{"id":3465,"date":"2017-10-13T14:44:28","date_gmt":"2017-10-13T20:44:28","guid":{"rendered":"http:\/\/actioninsurancegroup.com\/?page_id=3465"},"modified":"2020-02-24T14:44:27","modified_gmt":"2020-02-24T21:44:27","slug":"auto-insurance-alberta-quote-form","status":"publish","type":"page","link":"https:\/\/actioninsurancegroup.com\/auto-insurance-alberta-quote-form\/","title":{"rendered":"Auto Insurance Alberta Quote Form"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_3_4 3_4 fusion-three-fourth fusion-column-first\" style=\"--awb-bg-size:cover;width:75%;width:calc(75% - ( ( 4% ) * 0.75 ) );margin-right: 4%;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\"><div class=\"fusion-text fusion-text-1\"><h1>Auto Insurance Quote Form<\/h1>\n<\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-separator fusion-clearfix\" style=\"float:left;margin-bottom:20px;width:100%;max-width:25%;\"><div class=\"fusion-separator-border sep-single sep-solid\" style=\"--awb-height:20px;--awb-amount:20px;--awb-sep-color:rgba(28,129,184,0.59);border-color:rgba(28,129,184,0.59);border-top-width:3px;\"><\/div><\/div><div class=\"fusion-sep-clear\"><\/div><div class=\"fusion-text fusion-text-2\"><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_opera gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_1' style='display:none'><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' target='gform_ajax_frame_1' id='gform_1'  action='\/wp-json\/wp\/v2\/pages\/3465#gf_1' data-formid='1' novalidate>\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'><div id=\"field_1_249\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_1_249\" ><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_1_249'>Source<\/label><div class='ginput_container ginput_container_text'><input name='input_249' id='input_1_249' type='text' value='Direct' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_248\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_248\" ><p style=\"color: #b0e9fd;\">Depending on your driving record, completing this form takes as little as 2 minutes. Your request will be reviewed thoroughly by an auto insurance expert to ensure that we can provide you the best coverage at the most affordable price. You will receive a comprehensive quote by email within two (2) business hours. Our competitors <em>\"Instant Online Quotes\"<\/em> are often inaccurate and may fail to offer discounts and other savings that only our insurance experts can obtain for you. If you prefer to obtain a quote by phone, please contact our <a style=\"color: #ffffff;\" href=\"\/contact-us-calgary-insurance\/\">Calgary<\/a> or <a style=\"color: #ffffff;\" href=\"\/contact-us-strathmore-insurance\/\">Strathmore<\/a> office directly.<\/p><\/div><div id=\"field_1_5\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_5\" ><h3 class=\"gsection_title\">Pre-Requisite Questions<\/h3><\/div><fieldset id=\"field_1_1\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_1\" ><legend class='gfield_label gform-field-label' >Are you currently a resident of Alberta Canada?<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_1'>\n\t\t\t<div class='gchoice gchoice_1_1_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_1' type='radio' value='Yes'  id='choice_1_1_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_1_0' id='label_1_1_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_1_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_1' type='radio' value='No'  id='choice_1_1_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_1_1' id='label_1_1_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_8\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_8\" ><h3>Sorry, you must be a resident of Alberta Canada to apply for a quote.<\/h3>\n<\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_1_243' class='gform_next_button gform-theme-button button' value='Next'  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-243' 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'><fieldset id=\"field_1_7\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_7\" ><legend class='gfield_label gform-field-label' >How many vehicles require insurance?<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_7'>\n\t\t\t<div class='gchoice gchoice_1_7_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='One'  id='choice_1_7_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_7_0' id='label_1_7_0' class='gform-field-label gform-field-label--type-inline'>One<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_7_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Two'  id='choice_1_7_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_7_1' id='label_1_7_1' class='gform-field-label gform-field-label--type-inline'>Two<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_7_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_7' type='radio' value='Three +'  id='choice_1_7_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_7_2' id='label_1_7_2' class='gform-field-label gform-field-label--type-inline'>Three +<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_245\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_245\" ><h3>Sorry, this form can only accept up to two vehicles,\n\nWe can still provide you a quote by telephone.  Please call our office directly 1.866.457.4555.<\/h3><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_246' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  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_246' class='gform_next_button gform-theme-button button' value='Next'  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-246' 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'><fieldset id=\"field_1_2\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_2\" ><legend class='gfield_label gform-field-label' >How many drivers will you list?<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_2'>\n\t\t\t<div class='gchoice gchoice_1_2_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_2' type='radio' value='One (Applicant is Driver #1)'  id='choice_1_2_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_1_2\"   \/>\n\t\t\t\t\t<label for='choice_1_2_0' id='label_1_2_0' class='gform-field-label gform-field-label--type-inline'>One (Applicant is Driver #1)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_2_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_2' type='radio' value='Two (Referred to as Driver #2)'  id='choice_1_2_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_2_1' id='label_1_2_1' class='gform-field-label gform-field-label--type-inline'>Two (Referred to as Driver #2)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_2_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_2' type='radio' value='Three (Referred to as Driver #3)'  id='choice_1_2_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_2_2' id='label_1_2_2' class='gform-field-label gform-field-label--type-inline'>Three (Referred to as Driver #3)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_2_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_2' type='radio' value='Four +'  id='choice_1_2_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_2_3' id='label_1_2_3' class='gform-field-label gform-field-label--type-inline'>Four +<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_1_2'>Drivers include anyone over the age of 16 that live in the same household who DO NOT have their own auto insurance.<\/div><\/fieldset><div id=\"field_1_3\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_3\" ><h3>Sorry, this form can only accept up to three drivers.  \n\nWe can still provide you a quote by telephone.  Please call our office directly 1.866.457.4555.<\/h3><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_244' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  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_244' class='gform_next_button gform-theme-button button' value='Next'  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-244' 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'><div id=\"field_1_6\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_6\" ><h3 class=\"gsection_title\">Applicant  (Driver #1)<\/h3><\/div><fieldset id=\"field_1_9\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_9\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_9'>\n                            \n                            <span id='input_1_9_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.3' id='input_1_9_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_9_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_9_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_9.6' id='input_1_9_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_9_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_1_10\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_10\" ><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_10'>\n\t\t\t<div class='gchoice gchoice_1_10_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Male'  id='choice_1_10_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_10_0' id='label_1_10_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_10_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_10' type='radio' value='Female'  id='choice_1_10_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_10_1' id='label_1_10_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_11\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_11\" ><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_zip ginput_container_address gform-grid-row' id='input_1_11' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_11_1_container' >\n                                        <input type='text' name='input_11.1' id='input_1_11_1' value=''    aria-required='true'    \/>\n                                        <label for='input_1_11_1' id='input_1_11_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_1_11_3_container' >\n                                    <input type='text' name='input_11.3' id='input_1_11_3' value=''    aria-required='true'    \/>\n                                    <label for='input_1_11_3' id='input_1_11_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_11.4' id='input_1_11_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_1_11_5_container' >\n                                    <input type='text' name='input_11.5' id='input_1_11_5' value=''    aria-required='true'    \/>\n                                    <label for='input_1_11_5' id='input_1_11_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_11.6' id='input_1_11_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_12\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_12\" ><label class='gfield_label gform-field-label' for='input_1_12'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_12' id='input_1_12' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_1_13\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_13\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_1_13_container'>\n                                <span id='input_1_13_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_13' id='input_1_13' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_1_13' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_1_13_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_13_2' id='input_1_13_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_1_13_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_14' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  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_14' class='gform_next_button gform-theme-button button' value='Next'  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-14' 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'><div id=\"field_1_15\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_15\" ><h3 class=\"gsection_title\">Vehicle #1 Information<\/h3><\/div><div id=\"field_1_22\" class=\"gfield gfield--type-text gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_22\" ><label class='gfield_label gform-field-label' for='input_1_22'>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_22' id='input_1_22' type='text' value='' class='medium'    placeholder='Example: 2005' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_17\" class=\"gfield gfield--type-text gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_17\" ><label class='gfield_label gform-field-label' for='input_1_17'>Make<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_1_17' type='text' value='' class='medium'    placeholder='Example: Ford' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_18\" class=\"gfield gfield--type-text gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_18\" ><label class='gfield_label gform-field-label' for='input_1_18'>Model<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_1_18' type='text' value='' class='medium'    placeholder='Example: Mustang' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_19\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_19\" ><label class='gfield_label gform-field-label' for='input_1_19'>17 Digit VIN #<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_1_19' type='text' value='' class='large'    placeholder='Example: 145CD54AR88541FD5'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_20\" class=\"gfield gfield--type-select gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_20\" ><label class='gfield_label gform-field-label' for='input_1_20'>Purchase Month<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_20' id='input_1_20' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Jan' >Jan<\/option><option value='Feb' >Feb<\/option><option value='Mar' >Mar<\/option><option value='Apr' >Apr<\/option><option value='May' >May<\/option><option value='Jun' >Jun<\/option><option value='Jul' >Jul<\/option><option value='Aug' >Aug<\/option><option value='Sep' >Sep<\/option><option value='Oct' >Oct<\/option><option value='Nov' >Nov<\/option><option value='Dec' >Dec<\/option><\/select><\/div><\/div><div id=\"field_1_21\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_21\" ><label class='gfield_label gform-field-label' for='input_1_21'>Purchase 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_21' id='input_1_21' type='text' value='' class='medium'    placeholder='Example: 2007' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_23\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_23\" ><label class='gfield_label gform-field-label' for='input_1_23'>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_23' id='input_1_23' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Liability Only' >Liability Only<\/option><option value='Liability, Fire and Theft' >Liability, Fire and Theft<\/option><option value='Full (Limited Glass)' >Full (Limited Glass)<\/option><\/select><\/div><\/div><div id=\"field_1_24\" class=\"gfield gfield--type-number gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_24\" ><label class='gfield_label gform-field-label' for='input_1_24'>KMs to work<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_24' id='input_1_24' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_1_24\" \/><\/div><div class='gfield_description' id='gfield_description_1_24'>Enter the # of kms this vehicle is driven one-way to work.