{"id":2793,"date":"2021-06-04T16:10:21","date_gmt":"2021-06-04T20:10:21","guid":{"rendered":"http:\/\/theultimategroups.com\/?page_id=2793"},"modified":"2021-06-04T16:12:11","modified_gmt":"2021-06-04T20:12:11","slug":"surveillance-online-referral","status":"publish","type":"page","link":"https:\/\/richardblaise.com\/index.php\/surveillance-online-referral\/","title":{"rendered":"Surveillance Online Referral"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full wpforms-block\" id=\"wpforms-2729\"><form id=\"wpforms-form-2729\" class=\"wpforms-validate wpforms-form\" data-formid=\"2729\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/index.php\/wp-json\/wp\/v2\/pages\/2793?wpforms_form_id=2729\" data-token=\"a6ba665b499c2ee4cd2829b13a15750f\" data-token-time=\"1781379623\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-2729-field_1-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_1\">Your Email: <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-2729-field_1\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][1]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-2729-field_2-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"2\"><h3 id=\"wpforms-2729-field_2\">Case Referral Form<\/h3><\/div><div id=\"wpforms-2729-field_3-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_3\">From:<\/label><input type=\"text\" id=\"wpforms-2729-field_3\" class=\"wpforms-field-medium\" name=\"wpforms[fields][3]\" ><\/div><div id=\"wpforms-2729-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_4\">Company:<\/label><input type=\"text\" id=\"wpforms-2729-field_4\" class=\"wpforms-field-medium\" name=\"wpforms[fields][4]\" ><\/div><div id=\"wpforms-2729-field_5-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"5\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_5\">Phone:<\/label><input type=\"tel\" id=\"wpforms-2729-field_5\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][5]\" aria-label=\"Phone:\" ><\/div><div id=\"wpforms-2729-field_6-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_6\">Fax:<\/label><input type=\"tel\" id=\"wpforms-2729-field_6\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][6]\" aria-label=\"Fax:\" ><\/div><div id=\"wpforms-2729-field_7-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"7\"><label class=\"wpforms-field-label\">Address:<\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-2729-field_7\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][7][address1]\" ><label for=\"wpforms-2729-field_7\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-2729-field_7-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][7][address2]\" ><label for=\"wpforms-2729-field_7-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-2729-field_7-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][7][city]\" ><label for=\"wpforms-2729-field_7-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-2729-field_7-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][7][state]\" ><option class=\"placeholder\" value=\"\" selected disabled>&#8212; Select state &#8212;<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-2729-field_7-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-2729-field_7-postal\" class=\"wpforms-field-address-postal wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][7][postal]\" ><label for=\"wpforms-2729-field_7-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-2729-field_8-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"8\"><h3 id=\"wpforms-2729-field_8\">Claim<\/h3><\/div><div id=\"wpforms-2729-field_9-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_9\">Claim Date:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-2729-field_9\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][9][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-2729-field_10-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_10\">Claim Due Date:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-2729-field_10\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][10][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-2729-field_11-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_11\">Date of Loss:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-2729-field_11\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][11][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-2729-field_12-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_12\">Claimant:<\/label><input type=\"text\" id=\"wpforms-2729-field_12\" class=\"wpforms-field-medium\" name=\"wpforms[fields][12]\" ><\/div><div id=\"wpforms-2729-field_13-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_13\">Claim # <\/label><input type=\"text\" id=\"wpforms-2729-field_13\" class=\"wpforms-field-medium\" name=\"wpforms[fields][13]\" ><\/div><div id=\"wpforms-2729-field_14-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"14\"><label class=\"wpforms-field-label\">Claim Address:<\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-2729-field_14\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][14][address1]\" ><label for=\"wpforms-2729-field_14\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-2729-field_14-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][14][address2]\" ><label for=\"wpforms-2729-field_14-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-2729-field_14-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][14][city]\" ><label for=\"wpforms-2729-field_14-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-2729-field_14-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][14][state]\" ><option class=\"placeholder\" value=\"\" selected disabled>&#8212; Select state &#8212;<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-2729-field_14-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-2729-field_14-postal\" class=\"wpforms-field-address-postal wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][14][postal]\" ><label