{"id":108,"date":"2020-09-09T12:17:34","date_gmt":"2020-09-09T17:17:34","guid":{"rendered":"http:\/\/marcusagent.com\/?page_id=108"},"modified":"2021-10-26T17:11:29","modified_gmt":"2021-10-26T22:11:29","slug":"commercial-property","status":"publish","type":"page","link":"https:\/\/marcusagent.com\/commercial-property\/","title":{"rendered":"Commercial Property Questionnaire"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"108\" class=\"elementor elementor-108\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-323855b4 elementor-section-height-min-height elementor-section-items-bottom elementor-section-boxed elementor-section-height-default\" data-id=\"323855b4\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-6a4d8567\" data-id=\"6a4d8567\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-ac3226d elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"ac3226d\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-db5ead2\" data-id=\"db5ead2\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-453ca3f elementor-widget elementor-widget-text-editor\" data-id=\"453ca3f\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<p><a href=\"https:\/\/marcusagent.com\/wp-content\/uploads\/2021\/01\/Lighthouse_Insurance_Agency_Commercial-Property-App-1-1.pdf\"><strong>Prefer to fill out by hand? Click here to download a printable version<\/strong><\/a><\/p>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-3280910 uael-gf-ajax-yes uael-gf-check-yes uael-gf-style-box uael-gf-input-size-sm uael-gf-button-left uael-gf-btn-size-sm elementor-widget elementor-widget-uael-gf-styler\" data-id=\"3280910\" data-element_type=\"widget\" data-widget_type=\"uael-gf-styler.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class=\"uael-gf-style uael-gf-check-style elementor-clickable\">\n\t<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_unknown gform_wrapper gravity-theme gform-theme--no-framework gf_stylespro_wrapper sp_flat_wrapper' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_3' style='display:none'><div id='gf_3' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_3' id='gform_3' class=' gf_stylespro sp_flat' action='\/wp-json\/wp\/v2\/pages\/108#gf_3' data-formid='3' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6Ldp8PYcAAAAAINtibmU-8VaOxIEUjlWW9EpdmEj' data-tabindex='1'><input id=\"input_254475cdb88ecb567660fd9e2f4750d0\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_254475cdb88ecb567660fd9e2f4750d0\" value=\"\"\/><\/div>\n                        <div class='gform-body gform_body'><div id='gform_fields_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_3_82\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third_two gf_left o_medium\"  data-field-class=\"gf_third_two gf_left o_medium\" data-js-reload=\"field_3_82\" ><label class='gfield_label gform-field-label' for='input_3_82'>Business Name<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_3_82' type='text' value='' class='small'   tabindex='2'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_84\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third gf_right o_medium\"  data-field-class=\"gf_third gf_right o_medium\" data-js-reload=\"field_3_84\" ><label class='gfield_label gform-field-label' for='input_3_84'>DBA<\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_3_84' type='text' value='' class='small'   tabindex='3'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_83\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third gf_left o_medium\"  data-field-class=\"gf_third gf_left o_medium\" data-js-reload=\"field_3_83\" ><label class='gfield_label gform-field-label' for='input_3_83'>Federal Tax ID Number<\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_3_83' type='text' value='' class='small'   tabindex='4'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_120\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" data-js-reload=\"field_3_120\" ><label class='gfield_label gform-field-label' for='input_3_120'>Year Established<\/label><div class='ginput_container ginput_container_text'><input name='input_120' id='input_3_120' type='text' value='' class='small'   tabindex='5'   aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_3_85\" class=\"gfield gfield--type-date gfield--input-type-datefield field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third gf_right o_medium\"  data-field-class=\"gf_third gf_right o_medium\" data-js-reload=\"field_3_85\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Coverage Effective Date<\/legend><div id='input_3_85' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_3_85_1_container'>\n                                            <input type='number' maxlength='2' name='input_85[]' id='input_3_85_1' value='' tabindex='6'  aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_3_85_1' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Month<\/label>\n                                        <\/div><div class='gfield_date_day ginput_container ginput_container_date gform-grid-col' id='input_3_85_2_container'>\n                                            <input type='number' maxlength='2' name='input_85[]' id='input_3_85_2' value='' tabindex='7'  aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_3_85_2' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Day<\/label>\n                                        <\/div><div class='gfield_date_year ginput_container ginput_container_date gform-grid-col' id='input_3_85_3_container'>\n                                            <input type='number' maxlength='4' name='input_85[]' id='input_3_85_3' value='' tabindex='8'  aria-required='false'   placeholder='YYYY' min='1920' max='2025' step='1'\/>\n                                            <label for='input_3_85_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><fieldset id=\"field_3_11\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_left gf_list_5col gfsp_dot o_small\"  data-field-class=\"gf_left gf_list_5col gfsp_dot o_small\" data-js-reload=\"field_3_11\" ><legend class='gfield_label gform-field-label' >Business Entity<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_11'>\n\t\t\t<div class='gchoice gchoice_3_11_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Individual'  id='choice_3_11_0' onchange='gformToggleRadioOther( this )'  tabindex='9'  \/>\n\t\t\t\t\t<label for='choice_3_11_0' id='label_3_11_0' class='gform-field-label gform-field-label--type-inline'>Individual<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_11_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Corporation'  id='choice_3_11_1' onchange='gformToggleRadioOther( this )'  tabindex='10'  \/>\n\t\t\t\t\t<label for='choice_3_11_1' id='label_3_11_1' class='gform-field-label gform-field-label--type-inline'>Corporation<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_11_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='LLC'  