<\/div><\/div><div id=\"field_1_25\" class=\"gfield gfield--type-number gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_25\" ><label class='gfield_label gform-field-label' for='input_1_25'>KMs yearly?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_25' id='input_1_25' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_1_25\" \/><\/div><div class='gfield_description' id='gfield_description_1_25'>Enter the total kms driven yearly.<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_27' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  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]); } ' \/> <input type='button' id='gform_next_button_1_27' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_6' class='gform_page' data-js='page-field-id-27' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_6' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_26\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_26\" ><h3 class=\"gsection_title\">Vehicle #2 Info<\/h3><\/div><div id=\"field_1_28\" class=\"gfield gfield--type-text gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_28\" ><label class='gfield_label gform-field-label' for='input_1_28'>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_28' id='input_1_28' type='text' value='' class='medium'    placeholder='Example: 2006' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_29\" class=\"gfield gfield--type-text gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_29\" ><label class='gfield_label gform-field-label' for='input_1_29'>Make<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='medium'    placeholder='Example: Ford' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_30\" class=\"gfield gfield--type-text gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_30\" ><label class='gfield_label gform-field-label' for='input_1_30'>Model<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='medium'    placeholder='Example: Mustang' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_31\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_31\" ><label class='gfield_label gform-field-label' for='input_1_31'>17 Digit VIN #<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_1_31' type='text' value='' class='large'    placeholder='Example: 145CD54AR88541FD5'  aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_32\" class=\"gfield gfield--type-select gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_32\" ><label class='gfield_label gform-field-label' for='input_1_32'>Purchase Month<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_32' id='input_1_32' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Jan' >Jan<\/option><option value='Feb' >Feb<\/option><option value='Mar' >Mar<\/option><option value='Apr' >Apr<\/option><option value='May' >May<\/option><option value='Jun' >Jun<\/option><option value='Jul' >Jul<\/option><option value='Aug' >Aug<\/option><option value='Sep' >Sep<\/option><option value='Oct' >Oct<\/option><option value='Nov' >Nov<\/option><option value='Dec' >Dec<\/option><\/select><\/div><\/div><div id=\"field_1_33\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_33\" ><label class='gfield_label gform-field-label' for='input_1_33'>Purchase 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_33' id='input_1_33' type='text' value='' class='medium'    placeholder='Example: 2009' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_34\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_34\" ><label class='gfield_label gform-field-label' for='input_1_34'>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_34' id='input_1_34' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Liability Only' >Liability Only<\/option><option value='Liability, Fire and Theft.' >Liability, Fire and Theft.<\/option><option value='Full (Limited Glass)' >Full (Limited Glass)<\/option><\/select><\/div><\/div><div id=\"field_1_35\" class=\"gfield gfield--type-number gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_35\" ><label class='gfield_label gform-field-label' for='input_1_35'>KMs to work<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_35' id='input_1_35' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_1_35\" \/><\/div><div class='gfield_description' id='gfield_description_1_35'>Enter the number of kms this vehicle is driven one-way to work.<\/div><\/div><div id=\"field_1_36\" class=\"gfield gfield--type-number gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_36\" ><label class='gfield_label gform-field-label' for='input_1_36'>KMs yearly?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_36' id='input_1_36' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_1_36\" \/><\/div><div class='gfield_description' id='gfield_description_1_36'>Enter the total kms driven yearly.<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_37' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  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]); } ' \/> <input type='button' id='gform_next_button_1_37' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"7\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"7\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_7' class='gform_page' data-js='page-field-id-37' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_7' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_39\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_39\" ><h3 class=\"gsection_title\">Applicant (Driver #1)<\/h3><\/div><div id=\"field_1_233\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_233\" ><label class='gfield_label gform-field-label' for='input_1_233'>Birth Month<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_233' id='input_1_233' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='January' >January<\/option><option value='February' >February<\/option><option value='March' >March<\/option><option value='April' >April<\/option><option value='May' >May<\/option><option value='June' >June<\/option><option value='July' >July<\/option><option value='August' >August<\/option><option value='September' >September<\/option><option value='October' >October<\/option><option value='November' >November<\/option><option value='December' >December<\/option><\/select><\/div><\/div><div id=\"field_1_234\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_234\" ><label class='gfield_label gform-field-label' for='input_1_234'>Birth Day<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_234' id='input_1_234' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><\/div><div id=\"field_1_236\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_236\" ><label class='gfield_label gform-field-label' for='input_1_236'>Birth Year<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_236' id='input_1_236' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='1930' >1930<\/option><option value='1931' >1931<\/option><option value='1932' >1932<\/option><option value='1933' >1933<\/option><option value='1934' >1934<\/option><option value='1935' >1935<\/option><option value='1936' >1936<\/option><option value='1937' >1937<\/option><option value='1938' >1938<\/option><option value='1939' >1939<\/option><option value='1940' >1940<\/option><option value='1941' >1941<\/option><option value='1942' >1942<\/option><option value='1943' >1943<\/option><option value='1944' >1944<\/option><option value='1945' >1945<\/option><option value='1946' >1946<\/option><option value='1947' >1947<\/option><option value='1948' >1948<\/option><option value='1949' >1949<\/option><option value='1950' >1950<\/option><option value='1951' >1951<\/option><option value='1952' >1952<\/option><option value='1953' >1953<\/option><option value='1954' >1954<\/option><option value='1955' >1955<\/option><option value='1956' >1956<\/option><option value='1957' >1957<\/option><option value='1958' >1958<\/option><option value='1959' >1959<\/option><option value='1960' >1960<\/option><option value='1961' >1961<\/option><option value='1962' >1962<\/option><option value='1963' >1963<\/option><option value='1964' >1964<\/option><option value='1965' >1965<\/option><option value='1966' >1966<\/option><option value='1967' >1967<\/option><option value='1968' >1968<\/option><option value='1969' >1969<\/option><option value='1970' >1970<\/option><option value='1971' >1971<\/option><option value='1972' >1972<\/option><option value='1973' >1973<\/option><option value='1974' >1974<\/option><option value='1975' >1975<\/option><option value='1976' >1976<\/option><option value='1977' >1977<\/option><option value='1978' >1978<\/option><option value='1979' >1979<\/option><option value='1980' >1980<\/option><option value='1981' >1981<\/option><option value='1982' >1982<\/option><option value='1983' >1983<\/option><option value='1984' >1984<\/option><option value='1985' >1985<\/option><option value='1986' >1986<\/option><option value='1987' >1987<\/option><option value='1988' >1988<\/option><option value='1989' >1989<\/option><option value='1990' >1990<\/option><option value='1991' >1991<\/option><option value='1992' >1992<\/option><option value='1993' >1993<\/option><option value='1994' >1994<\/option><option value='1995' >1995<\/option><option value='1996' >1996<\/option><option value='1997' >1997<\/option><option value='1998' >1998<\/option><option value='1999' >1999<\/option><option value='2000' >2000<\/option><option value='2001' >2001<\/option><option value='2002' >2002<\/option><\/select><\/div><\/div><div id=\"field_1_41\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_41\" ><label class='gfield_label gform-field-label' for='input_1_41'>Applicant: 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_41' id='input_1_41' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Married' >Married<\/option><option value='Single' >Single<\/option><option value='Common Law' >Common Law<\/option><\/select><\/div><\/div><div id=\"field_1_216\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_216\" ><label class='gfield_label gform-field-label' for='input_1_216'>Applicant:  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_216' id='input_1_216' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_216\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_1_216'>Certain occupations are eligible for additional group discounts!<\/div><\/div><div id=\"field_1_217\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_217\" ><label class='gfield_label gform-field-label' for='input_1_217'>Applicant:  Do you own a home or condo?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_217' id='input_1_217' class='medium gfield_select'  aria-describedby=\"gfield_description_1_217\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_217'>We offer additional discounts when you bundle your home and auto insurance.<\/div><\/div><div id=\"field_1_224\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_224\" ><label class='gfield_label gform-field-label' for='input_1_224'>Applicant:  What &#039;class&#039; of license do you hold?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_224' id='input_1_224' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='5 and 6' >5 and 6<\/option><option value='6' >6<\/option><option value='7' >7<\/option><\/select><\/div><\/div><div id=\"field_1_225\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_225\" ><label class='gfield_label gform-field-label' for='input_1_225'>Applicant:  Alberta Driver&#039;s License #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_225' id='input_1_225' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_43\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_43\" ><label class='gfield_label gform-field-label' for='input_1_43'>Applicant: Date driver&#039;s license was obtained<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_43' id='input_1_43' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_43_date_format gfield_description_1_43\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_43_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_43' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_43'>Using the calendar, choose a YEAR first and then Month and Day.  Guess on day and month if not available.  The YEAR is important.<\/div><\/div><div id=\"field_1_97\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_97\" ><label class='gfield_label gform-field-label' for='input_1_97'>Applicant: Did you take certified driver training?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_97' id='input_1_97' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/div><\/div><div id=\"field_1_95\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_95\" ><label class='gfield_label gform-field-label' for='input_1_95'>Applicant:  How many years of CONTINUOUS insurance have you held in the past 15 years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_95' id='input_1_95' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='None' >None<\/option><option value='1 Year' >1 Year<\/option><option value='2 Years' >2 Years<\/option><option value='3 Years' >3 Years<\/option><option value='4 Years' >4 Years<\/option><option value='5 Years' >5 Years<\/option><option value='6 Years' >6 Years<\/option><option value='7 Years' >7 Years<\/option><option value='8 Years' >8 Years<\/option><option value='9 Years' >9 Years<\/option><option value='10 Years' >10 Years<\/option><option value='11 Years' >11 Years<\/option><option value='12 Years' >12 Years<\/option><option value='13 Years' >13 Years<\/option><option value='14 Years' >14 Years<\/option><option value='15 Years' >15 Years<\/option><\/select><\/div><\/div><div id=\"field_1_96\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_96\" ><label class='gfield_label gform-field-label' for='input_1_96'>Applicant:  Current Insurance 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_96' id='input_1_96' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Insured' >Insured<\/option><option value='Un-Insured' >Un-Insured<\/option><\/select><\/div><\/div><div id=\"field_1_50\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_50\" ><label class='gfield_label gform-field-label' for='input_1_50'>Applicant:  Why are you un-insured?