{"id":6159,"date":"2025-08-11T16:18:15","date_gmt":"2025-08-11T20:18:15","guid":{"rendered":"https:\/\/gulfinsuranceltd.com\/forms\/?page_id=6159"},"modified":"2025-09-22T15:22:38","modified_gmt":"2025-09-22T19:22:38","slug":"client-details-form-v2-0","status":"publish","type":"page","link":"https:\/\/gulfinsuranceltd.com\/forms\/client-details-form-v2-0\/","title":{"rendered":"Client Details Form V2.0"},"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;\">&nbsp;Client Details v2.0<\/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_112' style='display:none'><div id='gf_112' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_112' class='transaction-form' action='\/forms\/wp-json\/wp\/v2\/pages\/6159#gf_112' data-formid='112' novalidate autocomplete=\"off\">\n        <div id='gf_progressbar_wrapper_112' 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'>2<\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_50' style='width:50%;'><span>50%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_112_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><ul id='gform_fields_112' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_112_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_112_85\"><label class='gfield_label gform-field-label' for='input_112_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_112_85' class='medium gfield_select' tabindex='112'   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_112_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_112_7\"><label class='gfield_label gform-field-label' for='input_112_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_112_7' type='text' value='' class='medium'   tabindex='113' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_112_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_112_86\"><label class='gfield_label gform-field-label' for='input_112_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_112_86' type='text' value='' class='medium'   tabindex='114' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_112_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_112_87\"><label class='gfield_label gform-field-label' for='input_112_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_112_87' type='text' value='' class='medium'   tabindex='115' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_112_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_112_88\"><label class='gfield_label gform-field-label' for='input_112_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_112_88' type='text' value='' class='medium'   tabindex='116' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_112_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_112_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_112_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_112_89' type='text' value='' class='medium'   tabindex='117' placeholder='Policy No.'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_112_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_112_108\"><label class='gfield_label gform-field-label' for='input_112_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_112_108' type='text' value='' class='medium'  aria-describedby=\"gfield_description_112_108\" tabindex='118' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_112_108'>Golden Sunset<\/div><\/li><li id=\"field_112_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_112_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_112_71'><li class='gchoice gchoice_112_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_112_71_1' tabindex='119'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_112_71_1' id='label_112_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_112_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_112_72\"><\/li><li id=\"field_112_1\"  class=\"gfield gfield--type-select salutation field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_1\"><label class='gfield_label gform-field-label' for='input_112_1' >Salutation<\/label><div class='ginput_container ginput_container_select'><select name='input_1' id='input_112_1' class='large gfield_select' tabindex='120'    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_112_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_112_2\"><label class='gfield_label gform-field-label' for='input_112_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_112_2' type='text' value='' class='large'   tabindex='121' placeholder='First Name' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_112_6\"  class=\"gfield gfield--type-text name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_6\"><label class='gfield_label gform-field-label' for='input_112_6' >Middle Name<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_6' id='input_112_6' type='text' value='' class='large'   tabindex='122' placeholder='Middle Name'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_112_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_112_4\"><label class='gfield_label gform-field-label' for='input_112_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_112_4' type='text' value='' class='large'   tabindex='123' placeholder='Last Name' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_112_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_112_36\"><\/li><li id=\"field_112_94\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_94\"><h2 class=\"gsection_title\">Please update the information below<\/h2><\/li><li id=\"field_112_41\"  class=\"gfield gfield--type-select salutation field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_41\"><label class='gfield_label gform-field-label' for='input_112_41' >Salutation<\/label><div class='ginput_container ginput_container_select'><select name='input_41' id='input_112_41' class='large gfield_select' tabindex='124'    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_112_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_112_42\"><label class='gfield_label gform-field-label' for='input_112_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_112_42' type='text' value='' class='large'   tabindex='125' placeholder='First Name' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_112_43\"  