id='choice_3_11_2' onchange='gformToggleRadioOther( this )'  tabindex='11'  \/>\n\t\t\t\t\t<label for='choice_3_11_2' id='label_3_11_2' class='gform-field-label gform-field-label--type-inline'>LLC<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_11_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='Partnership'  id='choice_3_11_3' onchange='gformToggleRadioOther( this )'  tabindex='12'  \/>\n\t\t\t\t\t<label for='choice_3_11_3' id='label_3_11_3' class='gform-field-label gform-field-label--type-inline'>Partnership<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_11_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_11' type='radio' value='gf_other_choice'  id='choice_3_11_4' onchange='gformToggleRadioOther( this )'  tabindex='13'  \/>\n\t\t\t\t\t<label for='choice_3_11_4' id='label_3_11_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_3_11_other' class='gchoice_other_control' name='input_11_other' type='text' value='Other' aria-label='Other Choice, please specify' tabindex='13' disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_133\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible o_medium\"  data-field-class=\"o_medium\" data-js-reload=\"field_3_133\" ><label class='gfield_label gform-field-label' for='input_3_133'>Mailing\/Billing Address<\/label><div class='ginput_container ginput_container_text'><input name='input_133' id='input_3_133' type='text' value='' class='small'   tabindex='14'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_129\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half o_medium\"  data-field-class=\"gf_half o_medium\" data-js-reload=\"field_3_129\" ><label class='gfield_label gform-field-label' for='input_3_129'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_129' id='input_3_129' type='text' value='' class='small'   tabindex='15'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_130\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half o_medium\"  data-field-class=\"gf_half o_medium\" data-js-reload=\"field_3_130\" ><label class='gfield_label gform-field-label' for='input_3_130'>State<\/label><div class='ginput_container ginput_container_text'><input name='input_130' id='input_3_130' type='text' value='' class='small'   tabindex='16'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_131\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half o_medium\"  data-field-class=\"gf_half o_medium\" data-js-reload=\"field_3_131\" ><label class='gfield_label gform-field-label' for='input_3_131'>ZIP Code<\/label><div class='ginput_container ginput_container_text'><input name='input_131' id='input_3_131' type='text' value='' class='small'   tabindex='17'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_132\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half o_medium\"  data-field-class=\"gf_half o_medium\" data-js-reload=\"field_3_132\" ><label class='gfield_label gform-field-label' for='input_3_132'>Parish<\/label><div class='ginput_container ginput_container_select'><select name='input_132' id='input_3_132' class='small gfield_select' tabindex='18'    aria-invalid=\"false\" ><option value='' >Select...<\/option><option value='Acadia Parish' >Acadia Parish<\/option><option value='Allen Parish' >Allen Parish<\/option><option value='Ascension Parish' >Ascension Parish<\/option><option value='Assumption Parish' >Assumption Parish<\/option><option value='Avoyelles Parish' >Avoyelles Parish<\/option><option value='Beauregard Parish' >Beauregard Parish<\/option><option value='Bienville Parish' >Bienville Parish<\/option><option value='Bossier Parish' >Bossier Parish<\/option><option value='Caddo Parish' >Caddo Parish<\/option><option value='Calcasieu Parish' >Calcasieu Parish<\/option><option value='Caldwell Parish' >Caldwell Parish<\/option><option value='Cameron Parish' >Cameron Parish<\/option><option value='Catahoula Parish' >Catahoula Parish<\/option><option value='Claiborne Parish' >Claiborne Parish<\/option><option value='Concordia Parish' >Concordia Parish<\/option><option value='DeSoto Parish' >DeSoto Parish<\/option><option value='East Baton Rouge Parish' >East Baton Rouge Parish<\/option><option value='East Carroll Parish' >East Carroll Parish<\/option><option value='East Feliciana Parish' >East Feliciana Parish<\/option><option value='Evangeline Parish' >Evangeline Parish<\/option><option value='Franklin Parish' >Franklin Parish<\/option><option value='Grant Parish' >Grant Parish<\/option><option value='Iberia Parish' >Iberia Parish<\/option><option value='Iberville Parish' >Iberville Parish<\/option><option value='Jackson Parish' >Jackson Parish<\/option><option value='Jefferson Parish' >Jefferson Parish<\/option><option value='Jefferson Davis Parish' >Jefferson Davis Parish<\/option><option value='Lafayette Parish' >Lafayette Parish<\/option><option value='Lafourche Parish' >Lafourche Parish<\/option><option value='LaSalle Parish' >LaSalle Parish<\/option><option value='Lincoln Parish' >Lincoln Parish<\/option><option value='Livingston Parish' >Livingston Parish<\/option><option value='Madison Parish' >Madison Parish<\/option><option value='Morehouse Parish' >Morehouse Parish<\/option><option value='Natchitoches Parish' >Natchitoches Parish<\/option><option value='Orleans Parish' >Orleans Parish<\/option><option value='Ouachita Parish' >Ouachita Parish<\/option><option value='Plaquemines Parish' >Plaquemines Parish<\/option><option value='Pointe Coupee Parish' >Pointe Coupee Parish<\/option><option value='Rapides Parish' >Rapides Parish<\/option><option value='Red River Parish' >Red River Parish<\/option><option value='Richland Parish' >Richland Parish<\/option><option value='Sabine Parish' >Sabine Parish<\/option><option value='St. Bernard Parish' >St. Bernard Parish<\/option><option value='St. Charles Parish' >St. Charles Parish<\/option><option value='St. Helena Parish' >St. Helena Parish<\/option><option value='St. James Parish' >St. James Parish<\/option><option value='St. John the Baptist Parish' >St. John the Baptist Parish<\/option><option value='St. Landry Parish' >St. Landry Parish<\/option><option value='St. Martin Parish' >St. Martin Parish<\/option><option value='St. Mary Parish' >St. Mary Parish<\/option><option value='St. Tammany Parish' >St. Tammany Parish<\/option><option value='Tangipahoa Parish' >Tangipahoa Parish<\/option><option value='Tensas Parish' >Tensas Parish<\/option><option value='Terrebonne Parish' >Terrebonne Parish<\/option><option value='Union Parish' >Union Parish<\/option><option value='Vermillion Parish' >Vermillion Parish<\/option><option value='Vernon Parish' >Vernon Parish<\/option><option value='Washington Parish' >Washington Parish<\/option><option value='Webster Parish' >Webster Parish<\/option><option value='West Baton Rouge Parish' >West Baton Rouge