{"id":5804,"date":"2022-07-25T13:04:28","date_gmt":"2022-07-25T17:04:28","guid":{"rendered":"https:\/\/gulfinsuranceltd.com\/forms\/?page_id=5804"},"modified":"2022-07-25T13:20:27","modified_gmt":"2022-07-25T17:20:27","slug":"hm-renewal-form","status":"publish","type":"page","link":"https:\/\/gulfinsuranceltd.com\/forms\/hm-renewal-form\/","title":{"rendered":"H&#038;M Renewal Form"},"content":{"rendered":"<p style=\"text-align: center;\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter\" src=\"https:\/\/gulfinsuranceltd.com\/forms\/wp-content\/uploads\/2019\/08\/Gulf-Revised-Logo-300x140.png\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" srcset=\"https:\/\/gulfinsuranceltd.com\/forms\/wp-content\/uploads\/2019\/08\/Gulf-Revised-Logo-300x140.png 300w, https:\/\/gulfinsuranceltd.com\/forms\/wp-content\/uploads\/2019\/08\/Gulf-Revised-Logo-768x358.png 768w, https:\/\/gulfinsuranceltd.com\/forms\/wp-content\/uploads\/2019\/08\/Gulf-Revised-Logo-1024x477.png 1024w\" alt=\"\" width=\"300\" height=\"140\" \/><\/p>\n<h2 style=\"text-align: center;\">Property \/ Motor Renewal Form<\/h2>\n<p style=\"text-align: center;\"><script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_100' style='display:none'><div id='gf_100' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_100'  action='\/forms\/wp-json\/wp\/v2\/pages\/5804#gf_100' data-formid='100' novalidate autocomplete=\"off\">\n        <div id='gf_progressbar_wrapper_100' class='gf_progressbar_wrapper'>\n        \t<h3 class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>5<\/span> - Type of Renewal\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_0' style='width:0%;'><span>0%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_100_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_100' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_100_6068\"  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_100_6068\"><h3>PROPOSER DETAILS<\/h3><\/li><li id=\"field_100_6070\"  class=\"gfield gfield--type-select gf_left_half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_6070\"><label class='gfield_label gform-field-label' for='input_100_6070' >Renewal Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_6070' id='input_100_6070' class='medium gfield_select' tabindex='100' aria-describedby=\"gfield_description_100_6070\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Type of Renewal<\/option><option value='Motor' >Motor<\/option><option value='Property' >Property<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_100_6070'>Type of Renewal : Property, Motor<\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_100_6069' class='gform_next_button gform-theme-button button' value='Next' tabindex='101' onclick='jQuery(\"#gform_target_page_number_100\").val(\"2\");  jQuery(\"#gform_100\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_100\").val(\"2\");  jQuery(\"#gform_100\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_100_2' class='gform_page' data-js='page-field-id-6069' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_100_2' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_100_536\"  class=\"gfield gfield--type-consent gfield--type-choice exclude scroll-to-read gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_100_536\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Property Renewal Declaration<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description gfield_consent_description' id='gfield_consent_description_100_536'><p style=\"text-align: justify;\"><strong>GULF INSURANCE LIMITED AVERAGE NOTICE\/ADVISORY <\/strong><\/p><p style=\"text-align: justify;\">Gulf Insurance Ltd.&rsquo;s policy contract is based on Indemnity and is subject to an &ldquo;Average Provision&rdquo;.&nbsp;<\/p><p style=\"text-align: justify;\">Indemnity aims to place the insured in the same financial position (after a loss) that he or she would have enjoyed immediately prior to a loss.<\/p><p style=\"text-align: justify;\">An &ldquo;Average Provision&rdquo; is applicable if the <strong>Sum Insured<\/strong> declared on the value of the property is <strong>less than<\/strong> the Assessed Value to rebuild\/repair the property at the time of a claim\/loss. This provision is used to determine the value of the property which is deemed to not have been covered by the policy i.e., effectively self-insured by the policyholder.