{"id":6017,"date":"2024-06-18T13:22:38","date_gmt":"2024-06-18T17:22:38","guid":{"rendered":"https:\/\/gulfinsuranceltd.com\/forms\/?page_id=6017"},"modified":"2024-06-18T13:54:31","modified_gmt":"2024-06-18T17:54:31","slug":"update-client-details","status":"publish","type":"page","link":"https:\/\/gulfinsuranceltd.com\/forms\/update-client-details\/","title":{"rendered":"Client Details"},"content":{"rendered":"<p style=\"text-align: center;\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-5148\" src=\"https:\/\/gulfinsuranceltd.com\/forms\/wp-content\/uploads\/2021\/01\/Assuria_TT-logo-with-slogan-01-1-300x117.png\" alt=\"\" width=\"300\" height=\"117\" srcset=\"https:\/\/gulfinsuranceltd.com\/forms\/wp-content\/uploads\/2021\/01\/Assuria_TT-logo-with-slogan-01-1-300x117.png 300w, https:\/\/gulfinsuranceltd.com\/forms\/wp-content\/uploads\/2021\/01\/Assuria_TT-logo-with-slogan-01-1-1024x400.png 1024w, https:\/\/gulfinsuranceltd.com\/forms\/wp-content\/uploads\/2021\/01\/Assuria_TT-logo-with-slogan-01-1.png 1212w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/p>\n<h2 style=\"text-align: center;\">\u00a0Client Details<\/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 transaction-form_wrapper' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_108' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_108' class='transaction-form' action='\/forms\/wp-json\/wp\/v2\/pages\/6017' data-formid='108' novalidate autocomplete=\"off\">\n                        <div class='gform-body gform_body'><ul id='gform_fields_108' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_108_100\"  class=\"gfield gfield--type-select gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_100\"><label class='gfield_label gform-field-label' for='input_108_100' >Branch of Request<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_100' id='input_108_100' class='medium gfield_select' tabindex='108'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Choose the Branch<\/option><option value='Arima' >Arima<\/option><option value='Chaguanas' >Chaguanas<\/option><option value='Port of Spain' >Port of Spain<\/option><option value='San Fernando' >San Fernando<\/option><option value='Tobago' >Tobago<\/option><\/select><\/div><\/li><li id=\"field_108_101\"  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_108_101\"><label class='gfield_label gform-field-label' for='input_108_101' >CSR<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_101' id='input_108_101' class='medium gfield_select' tabindex='109'   aria-required=\"true\" aria-invalid=\"false\" ><option value='Abigail Thoma' >Abigail Thoma<\/option><option value='Anyka Quintin' >Anyka Quintin<\/option><option value='Brianna Nelson' >Brianna Nelson<\/option><option value='Isis Seerattan' >Isis Seerattan<\/option><option value='Nicolette Joseph' >Nicolette Joseph<\/option><\/select><\/div><\/li><li id=\"field_108_102\"  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_108_102\"><label class='gfield_label gform-field-label' for='input_108_102' >CSR<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_102' id='input_108_102' class='medium gfield_select' tabindex='110'   aria-required=\"true\" aria-invalid=\"false\" ><option value='Aartee Daniel' >Aartee Daniel<\/option><option value='Kamani Ramesh' >Kamani Ramesh<\/option><option value='Querida Paul' >Querida Paul<\/option><option value='Sharon George' >Sharon George<\/option><option value='Tianna Weekes' >Tianna Weekes<\/option><\/select><\/div><\/li><li id=\"field_108_103\"  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_108_103\"><label class='gfield_label gform-field-label' for='input_108_103' >CSR<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_108_103' class='medium gfield_select' tabindex='111'   aria-required=\"true\" aria-invalid=\"false\" ><option value='Karen Robinson' >Karen Robinson<\/option><option value='Lee-Anna Thomas' >Lee-Anna Thomas<\/option><option value='Lisa Toolsie' >Lisa Toolsie<\/option><option value='Shamfa Smith-Clarke' >Shamfa Smith-Clarke<\/option><option value='Thai&#039;la Reid-Davies' >Thai&#039;la Reid-Davies<\/option><\/select><\/div><\/li><li id=\"field_108_104\"  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_108_104\"><label class='gfield_label gform-field-label' for='input_108_104' >CSR<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_104' id='input_108_104' class='medium gfield_select' tabindex='112'   aria-required=\"true\" aria-invalid=\"false\" ><option value='Claudia Benjamin-Edwards' >Claudia Benjamin-Edwards<\/option><option value='Darius Hart' >Darius Hart<\/option><option value='Irma De Labastide' >Irma De Labastide<\/option><option value='Sursatee Seepersad' >Sursatee Seepersad<\/option><\/select><\/div><\/li><li id=\"field_108_105\"  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_108_105\"><label class='gfield_label gform-field-label' for='input_108_105' >CSR<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_105' id='input_108_105' class='medium gfield_select' tabindex='113'   aria-required=\"true\" aria-invalid=\"false\" ><option value='Alicia Guy-McNeil' >Alicia Guy-McNeil<\/option><option value='Darah Maynard-Daniel' >Darah Maynard-Daniel<\/option><option value='Denise De Gannes' >Denise De Gannes<\/option><\/select><\/div><\/li><li id=\"field_108_85\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_85\"><label class='gfield_label gform-field-label' for='input_108_85' >Policy 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_85' id='input_108_85' class='medium