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_50' id='input_1_50' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Non-Payment' >Non-Payment<\/option><option value='Non-Renewed' >Non-Renewed<\/option><option value='Non-Disclosure' >Non-Disclosure<\/option><option value='Self Cancelled' >Self Cancelled<\/option><option value='No Prior Insurance' >No Prior Insurance<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_52' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"6\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_52' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"8\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"8\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_8' class='gform_page' data-js='page-field-id-52' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_8' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_51\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_51\" ><h3 class=\"gsection_title\">Appicant History<\/h3><\/div><div id=\"field_1_53\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_53\" ><label class='gfield_label gform-field-label' for='input_1_53'>Applicant:  How many AT FAULT accidents in past 6 years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_53' id='input_1_53' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='None' >None<\/option><option value='One' >One<\/option><option value='Two' >Two<\/option><option value='Three' >Three<\/option><option value='Four' >Four<\/option><option value='Five +' >Five +<\/option><\/select><\/div><\/div><div id=\"field_1_54\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_54\" ><label class='gfield_label gform-field-label' for='input_1_54'>Date Accident #1<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_54' id='input_1_54' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_54_date_format gfield_description_1_54\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_54_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_54' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_54'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_57\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_57\" ><label class='gfield_label gform-field-label' for='input_1_57'>Date Accident #2<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_57' id='input_1_57' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_57_date_format gfield_description_1_57\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_57_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_57' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_57'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_56\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_56\" ><label class='gfield_label gform-field-label' for='input_1_56'>Date Accident #3<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_56' id='input_1_56' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_56_date_format gfield_description_1_56\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_56_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_56' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_56'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_55\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_55\" ><label class='gfield_label gform-field-label' for='input_1_55'>Date Accident #4<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_55' id='input_1_55' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_55_date_format gfield_description_1_55\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_55_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_55' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_55'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_91' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"7\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"7\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_91' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"9\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"9\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_9' class='gform_page' data-js='page-field-id-91' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_9' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_58\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_58\" ><label class='gfield_label gform-field-label' for='input_1_58'>Applicant:  How many TICKETS in the past 3 years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_58' id='input_1_58' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='None' >None<\/option><option value='One' >One<\/option><option value='Two' >Two<\/option><option value='Three' >Three<\/option><option value='Four' >Four<\/option><option value='Five' >Five<\/option><option value='Six' >Six<\/option><option value='Seven' >Seven<\/option><option value='Eight +' >Eight +<\/option><\/select><\/div><\/div><div id=\"field_1_59\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_59\" ><label class='gfield_label gform-field-label' for='input_1_59'>Date Ticket #1<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_59' id='input_1_59' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_59_date_format gfield_description_1_59\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_59_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_59' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_59'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_60\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_60\" ><label class='gfield_label gform-field-label' for='input_1_60'>Reason #1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_1_60' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_61\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_61\" ><label class='gfield_label gform-field-label' for='input_1_61'>Date Ticket #2<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_61' id='input_1_61' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_61_date_format gfield_description_1_61\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_61_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_61' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_61'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_62\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_62\" ><label class='gfield_label gform-field-label' for='input_1_62'>Reason #2<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_1_62' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_63\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_63\" ><label class='gfield_label gform-field-label' for='input_1_63'>Date Ticket #3<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_63' id='input_1_63' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_63_date_format gfield_description_1_63\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_63_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_63' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_63'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_64\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_64\" ><label class='gfield_label gform-field-label' for='input_1_64'>Reason #3<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_1_64' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_65\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_65\" ><label class='gfield_label gform-field-label' for='input_1_65'>Date Ticket #4<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_65' id='input_1_65' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_65_date_format gfield_description_1_65\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_65_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_65' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_65'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_66\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_66\" ><label class='gfield_label gform-field-label' for='input_1_66'>Reason #4<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='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_67\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_67\" ><label class='gfield_label gform-field-label' for='input_1_67'>Date Ticket #5<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_67' id='input_1_67' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_67_date_format gfield_description_1_67\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_67_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_67' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_67'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_68\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_68\" ><label class='gfield_label gform-field-label' for='input_1_68'>Reason #5<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_1_68' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_69\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_69\" ><label class='gfield_label gform-field-label' for='input_1_69'>Date Ticket #6<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_69' id='input_1_69' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_69_date_format gfield_description_1_69\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_69_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_69' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_69'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_70\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_70\" ><label class='gfield_label gform-field-label' for='input_1_70'>Reason #6<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='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_71\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_71\" ><label class='gfield_label gform-field-label' for='input_1_71'>Date Ticket #7<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_71' id='input_1_71' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_71_date_format gfield_description_1_71\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_71_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_71' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_71'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_72\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_72\" ><label class='gfield_label gform-field-label' for='input_1_72'>Reason #7<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_1_72' type='text' value='' class='medium'     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_92' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"8\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"8\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_92' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"10\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"10\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_10' class='gform_page' data-js='page-field-id-92' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_10' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_73\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_73\" ><label class='gfield_label gform-field-label' for='input_1_73'>Applicant:  In the past 3 years, how many times has your license been suspended for OVER 30 days?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_73' id='input_1_73' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Never' >Never<\/option><option value='Once' >Once<\/option><option value='Twice' >Twice<\/option><option value='Three  times' >Three  times<\/option><option value='More than three times' >More than three times<\/option><\/select><\/div><\/div><div id=\"field_1_74\" class=\"gfield gfield--type-select gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_74\" ><label class='gfield_label gform-field-label' for='input_1_74'>Reason for Suspension #1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_74' id='input_1_74' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Alcohol related' >Alcohol related<\/option><option value='Administrative' >Administrative<\/option><option value='Non-payment of fine' >Non-payment of fine<\/option><option value='Too many convictions or demerit points' >Too many convictions or demerit points<\/option><\/select><\/div><\/div><div id=\"field_1_75\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_75\" ><label class='gfield_label gform-field-label' for='input_1_75'>Date of Suspension #1<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_75' id='input_1_75' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_75_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_75_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_75' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_76\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_76\" ><label class='gfield_label gform-field-label' for='input_1_76'>Date of Reinstatement #1<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_76' id='input_1_76' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_76_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_76_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_76' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_77\" class=\"gfield gfield--type-select gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_77\" ><label class='gfield_label gform-field-label' for='input_1_77'>Reason for Suspension #2<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_77' id='input_1_77' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Alcohol related' >Alcohol related<\/option><option value='Administrative' >Administrative<\/option><option value='Non-payment of fine' >Non-payment of fine<\/option><option value='Too many convictions or demerit points' >Too many convictions or demerit points<\/option><\/select><\/div><\/div><div id=\"field_1_81\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_81\" ><label class='gfield_label gform-field-label' for='input_1_81'>Date of Suspension #2<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_81' id='input_1_81' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_81_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_81_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_81' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_79\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_79\" ><label class='gfield_label gform-field-label' for='input_1_79'>Date of Reinstatement #2<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_79' id='input_1_79' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_79_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_79_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_79' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_80\" class=\"gfield gfield--type-select gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_80\" ><label class='gfield_label gform-field-label' for='input_1_80'>Reason for Suspension #3<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_80' id='input_1_80' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Alcohol related' >Alcohol related<\/option><option value='Administrative' >Administrative<\/option><option value='Non-payment of fine' >Non-payment of fine<\/option><option value='Too many convictions or demerit points' >Too many convictions or demerit points<\/option><\/select><\/div><\/div><div id=\"field_1_82\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_82\" ><label class='gfield_label gform-field-label' for='input_1_82'>Date of Suspension #3<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_82' id='input_1_82' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_82_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_82_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_82' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_83\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_83\" ><label class='gfield_label gform-field-label' for='input_1_83'>Date of Reinstatement #3<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_83' id='input_1_83' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_83_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_83_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_83' class='gform_hidden' value='https:\/\/actioninsurancegroup.