&nbsp;<\/p><br \/>\n<p style=\"text-align: justify;\">The statement below shows the method for assessing the Average Provision used by Gulf.<\/p><p style=\"text-align: justify;\"><strong>Step 1&nbsp; &nbsp; -&nbsp; &nbsp; <\/strong>Sum Insured \/ Assessed Value = % Covered<\/p><p style=\"text-align: justify;\"><strong>Step 2&nbsp; &nbsp; -&nbsp; &nbsp; <\/strong>% Covered &times;&nbsp; Claim = Amount Due to Policyholder<\/p><p style=\"text-align: justify;\"><strong>Practical Example<\/strong><\/p><p style=\"text-align: justify;\">If the:<\/p><ul><li><em>Declared Sum Insured on Policy = $1,000,000<\/em><\/li><li><em>Assessed Value of property at the time of loss = $1,500,000<\/em><\/li><li><em>Claim\/Loss incurred = $750,000<\/em><\/li><\/ul><p style=\"text-align: justify;\"><strong>Step 1&nbsp; &nbsp; -&nbsp; &nbsp; <\/strong>1,000,000 \/ 1,500,000 = 66.67%<\/p><p style=\"text-align: justify;\"><strong>Step 2&nbsp; &nbsp; -&nbsp; &nbsp; <\/strong>66.67% &times;&nbsp; 750,000 = 500,000<\/p><p style=\"text-align: justify;\"><strong><em>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<\/em><\/strong><\/p><p style=\"text-align: justify;\">Therefore, Gulf would settle $500,000 to policyholder and the policyholder be responsible for the balance of the claim\/loss of $250,000.<\/p><p style=\"text-align: justify;\">To avoid the &lsquo;Average Provision&rsquo; being applied at the time of a claim\/loss, we recommend that you utilize the services of a professional valuator or assessor to confirm your sum insured regularly.&nbsp;<\/p><\/div><div class='ginput_container ginput_container_consent'><input autocomplete=\"off\"  name='input_536.1' id='input_100_536_1' type='checkbox' value='1' tabindex='102' aria-describedby=\"gfield_consent_description_100_536\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_100_536_1' >I have read and understood<\/label><input autocomplete=\"off\"  type='hidden' name='input_536.2' value='I have read and understood' class='gform_hidden' \/><input autocomplete=\"off\"  type='hidden' name='input_536.3' value='91' class='gform_hidden' \/><\/div><\/li><li id=\"field_100_6071\"  class=\"gfield gfield--type-consent gfield--type-choice exclude scroll-to-read gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_100_6071\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Motor Renewal Declaration<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description gfield_consent_description' id='gfield_consent_description_100_6071'><div style=\"text-align: justify;\"><strong>GULF INSURANCE LIMITED MOTOR NOTICE\/ADVISORY <\/strong><br><br \/>\n<ul><br \/>\n    <li><em>Please check to ensure that the renewal Sum Insured represents the current market value of the vehicle. In the event of a total loss, the amount payable is the market value or the sum insured, whichever is less&nbsp;<br><strong>(Not Applicable to Third Party Policies)<\/strong><\/em><\/li><br \/>\n    <li><em>Your policy does not cover Drivers under the age of 25 nor persons driving for less than 2 years, unless their name has been specifically added as a \"Named Driver\"on the policy.<\/em><\/li><br \/>\n<br \/>\n<\/ul><br \/>\n<\/div><\/div><div class='ginput_container ginput_container_consent'><input autocomplete=\"off\"  name='input_6071.1' id='input_100_6071_1' type='checkbox' value='1' tabindex='103' aria-describedby=\"gfield_consent_description_100_6071\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_100_6071_1' >I have read and understood<\/label><input autocomplete=\"off\"  type='hidden' name='input_6071.2' value='I have read and understood' class='gform_hidden' \/><input autocomplete=\"off\"  type='hidden' name='input_6071.3' value='91' class='gform_hidden' \/><\/div><\/li><li id=\"field_100_6063\"  class=\"gfield gfield--type-html d-none gfield_html field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_6063\">\n<h2>AVERAGE (UNDERINSURANCE) DISCLAIMER<\/h2>\n<p>We at Gulf Insurance Ltd have made\nit our duty to ensure you, the client, are never blind-sided and are\ncontinuously involved in the workings of your policy with us. That\nbeing said, Gulf Insurance Ltd. would like to remind you that\ncoverage is on an Indemnity basis. To understand what this means, it\nis important that you read the following: \n<\/p>\n<p><b>Definition of Terms<\/b><\/p>\n<ul>\n\t<li><b>Average<\/b> <b>Clause<\/b> \u2013\n\tThis clause penalizes you, the policyholder, if your property is\n\tunder-insured.