gfield_select' tabindex='114'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Select a Policy Type<\/option><option value='GEM' >GEM<\/option><option value='ERA' >ERA<\/option><option value='URA' >URA<\/option><option value='EDM' >EDM<\/option><option value='T0' >T0<\/option><option value='TD' >TD<\/option><option value='RAP' >RAP<\/option><option value='TARP' >TARP<\/option><option value='DS' >DS<\/option><option value='PS' >PS<\/option><option value='TT' >TT<\/option><option value='D' >D<\/option><option value='GS' >GS<\/option><\/select><\/div><\/li><li id=\"field_108_7\"  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_108_7\"><label class='gfield_label gform-field-label' for='input_108_7' >Policy No. (If unknown please tick box on the side)<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_7' id='input_108_7' type='text' value='' class='medium'   tabindex='115' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_108_86\"  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_108_86\"><label class='gfield_label gform-field-label' for='input_108_86' >Policy No. (If unknown please tick box on the side)<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_86' id='input_108_86' type='text' value='' class='medium'   tabindex='116' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_108_87\"  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_108_87\"><label class='gfield_label gform-field-label' for='input_108_87' >Policy No. (If unknown please tick box on the side)<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_87' id='input_108_87' type='text' value='' class='medium'   tabindex='117' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_108_88\"  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_108_88\"><label class='gfield_label gform-field-label' for='input_108_88' >Policy No. (If unknown please tick box on the side)<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_88' id='input_108_88' type='text' value='' class='medium'   tabindex='118' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_108_89\"  class=\"gfield gfield--type-text gf_left_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_108_89\"><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_108_89' >Policy No. (If unknown please tick box on the side)<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_89' id='input_108_89' type='text' value='' class='medium'   tabindex='119' placeholder='Policy No.'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_108_108\"  class=\"gfield gfield--type-text gf_left_half gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_108\"><label class='gfield_label gform-field-label' for='input_108_108' >Policy No. (If unknown please tick box on the side)<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_108' id='input_108_108' type='text' value='' class='medium'  aria-describedby=\"gfield_description_108_108\" tabindex='120' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_108_108'>Golden Sunset<\/div><\/li><li id=\"field_108_71\"  class=\"gfield gfield--type-checkbox gfield--type-choice gf_right_half checkboxes field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_71\"><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex'  ><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_108_71'><li class='gchoice gchoice_108_71_1'>\n\t\t\t\t\t\t\t\t<input autocomplete=\"off\"  class='gfield-choice-input' name='input_71.1' type='checkbox'  value='unknown'  id='choice_108_71_1' tabindex='121'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_108_71_1' id='label_108_71_1' class='gform-field-label gform-field-label--type-inline'><\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_108_72\"  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_108_72\"><\/li><li id=\"field_108_1\"  class=\"gfield gfield--type-select salutation field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_1\"><label class='gfield_label gform-field-label' for='input_108_1' >Salutation<\/label><div class='ginput_container ginput_container_select'><select name='input_1' id='input_108_1' class='large gfield_select' tabindex='122'    aria-invalid=\"false\" ><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_108_2\"  class=\"gfield gfield--type-text name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_2\"><label class='gfield_label gform-field-label' for='input_108_2' >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_2' id='input_108_2' type='text' value='' class='large'   tabindex='123' placeholder='First Name' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_108_6\"  class=\"gfield gfield--type-text name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_6\"><label class='gfield_label gform-field-label' for='input_108_6' >Middle Name<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_6' id='input_108_6' type='text' value='' class='large'   tabindex='124' placeholder='Middle Name'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_108_4\"  class=\"gfield gfield--type-text name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_4\"><label class='gfield_label gform-field-label' for='input_108_4' >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_4' id='input_108_4' type='text' value='' class='large'   tabindex='125' placeholder='Last Name' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_108_36\"  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_108_36\"><\/li><li id=\"field_108_94\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_94\"><h2 class=\"gsection_title\">Please update the information below<\/h2><\/li><li id=\"field_108_41\"  