Parish<\/option><option value='West Carroll Parish' >West Carroll Parish<\/option><option value='West Feliciana Parish' >West Feliciana Parish<\/option><option value='Winn Parish' >Winn Parish<\/option><\/select><\/div><\/div><fieldset id=\"field_3_25\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third gf_left o_medium\"  data-field-class=\"gf_third gf_left o_medium\" data-js-reload=\"field_3_25\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Contact Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_3_25'>\n                            \n                            <span id='input_3_25_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_25.3' id='input_3_25_3' value='' tabindex='20'  aria-required='false'     \/>\n                                                    <label for='input_3_25_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_3_25_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_25.6' id='input_3_25_6' value='' tabindex='22'  aria-required='false'     \/>\n                                                    <label for='input_3_25_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_3_111\" class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" data-js-reload=\"field_3_111\" ><label class='gfield_label gform-field-label' for='input_3_111'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_111' id='input_3_111' type='email' value='' class='small' tabindex='24'    aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_3_9\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third gf_right o_medium\"  data-field-class=\"gf_third gf_right o_medium\" data-js-reload=\"field_3_9\" ><label class='gfield_label gform-field-label' for='input_3_9'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_3_9' type='tel' value='' class='small' tabindex='25'   aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_3_145\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_145\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Privacy Policy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_3_145'><div class='gchoice gchoice_3_145_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_145.1' type='checkbox'  value='By submitting my phone number, I hereby authorize Lighthouse Insurance Agency LLC to communicate with me through text messaging. View our &lt;a href=&quot;https:\/\/marcusagent.com\/privacy-policy\/&quot; target=&quot;_blank&quot;&gt;Privacy Policy here&lt;\/a&gt;.'  id='choice_3_145_1' tabindex='26'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_3_145_1' id='label_3_145_1' class='gform-field-label gform-field-label--type-inline'>By submitting my phone number, I hereby authorize Lighthouse Insurance Agency LLC to communicate with me through text messaging. View our <a href=\"https:\/\/marcusagent.com\/privacy-policy\/\" target=\"_blank\">Privacy Policy here<\/a>.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_128\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible o_medium\"  data-field-class=\"o_medium\" data-js-reload=\"field_3_128\" ><label class='gfield_label gform-field-label' for='input_3_128'>Location Address<\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_3_128' type='text' value='' class='small'   tabindex='27'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_134\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half o_medium\"  data-field-class=\"gf_half o_medium\" data-js-reload=\"field_3_134\" ><label class='gfield_label gform-field-label' for='input_3_134'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_134' id='input_3_134' type='text' value='' class='small'   tabindex='28'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_135\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half o_medium\"  data-field-class=\"gf_half o_medium\" data-js-reload=\"field_3_135\" ><label class='gfield_label gform-field-label' for='input_3_135'>State<\/label><div class='ginput_container ginput_container_text'><input name='input_135' id='input_3_135' type='text' value='' class='small'   tabindex='29'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_136\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half o_medium\"  data-field-class=\"gf_half o_medium\" data-js-reload=\"field_3_136\" ><label class='gfield_label gform-field-label' for='input_3_136'>ZIP Code<\/label><div class='ginput_container ginput_container_text'><input name='input_136' id='input_3_136' type='text' value='' class='small'   tabindex='30'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_137\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half o_medium\"  data-field-class=\"gf_half o_medium\" data-js-reload=\"field_3_137\" ><label class='gfield_label gform-field-label' for='input_3_137'>Parish<\/label><div class='ginput_container ginput_container_select'><select name='input_137' id='input_3_137' class='small gfield_select' tabindex='31'    aria-invalid=\"false\" ><option value='' >Select...<\/option><option value='Acadia Parish' >Acadia Parish<\/option><option value='Allen Parish' >Allen Parish<\/option><option value='Ascension Parish' >Ascension Parish<\/option><option value='Assumption Parish' >Assumption Parish<\/option><option value='Avoyelles Parish' >Avoyelles Parish<\/option><option value='Beauregard Parish' >Beauregard Parish<\/option><option value='Bienville Parish' >Bienville Parish<\/option><option value='Bossier Parish' >Bossier Parish<\/option><option value='Caddo Parish' >Caddo Parish<\/option><option value='Calcasieu Parish' >Calcasieu Parish<\/option><option value='Caldwell Parish' >Caldwell Parish<\/option><option value='Cameron Parish' >Cameron Parish<\/option><option value='Catahoula Parish' >Catahoula Parish<\/option><option value='Claiborne Parish' >Claiborne Parish<\/option><option value='Concordia Parish' >Concordia Parish<\/option><option value='DeSoto Parish' >DeSoto Parish<\/option><option value='East Baton Rouge Parish' >East Baton Rouge Parish<\/option><option value='East Carroll Parish' >East Carroll Parish<\/option><option value='East Feliciana Parish' >East Feliciana Parish<\/option><option value='Evangeline Parish' >Evangeline Parish<\/option><option value='Franklin Parish' >Franklin Parish<\/option><option value='Grant Parish' >Grant Parish<\/option><option value='Iberia Parish' >Iberia Parish<\/option><option value='Iberville Parish' >Iberville Parish<\/option><option value='Jackson Parish' >Jackson Parish<\/option><option value='Jefferson Parish' >Jefferson Parish<\/option><option value='Jefferson Davis Parish' >Jefferson Davis Parish<\/option><option value='Lafayette Parish' >Lafayette Parish<\/option><option value='Lafourche Parish' >Lafourche Parish<\/option><option value='LaSalle Parish' >LaSalle Parish<\/option><option value='Lincoln Parish' >Lincoln Parish<\/option><option value='Livingston Parish' >Livingston Parish<\/option><option value='Madison