{"id":128,"date":"2020-09-25T10:19:58","date_gmt":"2020-09-25T15:19:58","guid":{"rendered":"http:\/\/marcusagent.com\/?page_id=128"},"modified":"2021-10-26T17:15:39","modified_gmt":"2021-10-26T22:15:39","slug":"workers-compensation","status":"publish","type":"page","link":"https:\/\/marcusagent.com\/workers-compensation\/","title":{"rendered":"Worker&#8217;s Compensation"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"128\" class=\"elementor elementor-128\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-2aa05789 elementor-section-height-min-height elementor-section-items-bottom elementor-section-boxed elementor-section-height-default\" data-id=\"2aa05789\" 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-7bb23dd6\" data-id=\"7bb23dd6\" 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-ee43ddf elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"ee43ddf\" 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-ee83eda\" data-id=\"ee83eda\" 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-0ffd37d elementor-widget elementor-widget-text-editor\" data-id=\"0ffd37d\" 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-Workers-Compensation-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-a93c10d 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=\"a93c10d\" 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_10' style='display:none'><div id='gf_10' 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_10' id='gform_10' class=' gf_stylespro sp_flat' action='\/wp-json\/wp\/v2\/pages\/128#gf_10' data-formid='10' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6Ldp8PYcAAAAAINtibmU-8VaOxIEUjlWW9EpdmEj' data-tabindex='1'><input id=\"input_f608777de011a275f282c785f99a48b5\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_f608777de011a275f282c785f99a48b5\" value=\"\"\/><\/div>\n        <div id='gf_progressbar_wrapper_10' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>2<\/span>\n        \t<\/p>\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_10_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><div id='gform_fields_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_10_79\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_left o_medium\"  data-field-class=\"gf_half gf_left o_medium\" data-js-reload=\"field_10_79\" ><label class='gfield_label gform-field-label' for='input_10_79'>Entity Name<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_10_79' type='text' value='' class='small'   tabindex='2'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_80\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_right o_medium\"  data-field-class=\"gf_half gf_right o_medium\" data-js-reload=\"field_10_80\" ><label class='gfield_label gform-field-label' for='input_10_80'>Email<\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_10_80' type='text' value='' class='small'   tabindex='3'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_5\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_left o_medium\"  data-field-class=\"gf_half gf_left o_medium\" data-js-reload=\"field_10_5\" ><label class='gfield_label gform-field-label' for='input_10_5'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_10_5' type='tel' value='' class='small' tabindex='4'   aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_106\" 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_10_106\" ><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_10_106'><div class='gchoice gchoice_10_106_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_106.1' 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_10_106_1' tabindex='5'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_106_1' id='label_10_106_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_10_97\" class=\"gfield gfield--type-website 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_10_97\" ><label class='gfield_label gform-field-label' for='input_10_97'>Website<\/label><div class='ginput_container ginput_container_website'>\n                    <input name='input_97' id='input_10_97' type='url' value='' class='small' tabindex='6'   placeholder='https:\/\/'  aria-invalid=\"false\"\/>\n                <\/div><\/div><fieldset id=\"field_10_89\" 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_10_89\" ><legend class='gfield_label gform-field-label' >Insured Form of Business<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_89'>\n\t\t\t<div class='gchoice gchoice_10_89_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='Individual'  id='choice_10_89_0' onchange='gformToggleRadioOther( this )'  tabindex='7'  \/>\n\t\t\t\t\t<label for='choice_10_89_0' id='label_10_89_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_10_89_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='Corporation'  id='choice_10_89_1' onchange='gformToggleRadioOther( this )'  tabindex='8'  \/>\n\t\t\t\t\t<label for='choice_10_89_1' id='label_10_89_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_10_89_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='LLC'  id='choice_10_89_2' onchange='gformToggleRadioOther( this )'  tabindex='9'  \/>\n\t\t\t\t\t<label for='choice_10_89_2' id='label_10_89_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_10_89_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='Partnership'  id='choice_10_89_3' onchange='gformToggleRadioOther( this )'  tabindex='10'  \/>\n\t\t\t\t\t<label for='choice_10_89_3' id='label_10_89_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_10_89_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_89' type='radio' value='gf_other_choice'  