apply?<\/div><div id=\"field_1_127\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_127\" ><ul>\n  <li>Your professional or occupational license or certification has ever been suspended, revoked, restricted, inactivated, surrendered, or the like.<\/li>\n  <li>There is a pending investigation or complaint concerning you with a regulatory, governmental, or other entity that oversees your profession.<\/li>\n  <li>You have been disbarred; or<\/li>\n<li>You have ever been fined or sanctioned by an entity that oversees your profession.<\/li>\n<\/ul> <\/div><fieldset id=\"field_1_114\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_114\" ><legend class='gfield_label gform-field-label' >Do any of the following apply?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_114'>\n\t\t\t<div class='gchoice gchoice_1_114_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='Yes'  id='choice_1_114_0' onchange='gformToggleRadioOther( this )'  tabindex='207'  \/>\n\t\t\t\t\t<label for='choice_1_114_0' id='label_1_114_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_114_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='No'  id='choice_1_114_1' onchange='gformToggleRadioOther( this )'  tabindex='208'  \/>\n\t\t\t\t\t<label for='choice_1_114_1' id='label_1_114_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_113\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_113\" ><label class='gfield_label gform-field-label' for='input_1_113'>Untitled<\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_1_113' type='text' value='' class='large'   tabindex='209' placeholder='Please provide details'  aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_115' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous' tabindex='210' onclick='jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"3\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_115' class='gform_next_button gform-theme-button button' value='Next' tabindex='211' onclick='jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"5\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_5' class='gform_page' data-js='page-field-id-115' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_1_117\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_117\" ><legend class='gfield_label gform-field-label' >Within the past five years, have you had any application for insurance declined, postponed, modified, rated, cancelled, rescinded, or have you withdrawn a pending application, or had a renewal or reinstatement request refused?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_117'>\n\t\t\t<div class='gchoice gchoice_1_117_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_117' type='radio' value='Yes'  id='choice_1_117_0' onchange='gformToggleRadioOther( this )'  tabindex='212'  \/>\n\t\t\t\t\t<label for='choice_1_117_0' id='label_1_117_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_117_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_117' type='radio' value='No'  id='choice_1_117_1' onchange='gformToggleRadioOther( this )'  tabindex='213'  \/>\n\t\t\t\t\t<label for='choice_1_117_1' id='label_1_117_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_119\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_119\" ><label class='gfield_label gform-field-label' for='input_1_119'>Untitled<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_1_119' type='text' value='' class='large'   tabindex='214' placeholder='Please provide details' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_121\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_121\" ><legend class='gfield_label gform-field-label' >Within the past six months, have you applied for life insurance through The Guardian Life Insurance Company of America (&quot;Guardian&quot;) or any other company?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_121'>\n\t\t\t<div class='gchoice gchoice_1_121_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='Yes'  id='choice_1_121_0' onchange='gformToggleRadioOther( this )'  tabindex='215'  \/>\n\t\t\t\t\t<label for='choice_1_121_0' id='label_1_121_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_121_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_121' type='radio' value='No'  id='choice_1_121_1' onchange='gformToggleRadioOther( this )'  tabindex='216'  \/>\n\t\t\t\t\t<label for='choice_1_121_1' id='label_1_121_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_120\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_120\" ><label class='gfield_label gform-field-label' for='input_1_120'>Untitled<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_120' id='input_1_120' type='text' value='' class='large'   tabindex='217' placeholder='Company Name' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_1_123\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_123\" ><legend class='gfield_label gform-field-label' >Do you have any disability insurance in force, or applied for, or for which you are eligible within the next 12 months with any company? This includes any group LTD that you may have at work<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_123'>\n\t\t\t<div class='gchoice gchoice_1_123_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='Yes'  id='choice_1_123_0' onchange='gformToggleRadioOther( this )'  tabindex='218'  \/>\n\t\t\t\t\t<label for='choice_1_123_0' id='label_1_123_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_123_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value='No'  id='choice_1_123_1' onchange='gformToggleRadioOther( this )'  tabindex='219'  \/>\n\t\t\t\t\t<label for='choice_1_123_1' id='label_1_123_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_124\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_124\" >COVERAGE DETAILS<\/div><div id=\"field_1_122\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_122\" ><label class='gfield_label gform-field-label' for='input_1_122'>Insurance Company Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_122' id='input_1_122' type='text' value='' class='large'   tabindex='220'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_125\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_125\" ><label class='gfield_label gform-field-label' for='input_1_125'>Status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_125' id='input_1_125' class='large gfield_select' tabindex='221'   aria-required=\"true\" aria-invalid=\"false\" ><option value='In Force' >In Force<\/option><option value='Applied For' >Applied For<\/option><\/select><\/div><\/div><fieldset id=\"field_1_129\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_129\" ><legend class='gfield_label gform-field-label' >Is this coverage being replaced?