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'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"9\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"9\");  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'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"11\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"11\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_11' class='gform_page' data-js='page-field-id-93' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_11' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_84\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_84\" ><label class='gfield_label gform-field-label' for='input_1_84'>Applicant:  How many times has your policy been cancelled for NON-PAYMENT in the past 3 years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_84' id='input_1_84' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Never' >Never<\/option><option value='Once' >Once<\/option><option value='Twice' >Twice<\/option><option value='Three times' >Three times<\/option><option value='More than three times' >More than three times<\/option><\/select><\/div><\/div><div id=\"field_1_85\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_85\" ><label class='gfield_label gform-field-label' for='input_1_85'>Date of 1st Cancellation<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_85' id='input_1_85' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_85_date_format gfield_description_1_85\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_85_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_85' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_85'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_86\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_86\" ><label class='gfield_label gform-field-label' for='input_1_86'>Date of 2nd Cancellation<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 dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_86_date_format gfield_description_1_86\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_86_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_86' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_86'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_87\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_87\" ><label class='gfield_label gform-field-label' for='input_1_87'>Date of 3rd Cancellation<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 dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_87_date_format gfield_description_1_87\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_87_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_87' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_87'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_94' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"10\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"10\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_94' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"12\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"12\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_12' class='gform_page' data-js='page-field-id-94' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_12' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_88\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_88\" ><label class='gfield_label gform-field-label' for='input_1_88'>Applicant:  Have you ever been cancelled for NON-DISCLOSURE?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_88' id='input_1_88' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_1_89\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_89\" ><label class='gfield_label gform-field-label' for='input_1_89'>Applicant:  Have you ever been cancelled for MIS-REPRESENTATION?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_89' id='input_1_89' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_99' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"11\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"11\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_99' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"13\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"13\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_13' class='gform_page' data-js='page-field-id-99' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_13' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_98\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_98\" ><h3 class=\"gsection_title\">Driver #2 Info<\/h3><\/div><fieldset id=\"field_1_100\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_100\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Driver #2: Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_100'>\n                            \n                            <span id='input_1_100_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_100.3' id='input_1_100_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_100_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_100_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_100.6' id='input_1_100_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_100_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_1_101\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_101\" ><legend class='gfield_label gform-field-label' >Driver #2: 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_101'>\n\t\t\t<div class='gchoice gchoice_1_101_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='Male'  id='choice_1_101_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_101_0' id='label_1_101_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_101_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='Female'  id='choice_1_101_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_101_1' id='label_1_101_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_237\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_237\" ><label class='gfield_label gform-field-label' for='input_1_237'>Birth Month<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_237' id='input_1_237' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='January' >January<\/option><option value='February' >February<\/option><option value='March' >March<\/option><option value='April' >April<\/option><option value='May' >May<\/option><option value='June' >June<\/option><option value='July' >July<\/option><option value='August' >August<\/option><option value='September' >September<\/option><option value='October' >October<\/option><option value='November' >November<\/option><option value='December' >December<\/option><\/select><\/div><\/div><div id=\"field_1_238\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_238\" ><label class='gfield_label gform-field-label' for='input_1_238'>Birth Day<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_238' id='input_1_238' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><\/div><div id=\"field_1_239\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_239\" ><label class='gfield_label gform-field-label' for='input_1_239'>Birth Year<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_239' id='input_1_239' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='1930' >1930<\/option><option value='1931' >1931<\/option><option value='1932' >1932<\/option><option value='1933' >1933<\/option><option value='1934' >1934<\/option><option value='1935' >1935<\/option><option value='1936' >1936<\/option><option value='1937' >1937<\/option><option value='1938' >1938<\/option><option value='1939' >1939<\/option><option value='1940' >1940<\/option><option value='1941' >1941<\/option><option value='1942' >1942<\/option><option value='1943' >1943<\/option><option value='1944' >1944<\/option><option value='1945' >1945<\/option><option value='1946' >1946<\/option><option value='1947' >1947<\/option><option value='1948' >1948<\/option><option value='1949' >1949<\/option><option value='1950' >1950<\/option><option value='1951' >1951<\/option><option value='1952' >1952<\/option><option value='1953' >1953<\/option><option value='1954' >1954<\/option><option value='1955' >1955<\/option><option value='1956' >1956<\/option><option value='1957' >1957<\/option><option value='1958' >1958<\/option><option value='1959' >1959<\/option><option value='1960' >1960<\/option><option value='1961' >1961<\/option><option value='1962' >1962<\/option><option value='1963' >1963<\/option><option value='1964' >1964<\/option><option value='1965' >1965<\/option><option value='1966' >1966<\/option><option value='1967' >1967<\/option><option value='1968' >1968<\/option><option value='1969' >1969<\/option><option value='1970' >1970<\/option><option value='1971' >1971<\/option><option value='1972' >1972<\/option><option value='1973' >1973<\/option><option value='1974' >1974<\/option><option value='1975' >1975<\/option><option value='1976' >1976<\/option><option value='1977' >1977<\/option><option value='1978' >1978<\/option><option value='1979' >1979<\/option><option value='1980' >1980<\/option><option value='1981' >1981<\/option><option value='1982' >1982<\/option><option value='1983' >1983<\/option><option value='1984' >1984<\/option><option value='1985' >1985<\/option><option value='1986' >1986<\/option><option value='1987' >1987<\/option><option value='1988' >1988<\/option><option value='1989' >1989<\/option><option value='1990' >1990<\/option><option value='1991' >1991<\/option><option value='1992' >1992<\/option><option value='1993' >1993<\/option><option value='1994' >1994<\/option><option value='1995' >1995<\/option><option value='1996' >1996<\/option><option value='1997' >1997<\/option><option value='1998' >1998<\/option><option value='1999' >1999<\/option><option value='2000' >2000<\/option><option value='2001' >2001<\/option><option value='2002' >2002<\/option><\/select><\/div><\/div><div id=\"field_1_103\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_103\" ><label class='gfield_label gform-field-label' for='input_1_103'>Driver #2: 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_103' id='input_1_103' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Married' >Married<\/option><option value='Single' >Single<\/option><option value='Common Law' >Common Law<\/option><\/select><\/div><\/div><div id=\"field_1_218\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_218\" ><label class='gfield_label gform-field-label' for='input_1_218'>Driver #2:  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_218' id='input_1_218' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_218\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_1_218'>Certain occupations are eligible for additional group discounts!<\/div><\/div><div id=\"field_1_219\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_219\" ><label class='gfield_label gform-field-label' for='input_1_219'>Driver #2:  Own a home or condo?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_219' id='input_1_219' class='medium gfield_select'  aria-describedby=\"gfield_description_1_219\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_219'>We offer additional discounts when you bundle your home and auto insurance.<\/div><\/div><div id=\"field_1_222\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_222\" ><label class='gfield_label gform-field-label' for='input_1_222'>Driver #2:  What &#039;class&#039; of license?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_222' id='input_1_222' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='5 and 6' >5 and 6<\/option><option value='6' >6<\/option><option value='7' >7<\/option><\/select><\/div><\/div><div id=\"field_1_108\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_108\" ><label class='gfield_label gform-field-label' for='input_1_108'>Driver #2: What date was licensed obtained?<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_108' id='input_1_108' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_108_date_format gfield_description_1_108\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_108_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_108' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_108'>Guess on day and month if unknown.  The YEAR must be exact.<\/div><\/div><div id=\"field_1_223\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_223\" ><label class='gfield_label gform-field-label' for='input_1_223'>Driver #2:  Alberta Driver&#039;s License #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_223' id='input_1_223' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_109\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_109\" ><label class='gfield_label gform-field-label' for='input_1_109'>Driver #2: Take certified driver training?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_109' id='input_1_109' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/div><\/div><div id=\"field_1_110\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_110\" ><label class='gfield_label gform-field-label' for='input_1_110'>Driver #2  How many years of CONTINUOUS insurance held in the past 15 years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_110' id='input_1_110' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='None' >None<\/option><option value='1 Year' >1 Year<\/option><option value='2 Years' >2 Years<\/option><option value='3 Years' >3 Years<\/option><option value='4 Years' >4 Years<\/option><option value='5 Years' >5 Years<\/option><option value='6 Years' >6 Years<\/option><option value='7 Years' >7 Years<\/option><option value='8 Years' >8 Years<\/option><option value='9 Years' >9 Years<\/option><option value='10 Years' >10 Years<\/option><option value='11 Years' >11 Years<\/option><option value='12 Years' >12 Years<\/option><option value='13 Years' >13 Years<\/option><option value='14 Years' >14 Years<\/option><option value='15 Years' >15 Years<\/option><\/select><\/div><\/div><div id=\"field_1_111\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_111\" ><label class='gfield_label gform-field-label' for='input_1_111'>Driver #2:  Current Insurance 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_111' id='input_1_111' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Insured' >Insured<\/option><option value='Un-Insured' >Un-Insured<\/option><\/select><\/div><\/div><div id=\"field_1_112\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_112\" ><label class='gfield_label gform-field-label' for='input_1_112'>Driver #2:  Why un-insured?