\n\t<\/li>\n\t<li><b>Excess<\/b> \u2013 This is the\n\tamount of each and every loss\/claim that is not covered by the\n\tpolicy and therefore is covered by the Insured. \n\t<\/li>\n\t<li><b>Indemnity<\/b> \u2013 Indemnity,\n\tsimply put, refers to a legal reimbursement principle that is agreed\n\tupon by means of a mutual contract between parties (e.g., the\n\tinsured and the insurer). See below for further details<\/li>\n\t<li><b>Limits<\/b> - maximum value\n\tto be derived from a policy<\/li>\n\t<li><b>Loss<\/b> \u2013 physical damage\n\tto property or bodily injury, Including loss of use or loss of\n\tincome<\/li>\n\t<li><b>Sum Insured<\/b> \u2013 Value of\n\tthe insured property\/goods; it is recommended that the sum insured\n\tof a building include not only the exact building\u2019s value, but\n\tdebris removal, architect and surveyor\u2019s fees etc.<\/li>\n\t<li><b>The Insurer<\/b> \u2013 The\n\tinsurance company (Gulf Insurance Ltd.) \n\t<\/li>\n\t<li><b>The Insured<\/b> \u2013 The\n\tpolicy holder (you, the client)<\/li>\n\t<li><b>Value at Risk<\/b> \u2013 Cost\n\tto rebuild at today\u2019s prices \n\t<\/li>\n<\/ul>\n<p>The main purpose of this literature\nis to ensure that the Insured understands how the application of\n\u2018average\u2019 works. However, in order to understand this, the\ninsured must first understand <b>indemnity<\/b>. In insurance,\n<b>indemnity<\/b> aims to place the insured in the <u>same<\/u>\nfinancial position (after a loss) that he or she would have enjoyed\nimmediately prior to the loss. In other words, the Insured shall get\nneither more nor less than the actual amount of loss sustained. This,\nof course, is always subject to the limit of the sum insured and is\nalso subject to terms and conditions of the policy. \n<\/p>\n<p>Under indemnity contracts, you the\nInsured should note that: \n<\/p>\n<ul>\n\t<li>Payments to the Insured do not\n\tgo beyond the extent of the sum that is insured by the company, as\n\tnot to provide an additional gain or profit by means of a loss.  \n\t<\/li>\n\t<li>It is up to the <u>Insurer<\/u>\n\tto choose the means of compensating the Insured by means inclusive\n\tof cash, repairs, reinstatement, or replacement.<\/li>\n<\/UL>\n<p>Traditionally,\nmishaps that tend to occur are the consequences of what can be\nreferred to as under-insurance. What this means is the value that was\nattached to the property\/goods insured, was less than its actual\nvalue at the time of the loss. The following list indicates the\npossible factors that may affect your indemnity payments or\nreimbursement:\n<\/p>\n<ul>\n\t<li>Limits on the\n\tpolicy for certain events or items (see your policy schedule)<\/li>\n\t<li>The application\n\tof any excess (as defined above) which is borne by the insured. \n\t<\/li>\n\t<li>Inadequate sum\n\tinsured or limit of liability<\/li>\n\t<li>The application\n\tof \u2018<u>average\u2019<\/u> which is used to combat under-insurance: <br>\n\t<\/li>\n<\/ul>\n\n<p>The\nexample below shows the standard formula for calculating <U>average<\/U>\nin <b>our<\/b> policies:<\/p>\n\n\n<p>\n\t<table style=\"text-align: center\">\n\t\t<tr>\n\t\t\t<td style=\"padding: 2px 10px;\">Sum Insured<\/td>\n\t\t\t<td rowspan=\"2\" style=\"padding: 2px 10px\"> x Loss<\/td>\n\t\t\t<td rowspan=\"2\" style=\"padding: 2px 10px; padding-right: 40px\">i.e.,<\/td>\n\t\t\t<td style=\"padding:2px 10px\">1,000,000<\/td>\n\t\t\t<td rowspan=\"2\" style=\"padding: 2px 10px\"> x 700,000<\/td>\n\t\t\t<td rowspan=\"2\" style=\"padding: 2px 10px\">= <strong style=\"padding-left: 20px\">560,000<\/strong><\/td>\n\t\t<\/tr>\n\t\t<tr>\n\t\t\t<td style=\"padding:2px 10px; border-top: 2px solid #000\">Value at Risk<\/td>\n\t\t\t<td style=\"padding:2px 10px; border-top: 2px solid #000\">1,250,000<\/td>\n\t\t<\/tr>\n\t<\/table>\n<\/p>\n\n<p>In\nthe example above, the Insurer only pays 80% of the claim due to the\nSum Insured not being a complete reflection of the property\u2019s Value\nat Risk, and as indicated prior, this is usually the consequence of\nundervaluing property when entering insurance. Therefore, to ensure\nyour coverage and settlement is adequate, Gulf Insurance Ltd implores\nyou to value your property with a professional valuation or appraisal\nat regular intervals, especially if improvements are done. \n<\/p>\n\n<p><i><b>*Insurers\nnormally accept 85% of the current value as full insurance and\nconsider this sum as adequate for the sum insured; however, this\ncondition is subject to decisions made by Gulf Insurance\u2019s\nmanagement.