Parish' >Madison Parish<\/option><option value='Morehouse Parish' >Morehouse Parish<\/option><option value='Natchitoches Parish' >Natchitoches Parish<\/option><option value='Orleans Parish' >Orleans Parish<\/option><option value='Ouachita Parish' >Ouachita Parish<\/option><option value='Plaquemines Parish' >Plaquemines Parish<\/option><option value='Pointe Coupee Parish' >Pointe Coupee Parish<\/option><option value='Rapides Parish' >Rapides Parish<\/option><option value='Red River Parish' >Red River Parish<\/option><option value='Richland Parish' >Richland Parish<\/option><option value='Sabine Parish' >Sabine Parish<\/option><option value='St. Bernard Parish' >St. Bernard Parish<\/option><option value='St. Charles Parish' >St. Charles Parish<\/option><option value='St. Helena Parish' >St. Helena Parish<\/option><option value='St. James Parish' >St. James Parish<\/option><option value='St. John the Baptist Parish' >St. John the Baptist Parish<\/option><option value='St. Landry Parish' >St. Landry Parish<\/option><option value='St. Martin Parish' >St. Martin Parish<\/option><option value='St. Mary Parish' >St. Mary Parish<\/option><option value='St. Tammany Parish' >St. Tammany Parish<\/option><option value='Tangipahoa Parish' >Tangipahoa Parish<\/option><option value='Tensas Parish' >Tensas Parish<\/option><option value='Terrebonne Parish' >Terrebonne Parish<\/option><option value='Union Parish' >Union Parish<\/option><option value='Vermillion Parish' >Vermillion Parish<\/option><option value='Vernon Parish' >Vernon Parish<\/option><option value='Washington Parish' >Washington Parish<\/option><option value='Webster Parish' >Webster Parish<\/option><option value='West Baton Rouge Parish' >West Baton Rouge Parish<\/option><option value='West Carroll Parish' >West Carroll Parish<\/option><option value='West Feliciana Parish' >West Feliciana Parish<\/option><option value='Winn Parish' >Winn Parish<\/option><\/select><\/div><\/div><div id=\"field_3_87\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_87\" ><label class='gfield_label gform-field-label' for='input_3_87'>Description of Business Operations<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_87' id='input_3_87' class='textarea small' tabindex='32'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_3_88\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_left gf_list_2col gfsp_dot o_medium\"  data-field-class=\"gf_half gf_left gf_list_2col gfsp_dot o_medium\" data-js-reload=\"field_3_88\" ><legend class='gfield_label gform-field-label' >Do you own the building?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_88'>\n\t\t\t<div class='gchoice gchoice_3_88_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='Yes'  id='choice_3_88_0' onchange='gformToggleRadioOther( this )'  tabindex='33'  \/>\n\t\t\t\t\t<label for='choice_3_88_0' id='label_3_88_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_88_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='No'  id='choice_3_88_1' onchange='gformToggleRadioOther( this )'  tabindex='34'  \/>\n\t\t\t\t\t<label for='choice_3_88_1' id='label_3_88_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_90\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_right gf_list_2col gfsp_dot o_medium\"  data-field-class=\"gf_half gf_right gf_list_2col gfsp_dot o_medium\" data-js-reload=\"field_3_90\" ><legend class='gfield_label gform-field-label' >Is the building leased?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_90'>\n\t\t\t<div class='gchoice gchoice_3_90_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='Yes'  id='choice_3_90_0' onchange='gformToggleRadioOther( this )'  tabindex='35'  \/>\n\t\t\t\t\t<label for='choice_3_90_0' id='label_3_90_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_90_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_90' type='radio' value='No'  id='choice_3_90_1' onchange='gformToggleRadioOther( this )'  tabindex='36'  \/>\n\t\t\t\t\t<label for='choice_3_90_1' id='label_3_90_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_89\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_left o_medium\"  data-field-class=\"gf_left o_medium\" data-js-reload=\"field_3_89\" ><label class='gfield_label gform-field-label' for='input_3_89'>Building Value\/Replacement Cost Limit in Dollars<\/label><div class='ginput_container ginput_container_text'><input name='input_89' id='input_3_89' type='text' value='' class='small'   tabindex='37'   aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_3_91\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_newline o_medium\"  data-field-class=\"gf_newline o_medium\" data-js-reload=\"field_3_91\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Landlord Name<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_3_91'>\n                            \n                            <span id='input_3_91_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_91.3' id='input_3_91_3' value='' tabindex='39'  aria-required='false'     \/>\n                                                    <label for='input_3_91_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_3_91_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_91.4' id='input_3_91_4' value='' tabindex='40'  aria-required='false'     \/>\n                                                    <label for='input_3_91_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_3_91_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_91.6' id='input_3_91_6' value='' tabindex='41'  aria-required='false'     \/>\n                                                    <label for='input_3_91_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_3_75\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_75\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Landlord Address<\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_3_75' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_3_75_1_container' >\n                                        <input type='text' name='input_75.1' id='input_3_75_1' value='' tabindex='43'   aria-required='false'    \/>\n                                        <label for='input_3_75_1' id='input_3_75_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_3_75_2_container' >\n                                        <input type='text' name='input_75.2' id='input_3_75_2' value='' tabindex='44'    aria-required='false'   \/>\n                                        <label for='input_3_75_2' id='input_3_75_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_3_75_3_container' >\n                                    <input type='text' name='input_75.3' id='input_3_75_3' value='' tabindex='45'   aria-required='false'    \/>\n                                    <label for='input_3_75_3' id='input_3_75_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_3_75_4_container' >\n                                        <input type='text' name='input_75.4' id='input_3_75_4' value='' tabindex='47'     aria-required='false'    \/>\n                                        <label for='input_3_75_4' id='input_3_75_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_3_75_5_container' >\n                                    <input type='text' name='input_75.5' id='input_3_75_5' value='' tabindex='48'   aria-required='false'    \/>\n                                    <label for='input_3_75_5' id='input_3_75_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_3_75_6_container' >\n                                        <select name='input_75.6' id='input_3_75_6' tabindex='49'  aria-required='false'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/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 Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/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' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/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='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/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' >Eswatini<\/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 Island and McDonald Islands' >Heard Island 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='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/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='Macao' >Macao<\/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 Macedonia' >North Macedonia<\/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='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/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 and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/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' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/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='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/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' selected='selected'>United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/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><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_3_75_6' id='input_3_75_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_3_112\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_left gf_list_2col gfsp_dot o_medium\"  data-field-class=\"gf_half gf_left gf_list_2col gfsp_dot o_medium\" data-js-reload=\"field_3_112\" ><legend class='gfield_label gform-field-label' >Owner Occupied?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_112'>\n\t\t\t<div class='gchoice gchoice_3_112_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='Yes'  id='choice_3_112_0' onchange='gformToggleRadioOther( this )'  tabindex='50'  \/>\n\t\t\t\t\t<label for='choice_3_112_0' id='label_3_112_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_112_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_112' type='radio' value='No'  id='choice_3_112_1' onchange='gformToggleRadioOther( this )'  tabindex='51'  \/>\n\t\t\t\t\t<label for='choice_3_112_1' id='label_3_112_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_144\" class=\"gfield gfield--type-list field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_144\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >List Tenants<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Tenant Type<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Square Ft Occupied<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Rent for Each<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_144_cell1 gform-grid-col' data-label='Tenant Type'><input aria-invalid='false'   aria-label='Tenant Type, Row 1' data-aria-label-template='Tenant Type, Row {0}' type='text' name='input_144[]' value='' tabindex='52'  \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_144_cell2 gform-grid-col' data-label='Square Ft Occupied'><input aria-invalid='false'   aria-label='Square Ft Occupied, Row 1' data-aria-label-template='Square Ft Occupied, Row {0}' type='text' name='input_144[]' value='' tabindex='53'  \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_144_cell3 gform-grid-col' data-label='Rent for Each'><input aria-invalid='false'   aria-label='Rent for Each, Row 1' data-aria-label-template='Rent for Each, Row {0}' type='text' name='input_144[]' value='' tabindex='54'  \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_3_123\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third gf_newline o_medium\"  data-field-class=\"gf_third gf_newline o_medium\" data-js-reload=\"field_3_123\" ><label class='gfield_label gform-field-label' for='input_3_123'>Business Property<\/label><div class='ginput_container ginput_container_text'><input name='input_123' id='input_3_123' type='text' value='' class='small'   tabindex='55'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_93\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" data-js-reload=\"field_3_93\" ><label class='gfield_label gform-field-label' for='input_3_93'>Contents Value<\/label><div class='ginput_container ginput_container_number'><input name='input_93' id='input_3_93' type='text' step='any'   value='' class='small' tabindex='56'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_3_94\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" data-js-reload=\"field_3_94\" ><label class='gfield_label gform-field-label' for='input_3_94'>Business Income Limit\/Loss of Rents<\/label><div class='ginput_container ginput_container_number'><input name='input_94' id='input_3_94' type='number' step='any'   value='' class='small' tabindex='57'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_3_102\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" data-js-reload=\"field_3_102\" ><label class='gfield_label gform-field-label' for='input_3_102'>Roof shape and material<\/label><div class='ginput_container ginput_container_text'><input name='input_102' id='input_3_102' type='text' value='' class='small'   tabindex='58'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_103\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" data-js-reload=\"field_3_103\" ><label class='gfield_label gform-field-label' for='input_3_103'>Square Footage Occupied<\/label><div class='ginput_container ginput_container_number'><input name='input_103' id='input_3_103' type='number' step='any'   value='' class='small' tabindex='59'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_3_104\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third gf_right o_medium\"  data-field-class=\"gf_third gf_right o_medium\" data-js-reload=\"field_3_104\" ><label class='gfield_label gform-field-label' for='input_3_104'>Square Footage of Entire Building<\/label><div class='ginput_container ginput_container_number'><input name='input_104' id='input_3_104' type='number' step='any'   