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_129'>\n\t\t\t<div class='gchoice gchoice_1_129_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='Yes'  id='choice_1_129_0' onchange='gformToggleRadioOther( this )'  tabindex='222'  \/>\n\t\t\t\t\t<label for='choice_1_129_0' id='label_1_129_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_129_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_129' type='radio' value='No'  id='choice_1_129_1' onchange='gformToggleRadioOther( this )'  tabindex='223'  \/>\n\t\t\t\t\t<label for='choice_1_129_1' id='label_1_129_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_131\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_131\" ><label class='gfield_label gform-field-label' for='input_1_131'>Benefit Amount<\/label><div class='ginput_container ginput_container_number'><input name='input_131' id='input_1_131' type='number' step='any'   value='' class='large' tabindex='224'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_1_132\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_132\" ><label class='gfield_label gform-field-label' for='input_1_132'>Type of coverage<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_132' id='input_1_132' class='large gfield_select' tabindex='225'   aria-required=\"true\" aria-invalid=\"false\" ><option value='Individual DI' >Individual DI<\/option><option value='Group LTD' >Group LTD<\/option><option value='Association' >Association<\/option><\/select><\/div><\/div><fieldset id=\"field_1_133\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_133\" ><legend class='gfield_label gform-field-label' >Employer Paid<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_133'>\n\t\t\t<div class='gchoice gchoice_1_133_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='Yes'  id='choice_1_133_0' onchange='gformToggleRadioOther( this )'  tabindex='226'  \/>\n\t\t\t\t\t<label for='choice_1_133_0' id='label_1_133_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_133_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_133' type='radio' value='No'  id='choice_1_133_1' onchange='gformToggleRadioOther( this )'  tabindex='227'  \/>\n\t\t\t\t\t<label for='choice_1_133_1' id='label_1_133_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_135\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_135\" ><label class='gfield_label gform-field-label' for='input_1_135'>Untitled<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_135' id='input_1_135' type='text' value='' class='large'   tabindex='228' placeholder='Height' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_136\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_136\" ><label class='gfield_label gform-field-label' for='input_1_136'>Untitled<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_136' id='input_1_136' type='text' value='' class='large'   tabindex='229' placeholder='Weight' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_116\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_116\" >Coverage Health Information<\/div><div id=\"field_1_137\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_1_137\" ><label class='gfield_label gform-field-label' for='input_1_137'>Please tell us a little about your overall health<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_137' id='input_1_137' class='textarea medium' tabindex='230'    aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_1' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous' tabindex='231' onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> <input type='submit' id='gform_submit_button_1' class='gform_button button gform-button--width-full' value='Submit' tabindex='232' onclick='if(window[\"gf_submitting_1\"]){return false;}  if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_1\"]){return false;} if( !jQuery(\"#gform_1\")[0].checkValidity || jQuery(\"#gform_1\")[0].checkValidity()){window[\"gf_submitting_1\"]=true;}  jQuery(\"#gform_1\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' value='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' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_1' id='gform_target_page_number_1' value='2' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_1' id='gform_source_page_number_1' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='check=First+Choice%2CSecond+Choice' \/>\n            \n        <\/div>\n                        <\/div><\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 1, 'https:\/\/drschoicesform.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', false );jQuery('#gform_ajax_frame_1').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_1');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_1').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_1').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_1').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_1').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_1').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_1').val();gformInitSpinner( 1, 'https:\/\/drschoicesform.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', false );jQuery(document).trigger('gform_page_loaded', [1, current_page]);window['gf_submitting_1'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_1').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_1').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [1]);window['gf_submitting_1'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_1').text());}, 50);}else{jQuery('#gform_1').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"1\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);                if (event.defaultPrevented) {                return;         }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_1\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_1\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_1\" );        let postRenderFired = false;                function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            jQuery( document ).trigger( 'gform_post_render', [1, current_page] );            gform.utils.trigger( { event: 'gform\/postRender', native: false, data: { formId: 1, currentPage: current_page } } );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>PRE-APPLICATION QUESTIONNAIRE The purpose of this form is simply to gather information to help complete an application for disability or life insurance &#8211; it is not an application. If you apply for insurance you may be asked additional or different questions. Once you have completed this form, your agent will use the information requested in [&hellip;]<\/p>\n","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"elementor_header_footer","meta":{"footnotes":""},"class_list":["post-14","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/drschoicesform.com\/index.php\/wp-json\/wp\/v2\/pages\/14","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/drschoicesform.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/drschoicesform.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/drschoicesform.com\/index.php\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/drschoicesform.com\/index.php\/wp-json\/wp\/v2\/comments?post=14"}],"version-history":[{"count":43,"href":"https:\/\/drschoicesform.com\/index.php\/wp-json\/wp\/v2\/pages\/14\/revisions"}],"predecessor-version":[{"id":1293,"href":"https:\/\/drschoicesform.com\/index.php\/wp-json\/wp\/v2\/pages\/14\/revisions\/1293"}],"wp:attachment":[{"href":"https:\/\/drschoicesform.com\/index.php\/wp-json\/wp\/v2\/media?parent=14"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}