for=\"wpforms-2729-field_14-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-2729-field_15-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_15\">Insured:<\/label><input type=\"text\" id=\"wpforms-2729-field_15\" class=\"wpforms-field-medium\" name=\"wpforms[fields][15]\" ><\/div><div id=\"wpforms-2729-field_16-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_16\">Claimant Phone:<\/label><input type=\"tel\" id=\"wpforms-2729-field_16\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][16]\" aria-label=\"Claimant Phone:\" ><\/div><div id=\"wpforms-2729-field_17-container\" class=\"wpforms-field wpforms-field-phone\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_17\">Contact Person Phone:<\/label><input type=\"tel\" id=\"wpforms-2729-field_17\" class=\"wpforms-field-medium wpforms-smart-phone-field\" data-rule-smart-phone-field=\"true\" name=\"wpforms[fields][17]\" aria-label=\"Contact Person Phone:\" ><\/div><div id=\"wpforms-2729-field_18-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"18\"><h3 id=\"wpforms-2729-field_18\">Services<\/h3><\/div><div id=\"wpforms-2729-field_19-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"19\"><label class=\"wpforms-field-label\">Check Type Of Service(s):<\/label><ul id=\"wpforms-2729-field_19\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2729-field_19_1\" name=\"wpforms[fields][19][]\" value=\"Activity Check - In Person or Neighbors\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2729-field_19_1\">Activity Check &#8211; In Person or Neighbors<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2729-field_19_2\" name=\"wpforms[fields][19][]\" value=\"Photographs\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2729-field_19_2\">Photographs<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-2729-field_19_3\" name=\"wpforms[fields][19][]\" value=\"Video Tape\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2729-field_19_3\">Video Tape<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-2729-field_19_4\" name=\"wpforms[fields][19][]\" value=\"Diagrams\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2729-field_19_4\">Diagrams<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-2729-field_19_5\" name=\"wpforms[fields][19][]\" value=\"Signed Statement\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2729-field_19_5\">Signed Statement<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-2729-field_19_6\" name=\"wpforms[fields][19][]\" value=\"Recorded Statement\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2729-field_19_6\">Recorded Statement<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-2729-field_19_7\" name=\"wpforms[fields][19][]\" value=\"Interview (No statement)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2729-field_19_7\">Interview (No statement)<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-2729-field_19_8\" name=\"wpforms[fields][19][]\" value=\"Survelliance\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2729-field_19_8\">Survelliance<\/label><\/li><li class=\"choice-9 depth-1\"><input type=\"checkbox\" id=\"wpforms-2729-field_19_9\" name=\"wpforms[fields][19][]\" value=\"Other (Indicate Below)\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-2729-field_19_9\">Other (Indicate Below)<\/label><\/li><\/ul><\/div><div id=\"wpforms-2729-field_20-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_20\">Other Specify:<\/label><textarea id=\"wpforms-2729-field_20\" class=\"wpforms-field-medium\" name=\"wpforms[fields][20]\" ><\/textarea><\/div><div id=\"wpforms-2729-field_21-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"21\"><h3 id=\"wpforms-2729-field_21\">Claimant&#039;s Personal Information<\/h3><\/div><div id=\"wpforms-2729-field_23-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_23\">Claimant DOB:<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-2729-field_23\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][23][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-2729-field_26-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"26\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_26\">Photo Available:<\/label><select id=\"wpforms-2729-field_26\" class=\"wpforms-field-medium\" name=\"wpforms[fields][26]\"><option value=\"Yes\" >Yes<\/option><option value=\"No\" >No<\/option><\/select><\/div><div id=\"wpforms-2729-field_27-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_27\">Claimant SSN:<\/label><input type=\"text\" id=\"wpforms-2729-field_27\" class=\"wpforms-field-medium\" name=\"wpforms[fields][27]\" ><\/div><div id=\"wpforms-2729-field_28-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_28\">Claimant Gender:<\/label><input type=\"text\" id=\"wpforms-2729-field_28\" class=\"wpforms-field-medium\" name=\"wpforms[fields][28]\" ><\/div><div id=\"wpforms-2729-field_29-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_29\">Claimant Height:<\/label><input type=\"text\" id=\"wpforms-2729-field_29\" class=\"wpforms-field-medium\" name=\"wpforms[fields][29]\" ><\/div><div id=\"wpforms-2729-field_30-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_30\">Claimant Weight:<\/label><input type=\"text\" id=\"wpforms-2729-field_30\" class=\"wpforms-field-medium\" name=\"wpforms[fields][30]\" ><\/div><div id=\"wpforms-2729-field_31-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"31\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_31\">Claimant Eye Color:<\/label><input type=\"text\" id=\"wpforms-2729-field_31\" class=\"wpforms-field-medium\" name=\"wpforms[fields][31]\" ><\/div><div id=\"wpforms-2729-field_32-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"32\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_32\">Claimant Hair Color:<\/label><input type=\"text\" id=\"wpforms-2729-field_32\" class=\"wpforms-field-medium\" name=\"wpforms[fields][32]\" ><\/div><div