value='' class='small' tabindex='60'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_3_95\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third gf_newline o_medium\"  data-field-class=\"gf_third gf_newline o_medium\" data-js-reload=\"field_3_95\" ><label class='gfield_label gform-field-label' for='input_3_95'>Year Building Was Constructed<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_3_95' type='text' value='' class='small'   tabindex='61'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_105\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" data-js-reload=\"field_3_105\" ><label class='gfield_label gform-field-label' for='input_3_105'>Number of Stories in Building<\/label><div class='ginput_container ginput_container_number'><input name='input_105' id='input_3_105' type='number' step='any'   value='' class='small' tabindex='62'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_3_107\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" data-js-reload=\"field_3_107\" ><label class='gfield_label gform-field-label' for='input_3_107'>What percentage of the building is sprinklered?<\/label><div class='ginput_container ginput_container_number'><input name='input_107' id='input_3_107' type='number' step='any'   value='' class='small' tabindex='63'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_3_110\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_right o_medium\"  data-field-class=\"gf_right o_medium\" data-js-reload=\"field_3_110\" ><label class='gfield_label gform-field-label' for='input_3_110'>Estimated Gross Annual Revenues<\/label><div class='ginput_container ginput_container_number'><input name='input_110' id='input_3_110' type='text' step='any'   value='' class='small' tabindex='64'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_3_124\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_124\" ><h3 class=\"gsection_title\">Property Policy Deductibles:<\/h3><\/div><div id=\"field_3_125\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" data-js-reload=\"field_3_125\" ><label class='gfield_label gform-field-label' for='input_3_125'>Wind\/Hail<\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_3_125' type='text' value='' class='small'   tabindex='65'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_126\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" data-js-reload=\"field_3_126\" ><label class='gfield_label gform-field-label' for='input_3_126'>Named Storm<\/label><div class='ginput_container ginput_container_text'><input name='input_126' id='input_3_126' type='text' value='' class='small'   tabindex='66'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_127\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third o_medium\"  data-field-class=\"gf_third o_medium\" data-js-reload=\"field_3_127\" ><label class='gfield_label gform-field-label' for='input_3_127'>All Other Peril<\/label><div class='ginput_container ginput_container_text'><input name='input_127' id='input_3_127' type='text' value='' class='small'   tabindex='67'   aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_3_101\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter gf_newline gf_left gfsp_dot o_medium\"  data-field-class=\"gf_quarter gf_newline gf_left gfsp_dot o_medium\" data-js-reload=\"field_3_101\" ><legend class='gfield_label gform-field-label' >Construction of Building<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_101'>\n\t\t\t<div class='gchoice gchoice_3_101_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='Joisted Masonry'  id='choice_3_101_0' onchange='gformToggleRadioOther( this )'  tabindex='68'  \/>\n\t\t\t\t\t<label for='choice_3_101_0' id='label_3_101_0' class='gform-field-label gform-field-label--type-inline'>Joisted Masonry<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_101_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='Frame'  id='choice_3_101_1' onchange='gformToggleRadioOther( this )'  tabindex='69'  \/>\n\t\t\t\t\t<label for='choice_3_101_1' id='label_3_101_1' class='gform-field-label gform-field-label--type-inline'>Frame<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_101_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='Masonry Non-Combustible'  id='choice_3_101_2' onchange='gformToggleRadioOther( this )'  tabindex='70'  \/>\n\t\t\t\t\t<label for='choice_3_101_2' id='label_3_101_2' class='gform-field-label gform-field-label--type-inline'>Masonry Non-Combustible<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_101_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_101' type='radio' value='Steel Frame Non-Combustible'  id='choice_3_101_3' onchange='gformToggleRadioOther( this )'  tabindex='71'  \/>\n\t\t\t\t\t<label for='choice_3_101_3' id='label_3_101_3' class='gform-field-label gform-field-label--type-inline'>Steel Frame Non-Combustible<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_109\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter gfsp_dot o_medium\"  data-field-class=\"gf_quarter gfsp_dot o_medium\" data-js-reload=\"field_3_109\" ><legend class='gfield_label gform-field-label' >Does the building have a monitored fire alarm?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_109'>\n\t\t\t<div class='gchoice gchoice_3_109_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='Yes'  id='choice_3_109_0' onchange='gformToggleRadioOther( this )'  tabindex='72'  \/>\n\t\t\t\t\t<label for='choice_3_109_0' id='label_3_109_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_109_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_109' type='radio' value='No'  id='choice_3_109_1' onchange='gformToggleRadioOther( this )'  tabindex='73'  \/>\n\t\t\t\t\t<label for='choice_3_109_1' id='label_3_109_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_108\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter gfsp_dot o_medium\"  data-field-class=\"gf_quarter gfsp_dot o_medium\" data-js-reload=\"field_3_108\" ><legend class='gfield_label gform-field-label' >Does the building have a monitored alarm system?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_108'>\n\t\t\t<div class='gchoice gchoice_3_108_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='Yes'  id='choice_3_108_0' onchange='gformToggleRadioOther( this )'  tabindex='74'  \/>\n\t\t\t\t\t<label for='choice_3_108_0' id='label_3_108_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_108_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_108' type='radio' value='No'  id='choice_3_108_1' onchange='gformToggleRadioOther( this )'  tabindex='75'  \/>\n\t\t\t\t\t<label for='choice_3_108_1' id='label_3_108_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_3_96\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter gf_right gfsp_dot o_medium\"  data-field-class=\"gf_quarter gf_right gfsp_dot o_medium\" data-js-reload=\"field_3_96\" ><legend class='gfield_label gform-field-label' >Any updates to property?