class=\"gfield gfield--type-select salutation field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_41\"><label class='gfield_label gform-field-label' for='input_108_41' >Salutation<\/label><div class='ginput_container ginput_container_select'><select name='input_41' id='input_108_41' class='large gfield_select' tabindex='126'    aria-invalid=\"false\" ><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_108_42\"  class=\"gfield gfield--type-text name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_42\"><label class='gfield_label gform-field-label' for='input_108_42' >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_42' id='input_108_42' type='text' value='' class='large'   tabindex='127' placeholder='First Name' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_108_43\"  class=\"gfield gfield--type-text name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_43\"><label class='gfield_label gform-field-label' for='input_108_43' >Middle Name<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_43' id='input_108_43' type='text' value='' class='large'   tabindex='128' placeholder='Middle Name'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_108_44\"  class=\"gfield gfield--type-text name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_44\"><label class='gfield_label gform-field-label' for='input_108_44' >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_44' id='input_108_44' type='text' value='' class='large'   tabindex='129' placeholder='Last Name' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_108_47\"  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_108_47\"><label class='gfield_label gform-field-label' for='input_108_47' >Current Home 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_47' id='input_108_47' type='text' value='' class='medium'   tabindex='130' placeholder='Address 1' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_108_48\"  class=\"gfield gfield--type-text gf_right_half field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_48\"><label class='gfield_label gform-field-label' for='input_108_48' >Current Home Address 2<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_48' id='input_108_48' type='text' value='' class='medium'   tabindex='131' placeholder='Address 2'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_108_49\"  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_108_49\"><label class='gfield_label gform-field-label' for='input_108_49' >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_49' id='input_108_49' type='text' value='' class='medium'   tabindex='132' placeholder='Town\/City' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_108_50\"  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_108_50\"><label class='gfield_label gform-field-label' for='input_108_50' >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_50' id='input_108_50' class='medium gfield_select' tabindex='133'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Country<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/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='Anguilla' >Anguilla<\/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='Cura\u00e7ao' >Cura\u00e7ao<\/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='Grenada' >Grenada<\/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 Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/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_108_45\"  class=\"gfield gfield--type-phone gf_left_third gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_45\"><label class='gfield_label gform-field-label' for='input_108_45' >Mobile No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input autocomplete=\"off\"  name='input_45' id='input_108_45' type='tel' value='' class='large' tabindex='134' placeholder='Mobile No.' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_108_90\"  class=\"gfield gfield--type-phone gf_middle_third field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_108_90\"><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_108_90' >Home No.<\/label><div class='ginput_container ginput_container_phone'><input autocomplete=\"off\"  name='input_90' id='input_108_90' type='tel' value='' class='large' tabindex='135' placeholder='Home No.'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_108_91\"  class=\"gfield gfield--type-phone gf_right_third field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_91\"><label class='gfield_label gform-field-label' for='input_108_91' >Work No.<\/label><div class='ginput_container ginput_container_phone'><input autocomplete=\"off\"  name='input_91' id='input_108_91' type='tel' value='' class='large' tabindex='136' placeholder='Home No.'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_108_98\"  class=\"gfield gfield--type-radio gfield--type-choice gf_left_half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_98\"><label class='gfield_label gform-field-label'  >Is your Mobile # your Whatsapp #<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_108_98'>\n\t\t\t<li class='gchoice gchoice_108_98_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_98' type='radio' value='Yes'  id='choice_108_98_0' tabindex='137'   \/>\n\t\t\t\t<label for='choice_108_98_0' id='label_108_98_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_108_98_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_98' type='radio' value='No'  id='choice_108_98_1' tabindex='138'   \/>\n\t\t\t\t<label for='choice_108_98_1' id='label_108_98_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_108_98_2'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_98' type='radio' value='I don&#039;t have Whatsapp'  id='choice_108_98_2' tabindex='139'   \/>\n\t\t\t\t<label for='choice_108_98_2' id='label_108_98_2' class='gform-field-label gform-field-label--type-inline'>I don't have Whatsapp<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_108_99\"  class=\"gfield gfield--type-phone gf_right_half field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_99\"><label class='gfield_label gform-field-label' for='input_108_99' >Mobile No.