id=\"wpforms-2729-field_33-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"33\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_33\">Claimant Complexion:<\/label><input type=\"text\" id=\"wpforms-2729-field_33\" class=\"wpforms-field-medium\" name=\"wpforms[fields][33]\" ><\/div><div id=\"wpforms-2729-field_34-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"34\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_34\">Claimant Physician:<\/label><input type=\"text\" id=\"wpforms-2729-field_34\" class=\"wpforms-field-medium\" name=\"wpforms[fields][34]\" ><\/div><div id=\"wpforms-2729-field_36-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"36\"><label class=\"wpforms-field-label\">Claimant Physician Address:<\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-2729-field_36\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][36][address1]\" ><label for=\"wpforms-2729-field_36\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div ><input type=\"text\" id=\"wpforms-2729-field_36-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][36][address2]\" ><label for=\"wpforms-2729-field_36-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-2729-field_36-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][36][city]\" ><label for=\"wpforms-2729-field_36-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-2729-field_36-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][36][state]\" ><option class=\"placeholder\" value=\"\" selected disabled>&#8212; Select state &#8212;<\/option><option value=\"AL\" >Alabama<\/option><option value=\"AK\" >Alaska<\/option><option value=\"AZ\" >Arizona<\/option><option value=\"AR\" >Arkansas<\/option><option value=\"CA\" >California<\/option><option value=\"CO\" >Colorado<\/option><option value=\"CT\" >Connecticut<\/option><option value=\"DE\" >Delaware<\/option><option value=\"DC\" >District of Columbia<\/option><option value=\"FL\" >Florida<\/option><option value=\"GA\" >Georgia<\/option><option value=\"HI\" >Hawaii<\/option><option value=\"ID\" >Idaho<\/option><option value=\"IL\" >Illinois<\/option><option value=\"IN\" >Indiana<\/option><option value=\"IA\" >Iowa<\/option><option value=\"KS\" >Kansas<\/option><option value=\"KY\" >Kentucky<\/option><option value=\"LA\" >Louisiana<\/option><option value=\"ME\" >Maine<\/option><option value=\"MD\" >Maryland<\/option><option value=\"MA\" >Massachusetts<\/option><option value=\"MI\" >Michigan<\/option><option value=\"MN\" >Minnesota<\/option><option value=\"MS\" >Mississippi<\/option><option value=\"MO\" >Missouri<\/option><option value=\"MT\" >Montana<\/option><option value=\"NE\" >Nebraska<\/option><option value=\"NV\" >Nevada<\/option><option value=\"NH\" >New Hampshire<\/option><option value=\"NJ\" >New Jersey<\/option><option value=\"NM\" >New Mexico<\/option><option value=\"NY\" >New York<\/option><option value=\"NC\" >North Carolina<\/option><option value=\"ND\" >North Dakota<\/option><option value=\"OH\" >Ohio<\/option><option value=\"OK\" >Oklahoma<\/option><option value=\"OR\" >Oregon<\/option><option value=\"PA\" >Pennsylvania<\/option><option value=\"RI\" >Rhode Island<\/option><option value=\"SC\" >South Carolina<\/option><option value=\"SD\" >South Dakota<\/option><option value=\"TN\" >Tennessee<\/option><option value=\"TX\" >Texas<\/option><option value=\"UT\" >Utah<\/option><option value=\"VT\" >Vermont<\/option><option value=\"VA\" >Virginia<\/option><option value=\"WA\" >Washington<\/option><option value=\"WV\" >West Virginia<\/option><option value=\"WI\" >Wisconsin<\/option><option value=\"WY\" >Wyoming<\/option><\/select><label for=\"wpforms-2729-field_36-state\" class=\"wpforms-field-sublabel after\">State<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-2729-field_36-postal\" class=\"wpforms-field-address-postal wpforms-masked-input\" data-inputmask-mask=\"(99999)|(99999-9999)\" data-inputmask-keepstatic=\"true\" data-rule-inputmask-incomplete=\"1\" name=\"wpforms[fields][36][postal]\" ><label for=\"wpforms-2729-field_36-postal\" class=\"wpforms-field-sublabel after\">Zip Code<\/label><\/div><\/div><\/div><div id=\"wpforms-2729-field_39-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_39\">Med. Exam Date(s):<\/label><input type=\"text\" id=\"wpforms-2729-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\" ><\/div><div id=\"wpforms-2729-field_40-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"40\"><h3 id=\"wpforms-2729-field_40\">Instructions:<\/h3><\/div><div id=\"wpforms-2729-field_41-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_41\">Special Instructions:<\/label><textarea id=\"wpforms-2729-field_41\" class=\"wpforms-field-medium\" name=\"wpforms[fields][41]\" ><\/textarea><\/div><div id=\"wpforms-2729-field_42-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-2729-field_42\">File 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viewBox=\"0 0 1024 1024\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M885.2 446.3l-.2-.8-112.2-285.1c-5-16.1-19.9-27.2-36.8-27.2H281.2c-17 0-32.1 11.3-36.9 27.6L139.4 443l-.3.7-.2.8c-1.3 4.9-1.7 9.9-1 14.8-.1 1.6-.2 3.2-.2 4.8V830a60.9 60.9 0 0 0 60.8 60.8h627.2c33.5 0 60.8-27.3 60.9-60.8V464.1c0-1.3 0-2.6-.1-3.7.4-4.9 0-9.6-1.3-14.1zm-295.8-43l-.3 15.7c-.8 44.9-31.8 75.1-77.1 75.1-22.1 0-41.1-7.1-54.8-20.6S436 441.2 435.6 419l-.3-15.7H229.5L309 210h399.2l81.7 193.3H589.4zm-375 76.8h157.3c24.3 57.1 76 90.8 140.4 90.8 33.7 0 65-9.4 90.3-27.2 22.2-15.6 39.5-37.4 50.7-63.6h156.5V814H214.4V480.1z\"><\/path>\n\t\t<\/svg>\n\t\t<span class=\"modern-title\">Click or drag a file to this area to 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name=\"wpforms[submit]\" id=\"wpforms-submit-2729\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\" aria-live=\"assertive\" value=\"wpforms-submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container 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