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_112' id='input_1_112' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Non-Payment' >Non-Payment<\/option><option value='Non-Renewed' >Non-Renewed<\/option><option value='Non-Disclosure' >Non-Disclosure<\/option><option value='Self Cancelled' >Self Cancelled<\/option><option value='No Prior Insurance' >No Prior Insurance<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_114' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"12\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"12\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_114' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"14\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"14\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_14' class='gform_page' data-js='page-field-id-114' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_14' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_113\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_113\" ><h3 class=\"gsection_title\">Driver #2 History<\/h3><\/div><div id=\"field_1_115\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_115\" ><label class='gfield_label gform-field-label' for='input_1_115'>Driver #2:  How many AT FAULT accidents in past 6 years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_115' id='input_1_115' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='None' >None<\/option><option value='One' >One<\/option><option value='Two' >Two<\/option><option value='Three' >Three<\/option><option value='Four' >Four<\/option><option value='Five +' >Five +<\/option><\/select><\/div><\/div><div id=\"field_1_116\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_116\" ><label class='gfield_label gform-field-label' for='input_1_116'>Date of Accident #1<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_116' id='input_1_116' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_116_date_format gfield_description_1_116\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_116_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_116' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_116'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_117\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_117\" ><label class='gfield_label gform-field-label' for='input_1_117'>Date of Accident #2<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_117' id='input_1_117' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_117_date_format gfield_description_1_117\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_117_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_117' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_117'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_118\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_118\" ><label class='gfield_label gform-field-label' for='input_1_118'>Date of Accident #3<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_118' id='input_1_118' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_118_date_format gfield_description_1_118\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_118_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_118' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_118'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_119\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_119\" ><label class='gfield_label gform-field-label' for='input_1_119'>Date of Accident #4<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_119' id='input_1_119' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_119_date_format gfield_description_1_119\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_119_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_119' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_119'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_120' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"13\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"13\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_120' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"15\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"15\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_15' class='gform_page' data-js='page-field-id-120' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_15' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_121\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_121\" ><label class='gfield_label gform-field-label' for='input_1_121'>Driver #2:  How many TICKETS in the past 3 years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_121' id='input_1_121' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='None' >None<\/option><option value='One' >One<\/option><option value='Two' >Two<\/option><option value='Three' >Three<\/option><option value='Four' >Four<\/option><option value='Five' >Five<\/option><option value='Six' >Six<\/option><option value='Seven' >Seven<\/option><option value='Eight +' >Eight +<\/option><\/select><\/div><\/div><div id=\"field_1_122\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_122\" ><label class='gfield_label gform-field-label' for='input_1_122'>Date Ticket #1<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_122' id='input_1_122' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_122_date_format gfield_description_1_122\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_122_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_122' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_122'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_123\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_123\" ><label class='gfield_label gform-field-label' for='input_1_123'>Reason #1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_123' id='input_1_123' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_124\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_124\" ><label class='gfield_label gform-field-label' for='input_1_124'>Date Ticket #2<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_124' id='input_1_124' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_124_date_format gfield_description_1_124\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_124_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_124' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_124'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_125\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_125\" ><label class='gfield_label gform-field-label' for='input_1_125'>Reason #2<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_1_125' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_126\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_126\" ><label class='gfield_label gform-field-label' for='input_1_126'>Date Ticket #3<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_126' id='input_1_126' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_126_date_format gfield_description_1_126\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_126_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_126' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_126'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_127\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_127\" ><label class='gfield_label gform-field-label' for='input_1_127'>Reason #3<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_127' id='input_1_127' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_128\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_128\" ><label class='gfield_label gform-field-label' for='input_1_128'>Date Ticket #4<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_128' id='input_1_128' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_128_date_format gfield_description_1_128\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_128_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_128' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_128'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_129\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_129\" ><label class='gfield_label gform-field-label' for='input_1_129'>Reason #4<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_1_129' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_130\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_130\" ><label class='gfield_label gform-field-label' for='input_1_130'>Date Ticket #5<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_130' id='input_1_130' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_130_date_format gfield_description_1_130\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_130_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_130' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_130'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_131\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_131\" ><label class='gfield_label gform-field-label' for='input_1_131'>Reason #5<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_131' id='input_1_131' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_132\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_132\" ><label class='gfield_label gform-field-label' for='input_1_132'>Date Ticket #6<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_132' id='input_1_132' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_132_date_format gfield_description_1_132\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_132_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_132' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_132'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_133\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_133\" ><label class='gfield_label gform-field-label' for='input_1_133'>Reason #6<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_133' id='input_1_133' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_134\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_134\" ><label class='gfield_label gform-field-label' for='input_1_134'>Date Ticket #7<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_134' id='input_1_134' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_134_date_format gfield_description_1_134\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_134_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_134' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_134'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_135\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_135\" ><label class='gfield_label gform-field-label' for='input_1_135'>Reason #7<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='medium'     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_136' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"14\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"14\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_136' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"16\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"16\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_16' class='gform_page' data-js='page-field-id-136' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_16' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_137\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_137\" ><label class='gfield_label gform-field-label' for='input_1_137'>Driver #2:  In the past 3 years, how many times has license been suspended for OVER 30 days?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_137' id='input_1_137' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Never' >Never<\/option><option value='Once' >Once<\/option><option value='Twice' >Twice<\/option><option value='Three  times' >Three  times<\/option><option value='More than three times' >More than three times<\/option><\/select><\/div><\/div><div id=\"field_1_138\" class=\"gfield gfield--type-select gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_138\" ><label class='gfield_label gform-field-label' for='input_1_138'>Reason for Suspension #1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_138' id='input_1_138' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Alcohol related' >Alcohol related<\/option><option value='Administrative' >Administrative<\/option><option value='Non-payment of fine' >Non-payment of fine<\/option><option value='Too many convictions or demerit points' >Too many convictions or demerit points<\/option><\/select><\/div><\/div><div id=\"field_1_139\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_139\" ><label class='gfield_label gform-field-label' for='input_1_139'>Date of Suspension #1<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_139' id='input_1_139' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_139_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_139_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_139' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_140\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_140\" ><label class='gfield_label gform-field-label' for='input_1_140'>Date of Reinstatement #1<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_140' id='input_1_140' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_140_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_140_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_140' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_141\" class=\"gfield gfield--type-select gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_141\" ><label class='gfield_label gform-field-label' for='input_1_141'>Reason for Suspension #2<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_141' id='input_1_141' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Alcohol related' >Alcohol related<\/option><option value='Administrative' >Administrative<\/option><option value='Non-payment of fine' >Non-payment of fine<\/option><option value='Too many convictions or demerit points' >Too many convictions or demerit points<\/option><\/select><\/div><\/div><div id=\"field_1_142\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_142\" ><label class='gfield_label gform-field-label' for='input_1_142'>Date of Suspension #2<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_142' id='input_1_142' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_142_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_142_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_142' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_143\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_143\" ><label class='gfield_label gform-field-label' for='input_1_143'>Date of Reinstatement #2<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_143' id='input_1_143' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_143_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_143_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_143' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_144\" class=\"gfield gfield--type-select gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_144\" ><label class='gfield_label gform-field-label' for='input_1_144'>Reason for Suspension #3<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_144' id='input_1_144' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Alcohol related' >Alcohol related<\/option><option value='Administrative' >Administrative<\/option><option value='Non-payment of fine' >Non-payment of fine<\/option><option value='Too many convictions or demerit points' >Too many convictions or demerit points<\/option><\/select><\/div><\/div><div id=\"field_1_145\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_145\" ><label class='gfield_label gform-field-label' for='input_1_145'>Date of Suspension #3<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_145' id='input_1_145' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_145_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_145_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_145' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_146\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_146\" ><label class='gfield_label gform-field-label' for='input_1_146'>Date of Reinstatement #3<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_146' id='input_1_146' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_146_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_146_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_146' class='gform_hidden' value='https:\/\/actioninsurancegroup.