<\/b><\/i><\/p>\n<\/li><li id=\"field_100_6065\"  class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_hidden\"  data-js-reload=\"field_100_6065\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label gfield_label_before_complex'  >I have read and understood<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input autocomplete=\"off\"  name='input_6065.1' id='input_100_6065_1' type='checkbox' value='1' tabindex='104'  aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_100_6065_1' >I have read and understood<span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/label><input autocomplete=\"off\"  type='hidden' name='input_6065.2' value='I have read and understood' class='gform_hidden' \/><input autocomplete=\"off\"  type='hidden' name='input_6065.3' value='91' class='gform_hidden' \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_100_529' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous' tabindex='105' onclick='jQuery(\"#gform_target_page_number_100\").val(\"1\");  jQuery(\"#gform_100\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_100\").val(\"1\");  jQuery(\"#gform_100\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_100_529' class='gform_next_button gform-theme-button button' value='Next' tabindex='106' onclick='jQuery(\"#gform_target_page_number_100\").val(\"3\");  jQuery(\"#gform_100\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_100\").val(\"3\");  jQuery(\"#gform_100\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_100_3' class='gform_page' data-js='page-field-id-529' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_100_3' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_100_21\"  class=\"gfield gfield--type-html gfield_html gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_21\"><style>\ndiv.parent{ \n    \n    display:table;\n    padding:5px; \n    width:100%;\n    margin:70px 0; \n}\ndiv.text{ \n    vertical-align:middle;\n    display:table-cell;\n    text-align:justify;\n}\ndiv.parent .img{\n    vertical-align:middle;\n    display:table-cell;\n    padding-right:5px;\n    width:100px; \/* you can change width *\/\n}\ndiv.img img{ \n    width:100%;\n    height:100px; \/* you can change height *\/\n    vertical-align:middle;\n}<\/style>\n<div class=\"parent\">\n    <div class=\"img\"><img decoding=\"async\" src=\"https:\/\/gulfinsuranceltd.com\/forms\/wp-content\/uploads\/2020\/02\/Insured-Details.png\" \/><\/div>\n    <div class=\"text\">CLIENT'S DETAILS.<\/div>\n<\/div>\n<\/li><li id=\"field_100_745\"  class=\"gfield gfield--type-radio gfield--type-choice gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_745\"><label class='gfield_label gform-field-label'  >Are you the current Policy Holder?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_100_745'>\n\t\t\t<li class='gchoice gchoice_100_745_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_745' type='radio' value='Yes'  id='choice_100_745_0' tabindex='107'   \/>\n\t\t\t\t<label for='choice_100_745_0' id='label_100_745_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_100_745_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_745' type='radio' value='No'  id='choice_100_745_1' tabindex='108'   \/>\n\t\t\t\t<label for='choice_100_745_1' id='label_100_745_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_100_22\"  class=\"gfield gfield--type-select salutation gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_22\"><label class='gfield_label gform-field-label' for='input_100_22' >Salutation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_22' id='input_100_22' class='large gfield_select' tabindex='109'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Title<\/option><option value='Mr.' >Mr.<\/option><option value='Miss.' >Miss.<\/option><option value='Mrs.' >Mrs.<\/option><option value='Dr.' >Dr.