id='choice_10_89_4' onchange='gformToggleRadioOther( this )'  tabindex='11'  \/>\n\t\t\t\t\t<label for='choice_10_89_4' id='label_10_89_4' class='gform-field-label gform-field-label--type-inline'>Other<\/label><br \/><input id='input_10_89_other' class='gchoice_other_control' name='input_89_other' type='text' value='Other' aria-label='Other Choice, please specify' tabindex='11' disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_90\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_10_90\" ><label class='gfield_label gform-field-label' for='input_10_90'>Number of Partners<\/label><div class='ginput_container ginput_container_number'><input name='input_90' id='input_10_90' type='number' step='any'   value='' class='small' tabindex='12'     aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_10_84\" class=\"gfield gfield--type-list field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_10_84\" ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/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\">Tax ID Number<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">NCCI Risk ID Number<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Date Established<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Years Experienced<\/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_84_cell1 gform-grid-col' data-label='Tax ID Number'><input aria-invalid='false'   aria-label='Tax ID Number, Row 1' data-aria-label-template='Tax ID Number, Row {0}' type='text' name='input_84[]' value='' tabindex='13'  \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_84_cell2 gform-grid-col' data-label='NCCI Risk ID Number'><input aria-invalid='false'   aria-label='NCCI Risk ID Number, Row 1' data-aria-label-template='NCCI Risk ID Number, Row {0}' type='text' name='input_84[]' value='' tabindex='14'  \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_84_cell3 gform-grid-col' data-label='Date Established'><input aria-invalid='false'   aria-label='Date Established, Row 1' data-aria-label-template='Date Established, Row {0}' type='text' name='input_84[]' value='' tabindex='15'  \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_84_cell4 gform-grid-col' data-label='Years Experienced'><input aria-invalid='false'   aria-label='Years Experienced, Row 1' data-aria-label-template='Years Experienced, Row {0}' type='text' name='input_84[]' value='' tabindex='16'  \/><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_10_92\" 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_10_92\" ><label class='gfield_label gform-field-label' for='input_10_92'>Mailing\/billing address<\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_10_92' type='text' value='' class='small'   tabindex='17'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_93\" 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_10_93\" ><label class='gfield_label gform-field-label' for='input_10_93'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_10_93' type='text' value='' class='small'   tabindex='18'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_94\" 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_10_94\" ><label class='gfield_label gform-field-label' for='input_10_94'>State<\/label><div class='ginput_container ginput_container_text'><input name='input_94' id='input_10_94' type='text' value='' class='small'   tabindex='19'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_95\" 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_10_95\" ><label class='gfield_label gform-field-label' for='input_10_95'>ZIP Code<\/label><div class='ginput_container ginput_container_text'><input name='input_95' id='input_10_95' type='text' value='' class='small'   tabindex='20'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_96\" 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_10_96\" ><label class='gfield_label gform-field-label' for='input_10_96'>Parish<\/label><div class='ginput_container ginput_container_select'><select name='input_96' id='input_10_96' class='small gfield_select' tabindex='21'    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_10_98\" 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_10_98\" ><label class='gfield_label gform-field-label' for='input_10_98'>Entity address<\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_10_98' type='text' value='' class='small'   tabindex='22'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_99\" 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_10_99\" ><label class='gfield_label gform-field-label' for='input_10_99'>City<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_10_99' type='text' value='' class='small'   tabindex='23'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_100\" 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_10_100\" ><label class='gfield_label gform-field-label' for='input_10_100'>State<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_10_100' type='text' value='' class='small'   tabindex='24'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_101\" 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_10_101\" ><label class='gfield_label gform-field-label' for='input_10_101'>ZIP Code<\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_10_101' type='text' value='' class='small'   tabindex='25'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_102\" 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_10_102\" ><label class='gfield_label gform-field-label' for='input_10_102'>Parish<\/label><div class='ginput_container ginput_container_select'><select