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_147' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"15\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"15\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_147' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"17\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"17\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_17' class='gform_page' data-js='page-field-id-147' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_17' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_148\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_148\" ><label class='gfield_label gform-field-label' for='input_1_148'>Driver #2:  How many times has policy been cancelled for NON-PAYMENT in the past 3 years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_148' id='input_1_148' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Never' >Never<\/option><option value='Once' >Once<\/option><option value='Twice' >Twice<\/option><option value='Three times' >Three times<\/option><option value='More than three times' >More than three times<\/option><\/select><\/div><\/div><div id=\"field_1_149\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_149\" ><label class='gfield_label gform-field-label' for='input_1_149'>Date of 1st Cancellation<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_149' id='input_1_149' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_149_date_format gfield_description_1_149\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_149_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_149' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_149'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_150\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_150\" ><label class='gfield_label gform-field-label' for='input_1_150'>Date of 2nd Cancellation<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_150' id='input_1_150' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_150_date_format gfield_description_1_150\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_150_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_150' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_150'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_151\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_151\" ><label class='gfield_label gform-field-label' for='input_1_151'>Date of 3rd Cancellation<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_151' id='input_1_151' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_151_date_format gfield_description_1_151\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_151_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_151' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_151'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_152' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"16\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"16\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_152' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"18\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"18\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_18' class='gform_page' data-js='page-field-id-152' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_18' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_153\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_153\" ><label class='gfield_label gform-field-label' for='input_1_153'>Driver #2:  Ever been cancelled for NON-DISCLOSURE?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_153' id='input_1_153' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_1_154\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_154\" ><label class='gfield_label gform-field-label' for='input_1_154'>Driver #2: Ever been cancelled for MIS-REPRESENTATION?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_154' id='input_1_154' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_155' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"17\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"17\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_155' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"19\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"19\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_19' class='gform_page' data-js='page-field-id-155' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_19' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_156\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_156\" ><h3 class=\"gsection_title\">Driver #3 Info<\/h3><\/div><fieldset id=\"field_1_157\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_157\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Driver #3: Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_1_157'>\n                            \n                            <span id='input_1_157_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_157.3' id='input_1_157_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_157_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_1_157_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_157.6' id='input_1_157_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_1_157_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_1_158\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_158\" ><legend class='gfield_label gform-field-label' >Driver #3: 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_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='Male'  id='choice_1_158_0' onchange='gformToggleRadioOther( this )'    \/>\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'>Male<\/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='Female'  id='choice_1_158_1' onchange='gformToggleRadioOther( this )'    \/>\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'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_240\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_240\" ><label class='gfield_label gform-field-label' for='input_1_240'>Birth Month<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_240' id='input_1_240' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='January' >January<\/option><option value='February' >February<\/option><option value='March' >March<\/option><option value='April' >April<\/option><option value='May' >May<\/option><option value='June' >June<\/option><option value='July' >July<\/option><option value='August' >August<\/option><option value='September' >September<\/option><option value='October' >October<\/option><option value='November' >November<\/option><option value='December' >December<\/option><\/select><\/div><\/div><div id=\"field_1_241\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_241\" ><label class='gfield_label gform-field-label' for='input_1_241'>Birth Day<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_241' id='input_1_241' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><\/div><div id=\"field_1_242\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_242\" ><label class='gfield_label gform-field-label' for='input_1_242'>Birth Year<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_242' id='input_1_242' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='1930' >1930<\/option><option value='1931' >1931<\/option><option value='1932' >1932<\/option><option value='1933' >1933<\/option><option value='1934' >1934<\/option><option value='1935' >1935<\/option><option value='1936' >1936<\/option><option value='1937' >1937<\/option><option value='1938' >1938<\/option><option value='1939' >1939<\/option><option value='1940' >1940<\/option><option value='1941' >1941<\/option><option value='1942' >1942<\/option><option value='1943' >1943<\/option><option value='1944' >1944<\/option><option value='1945' >1945<\/option><option value='1946' >1946<\/option><option value='1947' >1947<\/option><option value='1948' >1948<\/option><option value='1949' >1949<\/option><option value='1950' >1950<\/option><option value='1951' >1951<\/option><option value='1952' >1952<\/option><option value='1953' >1953<\/option><option value='1954' >1954<\/option><option value='1955' >1955<\/option><option value='1956' >1956<\/option><option value='1957' >1957<\/option><option value='1958' >1958<\/option><option value='1959' >1959<\/option><option value='1960' >1960<\/option><option value='1961' >1961<\/option><option value='1962' >1962<\/option><option value='1963' >1963<\/option><option value='1964' >1964<\/option><option value='1965' >1965<\/option><option value='1966' >1966<\/option><option value='1967' >1967<\/option><option value='1968' >1968<\/option><option value='1969' >1969<\/option><option value='1970' >1970<\/option><option value='1971' >1971<\/option><option value='1972' >1972<\/option><option value='1973' >1973<\/option><option value='1974' >1974<\/option><option value='1975' >1975<\/option><option value='1976' >1976<\/option><option value='1977' >1977<\/option><option value='1978' >1978<\/option><option value='1979' >1979<\/option><option value='1980' >1980<\/option><option value='1981' >1981<\/option><option value='1982' >1982<\/option><option value='1983' >1983<\/option><option value='1984' >1984<\/option><option value='1985' >1985<\/option><option value='1986' >1986<\/option><option value='1987' >1987<\/option><option value='1988' >1988<\/option><option value='1989' >1989<\/option><option value='1990' >1990<\/option><option value='1991' >1991<\/option><option value='1992' >1992<\/option><option value='1993' >1993<\/option><option value='1994' >1994<\/option><option value='1995' >1995<\/option><option value='1996' >1996<\/option><option value='1997' >1997<\/option><option value='1998' >1998<\/option><option value='1999' >1999<\/option><option value='2000' >2000<\/option><option value='2001' >2001<\/option><option value='2002' >2002<\/option><\/select><\/div><\/div><div id=\"field_1_160\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_160\" ><label class='gfield_label gform-field-label' for='input_1_160'>Driver #3: 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_160' id='input_1_160' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Married' >Married<\/option><option value='Single' >Single<\/option><option value='Common Law' >Common Law<\/option><\/select><\/div><\/div><div id=\"field_1_220\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_220\" ><label class='gfield_label gform-field-label' for='input_1_220'>Driver #3:  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_220' id='input_1_220' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_220\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_1_220'>Certain occupations are eligible for additional group discounts!<\/div><\/div><div id=\"field_1_221\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_221\" ><label class='gfield_label gform-field-label' for='input_1_221'>Driver #3:  Own a home or condo?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_221' id='input_1_221' class='medium gfield_select'  aria-describedby=\"gfield_description_1_221\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_221'>We offer additional discounts when you bundle your home and auto insurance.<\/div><\/div><div id=\"field_1_226\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_226\" ><label class='gfield_label gform-field-label' for='input_1_226'>Driver #3:  What &#039;class&#039; of Driver&#039;s License?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_226' id='input_1_226' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='5 and 6' >5 and 6<\/option><option value='6' >6<\/option><option value='7' >7<\/option><\/select><\/div><\/div><div id=\"field_1_227\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_227\" ><label class='gfield_label gform-field-label' for='input_1_227'>Driver #3:  Alberta Driver&#039;s License #<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_227' id='input_1_227' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_165\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_165\" ><label class='gfield_label gform-field-label' for='input_1_165'>Driver #3: What date was license obtained?<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_165' id='input_1_165' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_165_date_format gfield_description_1_165\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_165_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_165' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_165'>Guess on day and month if unknown.  The YEAR must be exact.<\/div><\/div><div id=\"field_1_166\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_166\" ><label class='gfield_label gform-field-label' for='input_1_166'>Driver #3: Take certified driver training?