{"id":3522,"date":"2017-10-16T12:34:33","date_gmt":"2017-10-16T18:34:33","guid":{"rendered":"http:\/\/actioninsurancegroup.com\/?page_id=3522"},"modified":"2020-02-24T14:44:34","modified_gmt":"2020-02-24T21:44:34","slug":"farm-insurance-alberta-quote-form","status":"publish","type":"page","link":"https:\/\/actioninsurancegroup.com\/farm-insurance-alberta-quote-form\/","title":{"rendered":"Farm 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_1_4 1_4 fusion-one-fourth fusion-column-first\" style=\"--awb-bg-size:cover;width:25%;width:calc(25% - ( ( 4% ) * 0.25 ) );margin-right: 4%;\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\"><div class=\"fusion-image-element in-legacy-container\" 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-1\"><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 class=\"fusion-layout-column fusion_builder_column fusion-builder-column-1 fusion_builder_column_3_4 3_4 fusion-three-fourth fusion-column-last\" style=\"--awb-bg-size:cover;width:75%;width:calc(75% - ( ( 4% ) * 0.75 ) );\"><div class=\"fusion-column-wrapper fusion-flex-column-wrapper-legacy\"><div class=\"fusion-text fusion-text-2\"><h1>Farm 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-3\"><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_chrome gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_11' style='display:none'><div id='gf_11' 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_11' id='gform_11'  action='\/wp-json\/wp\/v2\/pages\/3522#gf_11' data-formid='11' novalidate>\n        <div id='gf_progressbar_wrapper_11' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>6<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_16' style='width:16%;'><span>16%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_11_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><div id='gform_fields_11' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_11_48\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_above gfield_visibility_hidden\"  data-js-reload=\"field_11_48\" ><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_11_48'>Source<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_11_48' type='text' value='Direct' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_11_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_11_1\" ><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_11_1'>\n                            \n                            <span id='input_11_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_11_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_11_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_11_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_11_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_11_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_11_33\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_11_33\" ><label class='gfield_label gform-field-label' for='input_11_33'>Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_33' id='input_11_33' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_11_34\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_11_34\" ><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_11_34_container'>\n                                <span id='input_11_34_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_34' id='input_11_34' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_11_34' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_11_34_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_34_2' id='input_11_34_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_11_34_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_next_button_11_32' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_11\").val(\"2\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_11\").val(\"2\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_2' class='gform_page' data-js='page-field-id-32' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_2' class='gform_fields top_label form_sublabel_below description_above'><fieldset id=\"field_11_2\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_11_2\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Farm 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_11_2' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_11_2_1_container' >\n                                        <input type='text' name='input_2.1' id='input_11_2_1' value=''    aria-required='true'    \/>\n                                        <label for='input_11_2_1' id='input_11_2_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_11_2_3_container' >\n                                    <input type='text' name='input_2.3' id='input_11_2_3' value=''    aria-required='true'    \/>\n                                    <label for='input_11_2_3' id='input_11_2_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_2.4' id='input_11_2_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_11_2_5_container' >\n                                    <input type='text' name='input_2.5' id='input_11_2_5' value=''    aria-required='true'    \/>\n                                    <label for='input_11_2_5' id='input_11_2_5_label' class='gform-field-label gform-field-label--type-sub '>Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_2.6' id='input_11_2_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_11_44\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_11_44\" ><label class='gfield_label gform-field-label' for='input_11_44'>Farm Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_11_44'>Describe the type of farm you operate.  Example:  Cash Crop & Grain, Dairy & Goat Farms, Beef Farms, Poultry Farms, Sheep Farms, Hog Farms, Horse Farms, Mixed Farms, Hobby Farms or other.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_44' id='input_11_44' class='textarea medium'  aria-describedby=\"gfield_description_11_44\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_11_45\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_11_45\" ><label class='gfield_label gform-field-label' for='input_11_45'>Farm Details<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_11_45'>Please provide the size of your farm (acres) and type\/year of buildings.<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_45' id='input_11_45' class='textarea medium'  aria-describedby=\"gfield_description_11_45\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_11_46\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_11_46\" ><label class='gfield_label gform-field-label' for='input_11_46'>Equipment List<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_11_46'>Please list the type and estimated value of your major farm equipment ($5,000+).<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_46' id='input_11_46' class='textarea medium'  aria-describedby=\"gfield_description_11_46\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_11_47\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_11_47\" ><label class='gfield_label gform-field-label' for='input_11_47'>Gross Receipts<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_11_47'>What where your gross receipts last reporting period?