<\/label><div class='ginput_container ginput_container_phone'><input autocomplete=\"off\"  name='input_99' id='input_108_99' type='tel' value='' class='large' tabindex='140' placeholder='Mobile No.'  aria-invalid=\"false\" aria-describedby=\"gfield_description_108_99\"  \/><\/div><div class='gfield_description' id='gfield_description_108_99'>Enter the number you can be contacted on Whatsapp<\/div><\/li><li id=\"field_108_46\"  class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_46\"><label class='gfield_label gform-field-label' for='input_108_46' >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_46' id='input_108_46' type='email' value='' class='large' tabindex='141'  placeholder='Email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_108_106\"  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_108_106\"><label class='gfield_label gform-field-label'  >Pep Status:<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_108_106'>\n\t\t\t<li class='gchoice gchoice_108_106_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_106' type='radio' value='Yes'  id='choice_108_106_0' tabindex='142'   \/>\n\t\t\t\t<label for='choice_108_106_0' id='label_108_106_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_108_106_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_106' type='radio' value='No'  id='choice_108_106_1' tabindex='143'   \/>\n\t\t\t\t<label for='choice_108_106_1' id='label_108_106_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><div class='gfield_description' id='gfield_description_108_106'>Politically Exposed Person<\/div><\/li><li id=\"field_108_74\"  class=\"gfield gfield--type-html clr gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_74\"><\/li><li id=\"field_108_35\"  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_108_35\"><\/li><li id=\"field_108_109\"  class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_108_109\"><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_108_109' >Method of Information Collected<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_108_109' class='medium gfield_select' tabindex='144' aria-describedby=\"gfield_description_108_109\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='In House' >In House<\/option><option value='In Person' >In Person<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_108_109'>In House - Email \/ Telephone\n<\/div><\/li><li id=\"field_108_97\"  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_108_97\">For your convenience, all statements and communications from our Company, in the future, may be sent to you via email or Whatsapp messages. If you do not wish to receive such forms of communications, please inform us by sending an email to info@assurialifett.com<\/li><li id=\"field_108_107\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_107\"><label class='gfield_label gform-field-label' for='input_108_107' >General Comments<\/label><div class='ginput_container ginput_container_textarea'><textarea autocomplete=\"off\"  name='input_107' id='input_108_107' class='textarea medium' tabindex='145'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_108_22\"  class=\"gfield gfield--type-radio gfield--type-choice gf_left_third field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_108_22\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label'  >Signature of Policyholder<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_108_22'>\n\t\t\t<li class='gchoice gchoice_108_22_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_22' type='radio' value='Type-in Signature'  id='choice_108_22_0' tabindex='146'   \/>\n\t\t\t\t<label for='choice_108_22_0' id='label_108_22_0' class='gform-field-label gform-field-label--type-inline'>Type-in Signature<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_108_22_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_22' type='radio' value='Digital Signature'  id='choice_108_22_1' tabindex='147'   \/>\n\t\t\t\t<label for='choice_108_22_1' id='label_108_22_1' class='gform-field-label gform-field-label--type-inline'>Digital Signature<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_108_28\"  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_108_28\"><\/li><li id=\"field_108_110\"  class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_108_110\"><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_108_110' >In House Signature<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_110' id='input_108_110' type='text' value='' class='medium'   tabindex='148'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_108_29\"  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_108_29\"><\/li><li id=\"field_108_17\"  class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_108_17\"><label class='gfield_label gform-field-label' for='input_108_17' >Client Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_108_17_Container' class='gfield_signature_container ginput_container' style='height:180px; 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