class=\"gfield gfield--type-text name field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_43\"><label class='gfield_label gform-field-label' for='input_112_43' >Middle Name<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_43' id='input_112_43' type='text' value='' class='large'   tabindex='126' placeholder='Middle Name'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_112_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_112_44\"><label class='gfield_label gform-field-label' for='input_112_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_112_44' type='text' value='' class='large'   tabindex='127' placeholder='Last Name' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_112_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_112_47\"><label class='gfield_label gform-field-label' for='input_112_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_112_47' type='text' value='' class='medium'   tabindex='128' placeholder='Address 1' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_112_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_112_48\"><label class='gfield_label gform-field-label screen-reader-text' for='input_112_48' >Address 2<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_48' id='input_112_48' type='text' value='' class='medium'   tabindex='129' placeholder='Address 2'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_112_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_112_49\"><label class='gfield_label gform-field-label' for='input_112_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_112_49' type='text' value='' class='medium'   tabindex='130' placeholder='Town\/City' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_112_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_112_50\"><label class='gfield_label gform-field-label' for='input_112_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_112_50' class='medium gfield_select' tabindex='131'   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_112_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_112_45\"><label class='gfield_label gform-field-label' for='input_112_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_112_45' type='tel' value='' class='large' tabindex='132' placeholder='Mobile No.' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_112_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_112_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_112_90' >Home No.<\/label><div class='ginput_container ginput_container_phone'><input autocomplete=\"off\"  name='input_90' id='input_112_90' type='tel' value='' class='large' tabindex='133' placeholder='Home No.'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_112_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_112_91\"><label class='gfield_label gform-field-label' for='input_112_91' >Work No.<\/label><div class='ginput_container ginput_container_phone'><input autocomplete=\"off\"  name='input_91' id='input_112_91' type='tel' value='' class='large' tabindex='134' placeholder='Home No.'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_112_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_112_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_112_98'>\n\t\t\t<li class='gchoice gchoice_112_98_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_98' type='radio' value='Yes'  id='choice_112_98_0' tabindex='135'   \/>\n\t\t\t\t<label for='choice_112_98_0' id='label_112_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_112_98_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_98' type='radio' value='No'  id='choice_112_98_1' tabindex='136'   \/>\n\t\t\t\t<label for='choice_112_98_1' id='label_112_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_112_98_2'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_98' type='radio' value='I don&#039;t have Whatsapp'  id='choice_112_98_2' tabindex='137'   \/>\n\t\t\t\t<label for='choice_112_98_2' id='label_112_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_112_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_112_99\"><label class='gfield_label gform-field-label' for='input_112_99' >Mobile No.<\/label><div class='ginput_container ginput_container_phone'><input autocomplete=\"off\"  name='input_99' id='input_112_99' type='tel' value='' class='large' tabindex='138' placeholder='Mobile No.'  aria-invalid=\"false\" aria-describedby=\"gfield_description_112_99\"  \/><\/div><div class='gfield_description' id='gfield_description_112_99'>Enter the number you can be contacted on Whatsapp<\/div><\/li><li id=\"field_112_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_112_46\"><label class='gfield_label gform-field-label' for='input_112_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_112_46' type='email' value='' class='large' tabindex='139'  placeholder='Email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_112_114\"  class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_114\"><label class='gfield_label gform-field-label'  >Are you a resident of Trinidad and Tobago ?<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_112_114'>\n\t\t\t<li class='gchoice gchoice_112_114_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_114' type='radio' value='Yes'  id='choice_112_114_0' tabindex='140'   \/>\n\t\t\t\t<label for='choice_112_114_0' id='label_112_114_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_112_114_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_114' type='radio' value='No'  id='choice_112_114_1' tabindex='141'   \/>\n\t\t\t\t<label for='choice_112_114_1' id='label_112_114_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_112_122\"  class=\"gfield gfield--type-section gsection fatca-start field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_122\"><h2 class=\"gsection_title\">FATCA INFORMATION<\/h2><\/li><li id=\"field_112_120\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_120\"><label class='gfield_label gform-field-label'  >U.S Citizenship of Lawful Permanent Resident : ( Obtain W-9 )<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_112_120'>\n\t\t\t<li class='gchoice