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_166' id='input_1_166' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/div><\/div><div id=\"field_1_167\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_167\" ><label class='gfield_label gform-field-label' for='input_1_167'>Driver #3: How many years of CONTINUOUS insurance held in the past 15 years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_167' id='input_1_167' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='None' >None<\/option><option value='1 Year' >1 Year<\/option><option value='2 Years' >2 Years<\/option><option value='3 Years' >3 Years<\/option><option value='4 Years' >4 Years<\/option><option value='5 Years' >5 Years<\/option><option value='6 Years' >6 Years<\/option><option value='7 Years' >7 Years<\/option><option value='8 Years' >8 Years<\/option><option value='9 Years' >9 Years<\/option><option value='10 Years' >10 Years<\/option><option value='11 Years' >11 Years<\/option><option value='12 Years' >12 Years<\/option><option value='13 Years' >13 Years<\/option><option value='14 Years' >14 Years<\/option><option value='15 Years' >15 Years<\/option><\/select><\/div><\/div><div id=\"field_1_168\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_168\" ><label class='gfield_label gform-field-label' for='input_1_168'>Driver #3:  Current Insurance 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_168' id='input_1_168' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Insured' >Insured<\/option><option value='Un-Insured' >Un-Insured<\/option><\/select><\/div><\/div><div id=\"field_1_169\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_169\" ><label class='gfield_label gform-field-label' for='input_1_169'>Driver #3:  Why un-insured?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_169' id='input_1_169' class='small gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Non-Payment' >Non-Payment<\/option><option value='Non-Renewed' >Non-Renewed<\/option><option value='Non-Disclosure' >Non-Disclosure<\/option><option value='Self Cancelled' >Self Cancelled<\/option><option value='No Prior Insurance' >No Prior Insurance<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_170' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"18\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"18\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_170' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"20\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"20\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_20' class='gform_page' data-js='page-field-id-170' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_20' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_171\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_171\" ><h3 class=\"gsection_title\">Driver #3 History<\/h3><\/div><div id=\"field_1_172\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_172\" ><label class='gfield_label gform-field-label' for='input_1_172'>Driver #3:  How many AT FAULT accidents in past 6 years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_172' id='input_1_172' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='None' >None<\/option><option value='One' >One<\/option><option value='Two' >Two<\/option><option value='Three' >Three<\/option><option value='Four' >Four<\/option><option value='Five +' >Five +<\/option><\/select><\/div><\/div><div id=\"field_1_173\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_173\" ><label class='gfield_label gform-field-label' for='input_1_173'>Date of Accident #1<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_173' id='input_1_173' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_173_date_format gfield_description_1_173\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_173_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_173' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_173'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_174\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_174\" ><label class='gfield_label gform-field-label' for='input_1_174'>Date of Accident #2<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_174' id='input_1_174' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_174_date_format gfield_description_1_174\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_174_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_174' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_174'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_175\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_175\" ><label class='gfield_label gform-field-label' for='input_1_175'>Date of Accident #3<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_175' id='input_1_175' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_175_date_format gfield_description_1_175\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_175_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_175' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_175'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_176\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_176\" ><label class='gfield_label gform-field-label' for='input_1_176'>Date of Accident #4<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_176' id='input_1_176' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_176_date_format gfield_description_1_176\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_176_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_176' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_176'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_177' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"19\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"19\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_177' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"21\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"21\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_21' class='gform_page' data-js='page-field-id-177' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_21' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_178\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_178\" ><label class='gfield_label gform-field-label' for='input_1_178'>Driver #3: How many TICKETS in the past 3 years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_178' id='input_1_178' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='None' >None<\/option><option value='One' >One<\/option><option value='Two' >Two<\/option><option value='Three' >Three<\/option><option value='Four' >Four<\/option><option value='Five' >Five<\/option><option value='Six' >Six<\/option><option value='Seven' >Seven<\/option><option value='Eight +' >Eight +<\/option><\/select><\/div><\/div><div id=\"field_1_179\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_179\" ><label class='gfield_label gform-field-label' for='input_1_179'>Date Ticket #1<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_179' id='input_1_179' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_179_date_format gfield_description_1_179\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_179_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_179' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_179'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_180\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_180\" ><label class='gfield_label gform-field-label' for='input_1_180'>Reason #1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_180' id='input_1_180' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_181\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_181\" ><label class='gfield_label gform-field-label' for='input_1_181'>Date Ticket #2<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_181' id='input_1_181' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_181_date_format gfield_description_1_181\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_181_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_181' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_181'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_182\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_182\" ><label class='gfield_label gform-field-label' for='input_1_182'>Reason #2<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_182' id='input_1_182' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_183\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_183\" ><label class='gfield_label gform-field-label' for='input_1_183'>Date Ticket #3<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_183' id='input_1_183' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_183_date_format gfield_description_1_183\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_183_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_183' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_183'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_184\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_184\" ><label class='gfield_label gform-field-label' for='input_1_184'>Reason #3<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_184' id='input_1_184' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_185\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_185\" ><label class='gfield_label gform-field-label' for='input_1_185'>Date Ticket #4<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_185' id='input_1_185' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_185_date_format gfield_description_1_185\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_185_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_185' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_185'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_186\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_186\" ><label class='gfield_label gform-field-label' for='input_1_186'>Reason #4<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_186' id='input_1_186' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_187\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_187\" ><label class='gfield_label gform-field-label' for='input_1_187'>Date Ticket #5<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_187' id='input_1_187' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_187_date_format gfield_description_1_187\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_187_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_187' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_187'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_188\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_188\" ><label class='gfield_label gform-field-label' for='input_1_188'>Reason #5<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_188' id='input_1_188' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_189\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_189\" ><label class='gfield_label gform-field-label' for='input_1_189'>Date Ticket #6<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_189' id='input_1_189' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_189_date_format gfield_description_1_189\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_189_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_189' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_189'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_190\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_190\" ><label class='gfield_label gform-field-label' for='input_1_190'>Reason #6<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_190' id='input_1_190' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_1_191\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_191\" ><label class='gfield_label gform-field-label' for='input_1_191'>Date Ticket #7<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_191' id='input_1_191' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_191_date_format gfield_description_1_191\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_191_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_191' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_191'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_192\" class=\"gfield gfield--type-text gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_192\" ><label class='gfield_label gform-field-label' for='input_1_192'>Reason #7<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_192' id='input_1_192' type='text' value='' class='medium'     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_193' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"20\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"20\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_193' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"22\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"22\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_22' class='gform_page' data-js='page-field-id-193' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_22' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_194\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_194\" ><label class='gfield_label gform-field-label' for='input_1_194'>Driver #3:  In the past 3 years, how many times has license been suspended for OVER 30 days?