<\/div><div class='ginput_container ginput_container_text'><input name='input_47' id='input_11_47' type='text' value='' class='medium'  aria-describedby=\"gfield_description_11_47\"   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_11_3' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_11\").val(\"1\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_11\").val(\"1\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_11_3' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_11\").val(\"3\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_11\").val(\"3\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_3' class='gform_page' data-js='page-field-id-3' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_3' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_11_42\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_11_42\" ><label class='gfield_label gform-field-label' for='input_11_42'>How many years have you operated this farm?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_42' id='input_11_42' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='&lt; 1' >&lt; 1<\/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><\/select><\/div><\/div><div id=\"field_11_4\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_11_4\" ><label class='gfield_label gform-field-label' for='input_11_4'>How many years have you held continuous farm insurance?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_4' id='input_11_4' class='large 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' >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><\/select><\/div><\/div><div id=\"field_11_6\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_11_6\" ><label class='gfield_label gform-field-label' for='input_11_6'>How many claims have you had on your farm insurance in the past five (5) years?<\/label><div class='ginput_container ginput_container_select'><select name='input_6' id='input_11_6' class='large gfield_select'     aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='None' >None<\/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><\/select><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_11_5' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_11\").val(\"2\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_11\").val(\"2\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_11_5' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_11\").val(\"4\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_11\").val(\"4\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_4' class='gform_page' data-js='page-field-id-5' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_4' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_11_9\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_11_9\" ><label class='gfield_label gform-field-label' for='input_11_9'>What is the current approx market value of your farm?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_11_9'>If you were to sell your farm today, what would be the asking price?<\/div><div class='ginput_container ginput_container_number'><input name='input_9' id='input_11_9' type='text' step='any'   value='' class='large'    placeholder='example: $520,000' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_11_9\" \/><\/div><\/div><div id=\"field_11_7\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_11_7\" ><label class='gfield_label gform-field-label' for='input_11_7'>Do you have a mortgage on your farm?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_7' id='input_11_7' class='large 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_11_8\" class=\"gfield gfield--type-number gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_11_8\" ><label class='gfield_label gform-field-label' for='input_11_8'>What is the current amount of your mortgage?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_11_8'>Please enter the amount owing your mortgage as of today.<\/div><div class='ginput_container ginput_container_number'><input name='input_8' id='input_11_8' type='text' step='any'   value='' class='large'    placeholder='example: $320,000' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_11_8\" \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_11_10' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_11\").val(\"3\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_11\").val(\"3\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_11_10' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_11\").val(\"5\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_11\").val(\"5\");  jQuery(\"#gform_11\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_11_5' class='gform_page' data-js='page-field-id-10' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_5' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_11_20\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_11_20\" ><label class='gfield_label gform-field-label' for='input_11_20'>Is your farm within 300 m (1000 ft) of a fire hydrant?<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_11_20' class='large 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_11_21\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_11_21\" ><label class='gfield_label gform-field-label' for='input_11_21'>Is your farm within 8 km (5 miles) of a fire station?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_21' id='input_11_21' class='large 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' 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               <\/div>\n                <div id='gform_page_11_6' class='gform_page' data-js='page-field-id-22' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_11_6' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_11_36\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_11_36\" ><label class='gfield_label gform-field-label' for='input_11_36'>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_36' id='input_11_36' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Google' >Google<\/option><option value='Facebook' >Facebook<\/option><option value='Radio Ad' >Radio Ad<\/option><option value='Referred by Broker' >Referred by Broker<\/option><option value='Referred by Other' >Referred by Other<\/option><\/select><\/div><\/div><div id=\"field_11_37\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_11_37\" ><label class='gfield_label gform-field-label' for='input_11_37'>Referred by:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_11_37'>Please provide us the name of the specific Broker or staff member who referred you.<\/div><div class='ginput_container ginput_container_text'><input name='input_37' id='input_11_37' type='text' value='' class='large'  aria-describedby=\"gfield_description_11_37\"   aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_11_43\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_11_43\" ><label class='gfield_label gform-field-label' for='input_11_43'>Office Location<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_11_43'>Which of our offices is closest to you?<\/div><div class='ginput_container ginput_container_select'><select name='input_43' id='input_11_43' class='medium gfield_select'  aria-describedby=\"gfield_description_11_43\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select ...<\/option><option value='Calgary' >Calgary<\/option><option value='Strathmore' >Strathmore<\/option><\/select><\/div><\/div><fieldset id=\"field_11_49\" 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_above gfield_visibility_visible\"  data-js-reload=\"field_11_49\" ><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='gfield_description gfield_consent_description' id='gfield_consent_description_11_49'>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 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