gchoice_112_120_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_120' type='radio' value='Yes'  id='choice_112_120_0' tabindex='142'   \/>\n\t\t\t\t<label for='choice_112_120_0' id='label_112_120_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_112_120_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_120' type='radio' value='No'  id='choice_112_120_1' tabindex='143'   \/>\n\t\t\t\t<label for='choice_112_120_1' id='label_112_120_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_112_124\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_124\"><label class='gfield_label gform-field-label'  >U.S. Birth Place:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_112_124'>\n\t\t\t<li class='gchoice gchoice_112_124_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_124' type='radio' value='Yes'  id='choice_112_124_0' tabindex='144'   \/>\n\t\t\t\t<label for='choice_112_124_0' id='label_112_124_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_112_124_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_124' type='radio' value='No'  id='choice_112_124_1' tabindex='145'   \/>\n\t\t\t\t<label for='choice_112_124_1' id='label_112_124_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_112_124'>(Obtain W-9 or W-8BEN; and Non-U.S. Passport or similar documentation establishing foreign citizenship; and written explanation regarding U.S. citizenship)<\/div><\/li><li id=\"field_112_125\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_125\"><label class='gfield_label gform-field-label'  >U.S. Address :<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_112_125'>\n\t\t\t<li class='gchoice gchoice_112_125_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_125' type='radio' value='Yes'  id='choice_112_125_0' tabindex='146'   \/>\n\t\t\t\t<label for='choice_112_125_0' id='label_112_125_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_112_125_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_125' type='radio' value='No'  id='choice_112_125_1' tabindex='147'   \/>\n\t\t\t\t<label for='choice_112_125_1' id='label_112_125_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_112_125'>( Residence, correspondence, or P.O. Box): (Obtain W-9 or W-8BEN; and Non-U.S. passport or similar documentation establishing citizenship )<\/div><\/li><li id=\"field_112_126\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_126\"><label class='gfield_label gform-field-label'  >Instructions to transfer funds to U.S. account or directions regularly received from a U.S. address :<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_112_126'>\n\t\t\t<li class='gchoice gchoice_112_126_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_126' type='radio' value='Yes'  id='choice_112_126_0' tabindex='148'   \/>\n\t\t\t\t<label for='choice_112_126_0' id='label_112_126_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_112_126_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_126' type='radio' value='No'  id='choice_112_126_1' tabindex='149'   \/>\n\t\t\t\t<label for='choice_112_126_1' id='label_112_126_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_112_126'>( Obtain W-9 or W-8BEN; and documentary evidence establishing Non-U.S. status )<\/div><\/li><li id=\"field_112_127\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_127\"><label class='gfield_label gform-field-label'  >Only if address on file is &quot;in care of&quot; or &quot;hold mail&quot; or U.S. P.O. Box; Notice 2011-34 excludes foreign P.O. Box as U.S. Indicia:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_112_127'>\n\t\t\t<li class='gchoice gchoice_112_127_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_127' type='radio' value='Yes'  id='choice_112_127_0' tabindex='150'   \/>\n\t\t\t\t<label for='choice_112_127_0' id='label_112_127_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_112_127_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_127' type='radio' value='No'  id='choice_112_127_1' tabindex='151'   \/>\n\t\t\t\t<label for='choice_112_127_1' id='label_112_127_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_112_127'>( Obtain W-9 or W-8BEN; and documentary evidence establishing Non-U.S. status )<\/div><\/li><li id=\"field_112_128\"  class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_128\"><label class='gfield_label gform-field-label'  >Power of Attorney or Signatory Authority granted to person with U.S. address:<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_112_128'>\n\t\t\t<li class='gchoice gchoice_112_128_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_128' type='radio' value='Yes'  id='choice_112_128_0' tabindex='152'   \/>\n\t\t\t\t<label for='choice_112_128_0' id='label_112_128_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_112_128_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_128' type='radio' value='No'  id='choice_112_128_1' tabindex='153'   \/>\n\t\t\t\t<label for='choice_112_128_1' id='label_112_128_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_112_128'>( Obtain W-9 or W-8BEN; and documentary evidence establishing Non-U.S. status )<\/div><\/li><li id=\"field_112_123\"  class=\"gfield gfield--type-section gsection fatca-end field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_123\"><h2 class=\"gsection_title\">Additional Information<\/h2><\/li><li id=\"field_112_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_112_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_112_106'>\n\t\t\t<li class='gchoice gchoice_112_106_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_106' type='radio' value='Yes'  id='choice_112_106_0' tabindex='154'   \/>\n\t\t\t\t<label for='choice_112_106_0' id='label_112_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_112_106_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_106' type='radio' value='No'  id='choice_112_106_1' tabindex='155'   \/>\n\t\t\t\t<label for='choice_112_106_1' id='label_112_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_112_106'>Politically Exposed Person<\/div><\/li><li id=\"field_112_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_112_74\"><\/li><li id=\"field_112_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_112_35\"><\/li><li