<\/option><\/select><\/div><\/li><li id=\"field_100_549\"  class=\"gfield gfield--type-text first-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_549\"><label class='gfield_label gform-field-label' for='input_100_549' >First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_549' id='input_100_549' type='text' value='' class='large'   tabindex='110' placeholder='First Name' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_100_550\"  class=\"gfield gfield--type-text last-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_550\"><label class='gfield_label gform-field-label' for='input_100_550' >Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_550' id='input_100_550' type='text' value='' class='large'   tabindex='111' placeholder='Last Name' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_100_12\"  class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_12\"><label class='gfield_label gform-field-label' for='input_100_12' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_12' id='input_100_12' type='text' value='' class='medium'   tabindex='112' placeholder='Address 1' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_100_17\"  class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_17\"><label class='gfield_label gform-field-label' for='input_100_17' >Town\/City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_17' id='input_100_17' type='text' value='' class='medium'   tabindex='113' placeholder='Town\/City' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_100_18\"  class=\"gfield gfield--type-select gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_18\"><label class='gfield_label gform-field-label' for='input_100_18' >Country<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_18' id='input_100_18' class='medium gfield_select' tabindex='114'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Country<\/option><option value='Anguilla' >Anguilla<\/option><option value='British Virgin Islands' >British Virgin Islands<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Grenada' >Grenada<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='St. Vincent' >St. Vincent<\/option><option value='St. Maarten' >St. Maarten<\/option><option value='St. Kitts &amp; Nevis' >St. Kitts &amp; Nevis<\/option><option value='-----------------' >-----------------<\/option><option value='Afghanistan' >Afghanistan<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darrussalam' >Brunei Darrussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/li><li id=\"field_100_10\"  class=\"gfield gfield--type-phone gf_left_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_10\"><label class='gfield_label gform-field-label' for='input_100_10' >Contact No.<\/label><div class='ginput_container ginput_container_phone'><input autocomplete=\"off\"  name='input_10' id='input_100_10' type='tel' value='' class='large' tabindex='115' placeholder='Contact No.'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_100_11\"  class=\"gfield gfield--type-email gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_11\"><label class='gfield_label gform-field-label' for='input_100_11' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input autocomplete=\"off\"  name='input_11' id='input_100_11' type='email' value='' class='medium' tabindex='116'  placeholder='Email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_100_768\"  class=\"gfield gfield--type-html clr 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_100_768\"><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_100_552' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous' tabindex='117' onclick='jQuery(\"#gform_target_page_number_100\").val(\"2\");  jQuery(\"#gform_100\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_100\").val(\"2\");  jQuery(\"#gform_100\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_100_552' class='gform_next_button gform-theme-button button' value='Next' tabindex='118' onclick='jQuery(\"#gform_target_page_number_100\").val(\"4\");  jQuery(\"#gform_100\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_100\").val(\"4\");  jQuery(\"#gform_100\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_100_4' class='gform_page' data-js='page-field-id-552' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_100_4' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_100_6078\"  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_100_6078\"><strong>Additional Questions : Motor<\/strong><\/li><li id=\"field_100_6090\"  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_100_6090\"><strong>Additional Questions : Property<\/strong><\/li><li id=\"field_100_6086\"  class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_6086\"><label class='gfield_label gform-field-label' for='input_100_6086' >What is the primary use of the vehicle<\/label><div class='ginput_container ginput_container_select'><select name='input_6086' id='input_100_6086' class='medium gfield_select' tabindex='119'    aria-invalid=\"false\" ><option value='Business' >Business<\/option><option value='Hire' >Hire<\/option><option value='Other' >Other<\/option><option value='Pleasure' >Pleasure<\/option><option value='Rental' >Rental<\/option><option value='Work to Own' >Work to Own<\/option><\/select><\/div><\/li><li id=\"field_100_6087\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_6087\"><label class='gfield_label gform-field-label'  >Were there any modifications done to the vehicle?