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_194' id='input_1_194' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Never' >Never<\/option><option value='Once' >Once<\/option><option value='Twice' >Twice<\/option><option value='Three  times' >Three  times<\/option><option value='More than three times' >More than three times<\/option><\/select><\/div><\/div><div id=\"field_1_195\" class=\"gfield gfield--type-select gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_195\" ><label class='gfield_label gform-field-label' for='input_1_195'>Reason for Suspension #1<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_195' id='input_1_195' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Alcohol related' >Alcohol related<\/option><option value='Administrative' >Administrative<\/option><option value='Non-payment of fine' >Non-payment of fine<\/option><option value='Too many convictions or demerit points' >Too many convictions or demerit points<\/option><\/select><\/div><\/div><div id=\"field_1_196\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_196\" ><label class='gfield_label gform-field-label' for='input_1_196'>Date of Suspension #1<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_196' id='input_1_196' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_196_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_196_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_196' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_197\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_197\" ><label class='gfield_label gform-field-label' for='input_1_197'>Date of Reinstatement #1<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_197' id='input_1_197' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_197_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_197_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_197' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_198\" class=\"gfield gfield--type-select gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_198\" ><label class='gfield_label gform-field-label' for='input_1_198'>Reason for Suspension #2<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_198' id='input_1_198' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Alcohol related' >Alcohol related<\/option><option value='Administrative' >Administrative<\/option><option value='Non-payment of fine' >Non-payment of fine<\/option><option value='Too many convictions or demerit points' >Too many convictions or demerit points<\/option><\/select><\/div><\/div><div id=\"field_1_199\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_199\" ><label class='gfield_label gform-field-label' for='input_1_199'>Date of Suspension #2<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_199' id='input_1_199' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_199_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_199_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_199' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_200\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_200\" ><label class='gfield_label gform-field-label' for='input_1_200'>Date of Reinstatement #2<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_200' id='input_1_200' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_200_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_200_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_200' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_201\" class=\"gfield gfield--type-select gf_left_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_201\" ><label class='gfield_label gform-field-label' for='input_1_201'>Reason for Suspension #3<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_201' id='input_1_201' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Alcohol related' >Alcohol related<\/option><option value='Administrative' >Administrative<\/option><option value='Non-payment of fine' >Non-payment of fine<\/option><option value='Too many convictions or demerit points' >Too many convictions or demerit points<\/option><\/select><\/div><\/div><div id=\"field_1_202\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_middle_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_202\" ><label class='gfield_label gform-field-label' for='input_1_202'>Date of Suspension #3<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_202' id='input_1_202' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_202_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_202_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_202' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_1_203\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_third gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_203\" ><label class='gfield_label gform-field-label' for='input_1_203'>Date of Reinstatement #3<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_203' id='input_1_203' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_203_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_203_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_203' class='gform_hidden' value='https:\/\/actioninsurancegroup.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_204' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"21\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"21\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_204' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"23\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"23\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_23' class='gform_page' data-js='page-field-id-204' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_23' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_205\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_205\" ><label class='gfield_label gform-field-label' for='input_1_205'>Driver #3:  How many times has policy been cancelled for NON-PAYMENT in the past 3 years?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_205' id='input_1_205' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Never' >Never<\/option><option value='Once' >Once<\/option><option value='Twice' >Twice<\/option><option value='Three times' >Three times<\/option><option value='More than three times' >More than three times<\/option><\/select><\/div><\/div><div id=\"field_1_206\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_206\" ><label class='gfield_label gform-field-label' for='input_1_206'>Date of 1st Cancellation<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_206' id='input_1_206' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_206_date_format gfield_description_1_206\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_206_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_206' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_206'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_207\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_207\" ><label class='gfield_label gform-field-label' for='input_1_207'>Date of 2nd Cancellation<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_207' id='input_1_207' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_207_date_format gfield_description_1_207\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_207_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_207' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_207'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><div id=\"field_1_208\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_208\" ><label class='gfield_label gform-field-label' for='input_1_208'>Date of 3rd Cancellation<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_208' id='input_1_208' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/yyyy' aria-describedby=\"input_1_208_date_format gfield_description_1_208\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_1_208_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_208' class='gform_hidden' value='https:\/\/actioninsurancegroup.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_208'>Enter 1st day of the month if unsure of the exact date.<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_209' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"22\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"22\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_209' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"24\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"24\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_24' class='gform_page' data-js='page-field-id-209' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_24' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_210\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_210\" ><label class='gfield_label gform-field-label' for='input_1_210'>Driver #3:  Ever been cancelled for NON-DISCLOSURE?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_210' id='input_1_210' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_1_211\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_211\" ><label class='gfield_label gform-field-label' for='input_1_211'>Driver #3: Ever been cancelled for MIS-REPRESENTATION?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_211' id='input_1_211' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_1_214' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"23\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"23\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_1_214' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_1\").val(\"25\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_1\").val(\"25\");  jQuery(\"#gform_1\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_1_25' class='gform_page' data-js='page-field-id-214' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_1_25' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_1_228\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_228\" ><h1>Phew ...  Final Questions!<\/h1><\/div><div id=\"field_1_229\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_229\" ><label class='gfield_label gform-field-label' for='input_1_229'>How did you hear about us?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_229' id='input_1_229' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Action Insurance Group Staff Member' >Action Insurance Group Staff Member<\/option><option value='Employee Group Program' >Employee Group Program<\/option><option value='A Specific Broker' >A Specific Broker<\/option><option value='Radio Ad' >Radio Ad<\/option><option value='Google' >Google<\/option><option value='Bing' >Bing<\/option><option value='Facebook' >Facebook<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_1_230\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_230\" ><label class='gfield_label gform-field-label' for='input_1_230'>Referral 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_230' id='input_1_230' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_230\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_1_230'>Please Specify the Action Insurance Group staff member, Employee Group, Friend or Family Member or Specific Broker's name that referred you to us.<\/div><\/div><div id=\"field_1_232\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_232\" ><label class='gfield_label gform-field-label' for='input_1_232'>What is your preferred contact method?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_232' id='input_1_232' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Email' >Email<\/option><option value='Phone' >Phone<\/option><option value='Either' >Either<\/option><\/select><\/div><\/div><fieldset id=\"field_1_247\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_247\" ><legend class='gfield_label gform-field-label' >What office are you nearest?<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_247'>\n\t\t\t<div class='gchoice gchoice_1_247_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_247' type='radio' value='Calgary, AB'  id='choice_1_247_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_247_0' id='label_1_247_0' class='gform-field-label gform-field-label--type-inline'>Calgary, AB<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_1_247_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_247' type='radio' value='Strathmore, AB'  id='choice_1_247_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_247_1' id='label_1_247_1' class='gform-field-label gform-field-label--type-inline'>Strathmore, AB<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_212\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_212\" ><label class='gfield_label gform-field-label' for='input_1_212'>Do you have any additional comments or notes you&#039;d like to add to your submission?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_212' id='input_1_212' class='textarea large'  aria-describedby=\"gfield_description_1_212\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_1_212'>Please let us know if you have any additional information or comments.<\/div><\/div><fieldset id=\"field_1_251\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_1_251\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_251.1' id='input_1_251_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_1_251\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_1_251_1' >I agree<\/label><input type='hidden' name='input_251.2' value='I agree' class='gform_hidden' \/><input type='hidden' name='input_251.3' value='1' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_1_251'>As your broker, I am gathering this consent on behalf of the insurer who advises me that: in respect of this quotation\/application, any policy we issue and subsequent renewals or changes, we may collect, use and disclose personal information reports including policy history, claims history, investigative information, rating information, risk information and only with respect to you, your personal credit information including credit score, as permitted by law and in accordance with our privacy policies. <br \/><br \/> Do you, and on behalf of others listed, authorize us to collect, use and disclose to appropriate third parties, including your broker, this information solely relating to your personal automobile policy for the purposes necessary to assess the risk, determine a premium, determine eligibility and conditions for a premium payment plan, investigate and settle claims, analyze business results and detect and prevent fraud?<\/div><\/fieldset><\/div><\/div>\n        <div 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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']) 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style=\"--awb-caption-title-font-family:var(--h2_typography-font-family);--awb-caption-title-font-weight:var(--h2_typography-font-weight);--awb-caption-title-font-style:var(--h2_typography-font-style);--awb-caption-title-size:var(--h2_typography-font-size);--awb-caption-title-transform:var(--h2_typography-text-transform);--awb-caption-title-line-height:var(--h2_typography-line-height);--awb-caption-title-letter-spacing:var(--h2_typography-letter-spacing);\"><span class=\" fusion-imageframe imageframe-none imageframe-1 hover-type-none\"><img decoding=\"async\" width=\"800\" height=\"325\" alt=\"secure auto insurance quote form\" title=\"secure-form\" src=\"https:\/\/actioninsurancegroup.com\/wp-content\/uploads\/2017\/10\/secure-form.png\" class=\"img-responsive wp-image-3484\" srcset=\"https:\/\/actioninsurancegroup.com\/wp-content\/uploads\/2017\/10\/secure-form-200x81.png 200w, https:\/\/actioninsurancegroup.com\/wp-content\/uploads\/2017\/10\/secure-form-400x163.png 400w, https:\/\/actioninsurancegroup.com\/wp-content\/uploads\/2017\/10\/secure-form-600x244.png 600w, https:\/\/actioninsurancegroup.com\/wp-content\/uploads\/2017\/10\/secure-form.png 800w\" sizes=\"(max-width: 800px) 100vw, 400px\" \/><\/span><\/div><div class=\"fusion-text fusion-text-3\"><p style=\"color: #ffffff; font-size: 12px;\">The information you provide on this form is encrypted with SSL technology to ensure your information is safe. We will never share, sell or publish your personal information. You can learn more by reading our <a href=\"\/privacy-policy\/\">privacy policy<\/a>.<\/p>\n<\/div><div class=\"fusion-clearfix\"><\/div><\/div><\/div><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":7,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"_links":{"self":[{"href":"https:\/\/actioninsurancegroup.com\/wp-json\/wp\/v2\/pages\/3465"}],"collection":[{"href":"https:\/\/actioninsurancegroup.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/actioninsurancegroup.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/actioninsurancegroup.com\/wp-json\/wp\/v2\/users\/7"}],"replies":[{"embeddable":true,"href":"https:\/\/actioninsurancegroup.com\/wp-json\/wp\/v2\/comments?post=3465"}],"version-history":[{"count":0,"href":"https:\/\/actioninsurancegroup.com\/wp-json\/wp\/v2\/pages\/3465\/revisions"}],"wp:attachment":[{"href":"https:\/\/actioninsurancegroup.com\/wp-json\/wp\/v2\/media?parent=3465"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}