id=\"field_112_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_112_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_112_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_112_109' class='medium gfield_select' tabindex='156' aria-describedby=\"gfield_description_112_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_112_109'>In House - Email \/ Telephone\n<\/div><\/li><li id=\"field_112_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_112_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_112_107\"  class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_107\"><label class='gfield_label gform-field-label' for='input_112_107' >General Comments<\/label><div class='ginput_container ginput_container_textarea'><textarea autocomplete=\"off\"  name='input_107' id='input_112_107' class='textarea medium' tabindex='157'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_112_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_112_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_112_22'>\n\t\t\t<li class='gchoice gchoice_112_22_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_22' type='radio' value='Type-in Signature'  id='choice_112_22_0' tabindex='158'   \/>\n\t\t\t\t<label for='choice_112_22_0' id='label_112_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_112_22_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_22' type='radio' value='Digital Signature'  id='choice_112_22_1' tabindex='159'   \/>\n\t\t\t\t<label for='choice_112_22_1' id='label_112_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_112_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_112_28\"><\/li><li id=\"field_112_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_112_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_112_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_112_110' type='text' value='' class='medium'   tabindex='160'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_112_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_112_29\"><\/li><li id=\"field_112_130\"  class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_130\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Consent<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_130.1' id='input_112_130_1' type='checkbox' value='1' tabindex='161'  aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_112_130_1' >I confirm that all the above statements are true, accurate and complete. I hereby consent to the disclosure of the above information or details of any transaction related thereto, to any third party as may be required by LAW.<\/label><input autocomplete=\"off\"  type='hidden' name='input_130.2' value='I confirm that all the above statements are true, accurate and complete. I hereby consent to the disclosure of the above information or details of any transaction related thereto, to any third party as may be required by LAW.' class='gform_hidden' \/><input autocomplete=\"off\"  type='hidden' name='input_130.3' value='95' class='gform_hidden' \/><\/div><\/li><li id=\"field_112_131\"  class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_131\"><label class='gfield_label gform-field-label' for='input_112_131' >Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_112_131_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><input autocomplete=\"off\"  type='hidden' class='gform_hidden' name='input_112_131_valid' id='input_112_131_valid' \/><canvas id='input_112_131' width='600' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_112_119\"  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_112_119\"><div style=\"\n    border: 2px solid #0073e6;\n    background-color: #eaf5ff;\n    padding: 20px;\n    margin-top: 25px;\n    border-radius: 8px;\n    text-align: center;\n    font-size: 1.1em;\n    line-height: 1.6;\n\">\n    <strong style=\"display: block; margin-bottom: 10px; font-size: 1.2em;\">Action Required<\/strong>\n    Please re-check that all your information is correct.\n    <br>\n    When you are finished, return the tablet to the representative to complete the form.\n<\/div><\/li><li id=\"field_112_121\"  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_112_121\"><style>\n\/* This style for the wrapper is still correct. *\/\n.fatca-wrapper {\n    background-color: #f5f5f5;\n    border-radius: 8px;\n    padding: 25px;\n    margin-top: 20px;\n    margin-bottom: 20px;\n}\n<\/style>\n\n<script type=\"text\/javascript\">\n    jQuery(document).on('gform_post_render', function(event, formId) {\n        \n        \/\/ Only run on your specific form\n        if (formId == 112) {\n            \n            \/\/ --- CONFIGURATION ---\n            \/\/ This is the radio button group that controls the logic.\n            \/\/ 'input_114' corresponds to your \"Are you a resident...\" question.\n            const conditionQuestionName = 'input_114'; \n            const startMarkerSelector = '.fatca-start';\n            const endMarkerSelector = '.fatca-end';\n            const wrapperClass = 'fatca-wrapper';\n            const wrapperSelector = '.' + wrapperClass;\n\n            \/\/ This is the main function that builds or removes the grey box\n            function updateFatcaContainer() {\n                \/\/ Find out if \"Yes\" or \"No\" is currently checked\n                const selectedValue = jQuery('input[name=\"' + conditionQuestionName + '\"]:checked').val();\n                \n                \/\/ --- ACTION: SHOW the container ---\n                \/\/ If the selected answer is \"No\"...\n                if (selectedValue === 'No') {\n                    const startMarker = jQuery(startMarkerSelector);\n                    \/\/ ...and if the container doesn't already exist...\n                    if (startMarker.length && jQuery(wrapperSelector).length === 0) {\n                        \/\/ ...then build the wrapper and move the fields into it.