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_100_6087'>\n\t\t\t<li class='gchoice gchoice_100_6087_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_6087' type='radio' value='Yes'  id='choice_100_6087_0' tabindex='120'   \/>\n\t\t\t\t<label for='choice_100_6087_0' id='label_100_6087_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_100_6087_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_6087' type='radio' value='No'  id='choice_100_6087_1' tabindex='121'   \/>\n\t\t\t\t<label for='choice_100_6087_1' id='label_100_6087_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_100_6092\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_6092\"><label class='gfield_label gform-field-label'  >Is this property likely to be unoccupied for more than 30 consecutive days in any give year?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_100_6092'>\n\t\t\t<li class='gchoice gchoice_100_6092_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_6092' type='radio' value='Yes'  id='choice_100_6092_0' tabindex='122'   \/>\n\t\t\t\t<label for='choice_100_6092_0' id='label_100_6092_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_100_6092_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_6092' type='radio' value='No'  id='choice_100_6092_1' tabindex='123'   \/>\n\t\t\t\t<label for='choice_100_6092_1' id='label_100_6092_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_100_6088\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_6088\"><label class='gfield_label gform-field-label'  >Will the vehicle be stored in a locked garage?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_100_6088'>\n\t\t\t<li class='gchoice gchoice_100_6088_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_6088' type='radio' value='Yes'  id='choice_100_6088_0' tabindex='124'   \/>\n\t\t\t\t<label for='choice_100_6088_0' id='label_100_6088_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_100_6088_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_6088' type='radio' value='No'  id='choice_100_6088_1' tabindex='125'   \/>\n\t\t\t\t<label for='choice_100_6088_1' id='label_100_6088_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_100_6093\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_6093\"><label class='gfield_label gform-field-label'  >Is the property used solely for residential purposes?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_100_6093'>\n\t\t\t<li class='gchoice gchoice_100_6093_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_6093' type='radio' value='Yes'  id='choice_100_6093_0' tabindex='126'   \/>\n\t\t\t\t<label for='choice_100_6093_0' id='label_100_6093_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_100_6093_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_6093' type='radio' value='No'  id='choice_100_6093_1' tabindex='127'   \/>\n\t\t\t\t<label for='choice_100_6093_1' id='label_100_6093_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_100_6089\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_6089\"><label class='gfield_label gform-field-label'  >Do you require roadside assistant?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_100_6089'>\n\t\t\t<li class='gchoice gchoice_100_6089_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_6089' type='radio' value='Yes'  id='choice_100_6089_0' tabindex='128'   \/>\n\t\t\t\t<label for='choice_100_6089_0' id='label_100_6089_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_100_6089_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_6089' type='radio' value='No'  id='choice_100_6089_1' tabindex='129'   \/>\n\t\t\t\t<label for='choice_100_6089_1' id='label_100_6089_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_100_6094\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_6094\"><label class='gfield_label gform-field-label'  >Is the building occupied solely by you and your family?