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_96'>\n\t\t\t<div class='gchoice gchoice_3_96_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='Yes'  id='choice_3_96_0' onchange='gformToggleRadioOther( this )'  tabindex='76'  \/>\n\t\t\t\t\t<label for='choice_3_96_0' id='label_3_96_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_96_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='No'  id='choice_3_96_1' onchange='gformToggleRadioOther( this )'  tabindex='77'  \/>\n\t\t\t\t\t<label for='choice_3_96_1' id='label_3_96_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_97\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter gf_newline gf_left o_medium\"  data-field-class=\"gf_quarter gf_newline gf_left o_medium\" data-js-reload=\"field_3_97\" ><label class='gfield_label gform-field-label' for='input_3_97'>Update year for wiring<\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_3_97' type='text' value='' class='small'   tabindex='78'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_98\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter o_medium\"  data-field-class=\"gf_quarter o_medium\" data-js-reload=\"field_3_98\" ><label class='gfield_label gform-field-label' for='input_3_98'>Update year for plumbing<\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_3_98' type='text' value='' class='small'   tabindex='79'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_99\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter o_medium\"  data-field-class=\"gf_quarter o_medium\" data-js-reload=\"field_3_99\" ><label class='gfield_label gform-field-label' for='input_3_99'>Update year for roof<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_3_99' type='text' value='' class='small'   tabindex='80'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_100\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter gf_right o_medium\"  data-field-class=\"gf_quarter gf_right o_medium\" data-js-reload=\"field_3_100\" ><label class='gfield_label gform-field-label' for='input_3_100'>Update year for heating<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_3_100' type='text' value='' class='small'   tabindex='81'   aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_3_114\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_list_2col gfsp_dot o_medium\"  data-field-class=\"gf_list_2col gfsp_dot o_medium\" data-js-reload=\"field_3_114\" ><legend class='gfield_label gform-field-label' >Pay in full or payment plan?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_114'>\n\t\t\t<div class='gchoice gchoice_3_114_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='Pay in full'  id='choice_3_114_0' onchange='gformToggleRadioOther( this )'  tabindex='82'  \/>\n\t\t\t\t\t<label for='choice_3_114_0' id='label_3_114_0' class='gform-field-label gform-field-label--type-inline'>Pay in full<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_114_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='Payment plan'  id='choice_3_114_1' onchange='gformToggleRadioOther( this )'  tabindex='83'  \/>\n\t\t\t\t\t<label for='choice_3_114_1' id='label_3_114_1' class='gform-field-label gform-field-label--type-inline'>Payment plan<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_116\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_116\" ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_3_115\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfsp_dot o_medium\"  data-field-class=\"gfsp_dot o_medium\" data-js-reload=\"field_3_115\" ><legend class='gfield_label gform-field-label' >Additional Interest Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_3_115'>\n\t\t\t<div class='gchoice gchoice_3_115_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='Builder'  id='choice_3_115_0' onchange='gformToggleRadioOther( this )'  tabindex='84'  \/>\n\t\t\t\t\t<label for='choice_3_115_0' id='label_3_115_0' class='gform-field-label gform-field-label--type-inline'>Builder<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_115_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='Mortgage'  id='choice_3_115_1' onchange='gformToggleRadioOther( this )'  tabindex='85'  \/>\n\t\t\t\t\t<label for='choice_3_115_1' id='label_3_115_1' class='gform-field-label gform-field-label--type-inline'>Mortgage<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_115_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='Loss Payee'  id='choice_3_115_2' onchange='gformToggleRadioOther( this )'  tabindex='86'  \/>\n\t\t\t\t\t<label for='choice_3_115_2' id='label_3_115_2' class='gform-field-label gform-field-label--type-inline'>Loss Payee<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_115_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='None'  id='choice_3_115_3' onchange='gformToggleRadioOther( this )'  tabindex='87'  \/>\n\t\t\t\t\t<label for='choice_3_115_3' id='label_3_115_3' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_3_115_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_115' type='radio' value='gf_other_choice'  id='choice_3_115_4' onchange='gformToggleRadioOther( this )'  tabindex='88'  \/>\n\t\t\t\t\t<label for='choice_3_115_4' id='label_3_115_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_3_115_other' class='gchoice_other_control' name='input_115_other' type='text' value='Other' aria-label='Other Choice, please specify' tabindex='88' disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_3_143\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half o_medium\"  data-field-class=\"gf_half o_medium\" data-js-reload=\"field_3_143\" ><label class='gfield_label gform-field-label' for='input_3_143'>Interest Name<\/label><div class='ginput_container ginput_container_text'><input name='input_143' id='input_3_143' type='text' value='' class='small'   tabindex='89'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_118\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half o_medium\"  data-field-class=\"gf_half o_medium\" data-js-reload=\"field_3_118\" ><label class='gfield_label gform-field-label' for='input_3_118'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_118' id='input_3_118' type='tel' value='' class='small' tabindex='90'   aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_3_138\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_138\" ><label class='gfield_label gform-field-label' for='input_3_138'>Interest Address<\/label><div class='ginput_container ginput_container_text'><input name='input_138' id='input_3_138' type='text' value='' class='small'   tabindex='91'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_139\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half o_medium\"  data-field-class=\"gf_half o_medium\" data-js-reload=\"field_3_139\" ><label class='gfield_label