\n                        const wrapper = jQuery('<div class=\"' + wrapperClass + '\"><\/div>');\n                        startMarker.before(wrapper);\n                        let currentElement = startMarker;\n                        while (currentElement.length && !currentElement.hasClass(endMarkerSelector.substring(1))) {\n                            let nextElement = currentElement.next();\n                            wrapper.append(currentElement);\n                            currentElement = nextElement;\n                        }\n                    }\n                } \n                \/\/ --- ACTION: HIDE the container ---\n                \/\/ If the answer is \"Yes\" or anything else...\n                else {\n                    const existingWrapper = jQuery(wrapperSelector);\n                    \/\/ ...and if the container currently exists...\n                    if (existingWrapper.length) {\n                        \/\/ ...then move the fields back out and remove the empty wrapper.\n                        existingWrapper.contents().insertBefore(existingWrapper);\n                        existingWrapper.remove();\n                    }\n                }\n            }\n\n            \/\/ --- TRIGGERS ---\n\n            \/\/ 1. Run the function once when the form first loads to set the correct initial state.\n            updateFatcaContainer();\n\n            \/\/ 2. Attach a listener that runs the function every time the user clicks on the Yes\/No question.\n            jQuery(document).on('change', 'input[name=\"' + conditionQuestionName + '\"]', updateFatcaContainer);\n        }\n    });\n<\/script><\/li><\/ul>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_112_118' class='gform_next_button gform-theme-button button' value='Next' tabindex='162' onclick='jQuery(\"#gform_target_page_number_112\").val(\"2\");  jQuery(\"#gform_112\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_112\").val(\"2\");  jQuery(\"#gform_112\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_112_2' class='gform_page' data-js='page-field-id-118' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_112_2' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_112_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_112_100\"><label class='gfield_label gform-field-label' for='input_112_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_112_100' class='medium gfield_select' tabindex='163'   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_112_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_112_101\"><label class='gfield_label gform-field-label' for='input_112_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_112_101' class='medium gfield_select' tabindex='164'   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_112_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_112_102\"><label class='gfield_label gform-field-label' for='input_112_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_112_102' class='medium gfield_select' tabindex='165'   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_112_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_112_103\"><label class='gfield_label gform-field-label' for='input_112_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_112_103' class='medium gfield_select' tabindex='166'   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_112_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_112_104\"><label class='gfield_label gform-field-label' for='input_112_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_112_104' class='medium gfield_select' tabindex='167'   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_112_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_112_105\"><label class='gfield_label gform-field-label' for='input_112_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_112_105' class='medium gfield_select' tabindex='168'   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_112_133\"  class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_133\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Consent<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_133.1' id='input_112_133_1' type='checkbox' value='1' tabindex='169'  aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_112_133_1' >Acknowledgement that the Policyholder\/Premium Payor signed the checklist in the presence of an Authorised Company Representative.<\/label><input autocomplete=\"off\"  type='hidden' name='input_133.2' value='Acknowledgement that the Policyholder\/Premium Payor signed the checklist in the presence of an Authorised Company Representative.' class='gform_hidden' \/><input autocomplete=\"off\"  type='hidden' name='input_133.3' value='95' class='gform_hidden' \/><\/div><\/li><li id=\"field_112_111\"  class=\"gfield gfield--type-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_111\"><label class='gfield_label gform-field-label' for='input_112_111' >Company Representative Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_112_111_Container' class='gfield_signature_container ginput_container' style='height:180px; width:700px; ' ><input autocomplete=\"off\"  type='hidden' class='gform_hidden' name='input_112_111_valid' id='input_112_111_valid' \/><canvas id='input_112_111' width='700' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_112_132\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_112_132\"><label class='gfield_label gform-field-label gfield_label_before_complex'  >Document Checklist<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_112_132'><li class='gchoice gchoice_112_132_1'>\n\t\t\t\t\t\t\t\t<input autocomplete=\"off\"  class='gfield-choice-input' name='input_132.1' type='checkbox'  value='Notarised Passport'  id='choice_112_132_1' tabindex='170'  aria-describedby=\"gfield_description_112_132\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_112_132_1' id='label_112_132_1' class='gform-field-label gform-field-label--type-inline'>Notarised Passport<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_112_132_2'>\n\t\t\t\t\t\t\t\t<input autocomplete=\"off\"  class='gfield-choice-input' name='input_132.2' type='checkbox'  value='Completed W-9 or W-8BEN Form'  id='choice_112_132_2' tabindex='171'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_112_132_2' id='label_112_132_2' class='gform-field-label gform-field-label--type-inline'>Completed W-9 or W-8BEN 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