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_100_6094'>\n\t\t\t<li class='gchoice gchoice_100_6094_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_6094' type='radio' value='Yes'  id='choice_100_6094_0' tabindex='130'   \/>\n\t\t\t\t<label for='choice_100_6094_0' id='label_100_6094_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_100_6094_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_6094' type='radio' value='No'  id='choice_100_6094_1' tabindex='131'   \/>\n\t\t\t\t<label for='choice_100_6094_1' id='label_100_6094_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_100_6096\"  class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_6096\"><label class='gfield_label gform-field-label' for='input_100_6096' >With respect to the Average Clause outlined previously, please confirm the sum insured \/ property value :<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_6096' id='input_100_6096' type='text' value='' class='medium'   tabindex='132'   aria-invalid=\"false\"   \/> <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_100_6083' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous' tabindex='133' onclick='jQuery(\"#gform_target_page_number_100\").val(\"3\");  jQuery(\"#gform_100\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_100\").val(\"3\");  jQuery(\"#gform_100\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_100_6083' class='gform_next_button gform-theme-button button' value='Next' tabindex='134' onclick='jQuery(\"#gform_target_page_number_100\").val(\"5\");  jQuery(\"#gform_100\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_100\").val(\"5\");  jQuery(\"#gform_100\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_100_5' class='gform_page' data-js='page-field-id-6083' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_100_5' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_100_6084\"  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_100_6084\"><strong>Policy Terms and Conditions<\/strong><\/li><li id=\"field_100_6082\"  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_100_6082\">By signing or printing my name, I agree that this signature will be an electronic representation of my signature for all purposes when I use them on this document, just the same as a wet ink signature on paper.<\/li><li id=\"field_100_6077\"  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_100_6077\">I hereby confirm that prior to entering into the insurance contract, I was clearly informed in writing by the Insurer of the nature and effect of the average provision contained in the Home Protection Policy, including whether the provision is based on indemnity or on replacement value of the property that is the subject matter of the contract.<\/li><li id=\"field_100_6080\"  class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gf_left_quarter gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_6080\"><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex'  ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input autocomplete=\"off\"  name='input_6080.1' id='input_100_6080_1' type='checkbox' value='1' tabindex='135'  aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_100_6080_1' >I agree to the privacy policy.<\/label><input autocomplete=\"off\"  type='hidden' name='input_6080.2' value='I agree to the privacy policy.' class='gform_hidden' \/><input autocomplete=\"off\"  type='hidden' name='input_6080.3' value='91' class='gform_hidden' \/><\/div><\/li><li id=\"field_100_6081\"  class=\"gfield gfield--type-signature gf_left gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_6081\"><label class='gfield_label gform-field-label' for='input_100_6081' >Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_100_6081_Container' class='gfield_signature_container ginput_container' style='height:180px; width:500px; ' ><input autocomplete=\"off\"  type='hidden' class='gform_hidden' name='input_100_6081_valid' id='input_100_6081_valid' \/><canvas id='input_100_6081' width='500' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_100_288\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_right_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_100_288\"><label class='gfield_label gform-field-label' for='input_100_288' 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