gform-field-label' for='input_3_139'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_3_139' type='text' value='' class='small'   tabindex='92'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_140\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half o_medium\"  data-field-class=\"gf_half o_medium\" data-js-reload=\"field_3_140\" ><label class='gfield_label gform-field-label' for='input_3_140'>State<\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_3_140' type='text' value='' class='small'   tabindex='93'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_141\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half o_medium\"  data-field-class=\"gf_half o_medium\" data-js-reload=\"field_3_141\" ><label class='gfield_label gform-field-label' for='input_3_141'>ZIP Code<\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_3_141' type='text' value='' class='small'   tabindex='94'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_3_142\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half o_medium\"  data-field-class=\"gf_half o_medium\" data-js-reload=\"field_3_142\" ><label class='gfield_label gform-field-label' for='input_3_142'>Parish<\/label><div class='ginput_container ginput_container_select'><select name='input_142' id='input_3_142' class='small gfield_select' tabindex='95'    aria-invalid=\"false\" ><option value='' >Select...<\/option><option value='Acadia Parish' >Acadia Parish<\/option><option value='Allen Parish' >Allen Parish<\/option><option value='Ascension Parish' >Ascension Parish<\/option><option value='Assumption Parish' >Assumption Parish<\/option><option value='Avoyelles Parish' >Avoyelles Parish<\/option><option value='Beauregard Parish' >Beauregard Parish<\/option><option value='Bienville Parish' >Bienville Parish<\/option><option value='Bossier Parish' >Bossier Parish<\/option><option value='Caddo Parish' >Caddo Parish<\/option><option value='Calcasieu Parish' >Calcasieu Parish<\/option><option value='Caldwell Parish' >Caldwell Parish<\/option><option value='Cameron Parish' >Cameron Parish<\/option><option value='Catahoula Parish' >Catahoula Parish<\/option><option value='Claiborne Parish' >Claiborne Parish<\/option><option value='Concordia Parish' >Concordia Parish<\/option><option value='DeSoto Parish' >DeSoto Parish<\/option><option value='East Baton Rouge Parish' >East Baton Rouge Parish<\/option><option value='East Carroll Parish' >East Carroll Parish<\/option><option value='East Feliciana Parish' >East Feliciana Parish<\/option><option value='Evangeline Parish' >Evangeline Parish<\/option><option value='Franklin Parish' >Franklin Parish<\/option><option value='Grant Parish' >Grant Parish<\/option><option value='Iberia Parish' >Iberia Parish<\/option><option value='Iberville Parish' >Iberville Parish<\/option><option value='Jackson Parish' >Jackson Parish<\/option><option value='Jefferson Parish' >Jefferson Parish<\/option><option value='Jefferson Davis Parish' >Jefferson Davis Parish<\/option><option value='Lafayette Parish' >Lafayette Parish<\/option><option value='Lafourche Parish' >Lafourche Parish<\/option><option value='LaSalle Parish' >LaSalle Parish<\/option><option value='Lincoln Parish' >Lincoln Parish<\/option><option value='Livingston Parish' >Livingston Parish<\/option><option value='Madison Parish' >Madison Parish<\/option><option value='Morehouse Parish' >Morehouse Parish<\/option><option value='Natchitoches Parish' >Natchitoches Parish<\/option><option value='Orleans Parish' >Orleans Parish<\/option><option value='Ouachita Parish' >Ouachita Parish<\/option><option value='Plaquemines Parish' >Plaquemines Parish<\/option><option value='Pointe Coupee Parish' >Pointe Coupee Parish<\/option><option value='Rapides Parish' >Rapides Parish<\/option><option value='Red River Parish' >Red River Parish<\/option><option value='Richland Parish' >Richland Parish<\/option><option value='Sabine Parish' >Sabine Parish<\/option><option value='St. Bernard Parish' >St. Bernard Parish<\/option><option value='St. Charles Parish' >St. Charles Parish<\/option><option value='St. Helena Parish' >St. Helena Parish<\/option><option value='St. James Parish' >St. James Parish<\/option><option value='St. John the Baptist Parish' >St. John the Baptist Parish<\/option><option value='St. Landry Parish' >St. Landry Parish<\/option><option value='St. Martin Parish' >St. Martin Parish<\/option><option value='St. Mary Parish' >St. Mary Parish<\/option><option value='St. Tammany Parish' >St. Tammany Parish<\/option><option value='Tangipahoa Parish' >Tangipahoa Parish<\/option><option value='Tensas Parish' >Tensas Parish<\/option><option value='Terrebonne Parish' >Terrebonne Parish<\/option><option value='Union Parish' >Union Parish<\/option><option value='Vermillion Parish' >Vermillion Parish<\/option><option value='Vernon Parish' >Vernon Parish<\/option><option value='Washington Parish' >Washington Parish<\/option><option value='Webster Parish' >Webster Parish<\/option><option value='West Baton Rouge Parish' >West Baton Rouge Parish<\/option><option value='West Carroll Parish' >West Carroll Parish<\/option><option value='West Feliciana Parish' >West Feliciana Parish<\/option><option value='Winn Parish' >Winn Parish<\/option><\/select><\/div><\/div><div id=\"field_3_146\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_3_146\" ><label class='gfield_label gform-field-label' for='input_3_146'>Phone<\/label><div class='ginput_container'><input name='input_146' id='input_3_146' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_3_146'>This field is for validation purposes and should be left unchanged.<\/div><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_3' class='gform_button button' value='Submit' tabindex='96' onclick='if(window[\"gf_submitting_3\"]){return false;}  if( !jQuery(\"#gform_3\")[0].checkValidity || jQuery(\"#gform_3\")[0].checkValidity()){window[\"gf_submitting_3\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_3\"]){return false;} if( !jQuery(\"#gform_3\")[0].checkValidity || jQuery(\"#gform_3\")[0].checkValidity()){window[\"gf_submitting_3\"]=true;}  jQuery(\"#gform_3\").trigger(\"submit\",[true]); }' \/> <input type='hidden' name='gform_ajax' value='form_id=3&amp;title=&amp;description=&amp;tabindex=1&amp;theme=gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_3' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='3' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_3' value='WyJ7XCIxNDUuMVwiOlwiMDJiOTIzMzhiNTI3ODlhYjc2YzUyY2Y4Y2UyMmNmZmRcIn0iLCIxOWZiOGQ4YWUwYTkyNGQxZDBlYTdiNzQxYmJjMzU2NCJd' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_3' id='gform_target_page_number_3' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_3' id='gform_source_page_number_3' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                 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