name='input_102' id='input_10_102' class='small gfield_select' tabindex='26'    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_10_11\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter gf_left o_medium\"  data-field-class=\"gf_quarter gf_left o_medium\" data-js-reload=\"field_10_11\" ><label class='gfield_label gform-field-label' for='input_10_11'>Owner and Percent Owned<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_10_11' type='text' value='' class='small'   tabindex='27'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_12\" class=\"gfield gfield--type-phone 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_10_12\" ><label class='gfield_label gform-field-label' for='input_10_12'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_12' id='input_10_12' type='tel' value='' class='small' tabindex='28'   aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_13\" 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_quarter o_medium\"  data-field-class=\"gf_quarter o_medium\" data-js-reload=\"field_10_13\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date of BIrth<\/legend><div id='input_10_13' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_10_13_1_container'>\n                                            <input type='number' maxlength='2' name='input_13[]' id='input_10_13_1' value='' tabindex='29'  aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_10_13_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_10_13_2_container'>\n                                            <input type='number' maxlength='2' name='input_13[]' id='input_10_13_2' value='' tabindex='30'  aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_10_13_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_10_13_3_container'>\n                                            <input type='number' maxlength='4' name='input_13[]' id='input_10_13_3' value='' tabindex='31'  aria-required='false'   placeholder='YYYY' min='1920' max='2025' step='1'\/>\n                                            <label for='input_10_13_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_10_14\" 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_10_14\" ><label class='gfield_label gform-field-label' for='input_10_14'>Social Security Number<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_10_14' type='text' value='' class='small'   tabindex='32'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_54\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter gf_left o_medium\"  data-field-class=\"gf_quarter gf_left o_medium\" data-js-reload=\"field_10_54\" ><label class='gfield_label gform-field-label' for='input_10_54'>Owner and Percent Owned<\/label><div class='ginput_container ginput_container_text'><input name='input_54' id='input_10_54' type='text' value='' class='small'   tabindex='33'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_55\" class=\"gfield gfield--type-phone 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_10_55\" ><label class='gfield_label gform-field-label' for='input_10_55'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_55' id='input_10_55' type='tel' value='' class='small' tabindex='34'   aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_10_56\" 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_quarter o_medium\"  data-field-class=\"gf_quarter o_medium\" data-js-reload=\"field_10_56\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Date of BIrth<\/legend><div id='input_10_56' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_month ginput_container ginput_container_date gform-grid-col' id='input_10_56_1_container'>\n                                            <input type='number' maxlength='2' name='input_56[]' id='input_10_56_1' value='' tabindex='35'  aria-required='false'   placeholder='MM' min='1' max='12' step='1'\/>\n                                            <label for='input_10_56_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_10_56_2_container'>\n                                            <input type='number' maxlength='2' name='input_56[]' id='input_10_56_2' value='' tabindex='36'  aria-required='false'   placeholder='DD' min='1' max='31' step='1'\/>\n                                            <label for='input_10_56_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_10_56_3_container'>\n                                            <input type='number' maxlength='4' name='input_56[]' id='input_10_56_3' value='' tabindex='37'  aria-required='false'   placeholder='YYYY' min='1920' max='2025' step='1'\/>\n                                            <label for='input_10_56_3' class='gform-field-label gform-field-label--type-sub screen-reader-text'>Year<\/label>\n                                       <\/div>\n                                   <\/div><\/fieldset><div id=\"field_10_57\" 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_10_57\" ><label class='gfield_label gform-field-label' for='input_10_57'>Social Security Number<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_10_57' type='text' value='' class='small'   tabindex='38'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_105\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_10_105\" ><label class='gfield_label gform-field-label' for='input_10_105'>Detailed description of business operations<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_105' id='input_10_105' class='textarea medium' tabindex='39'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_10_103\" 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_10_103\" ><legend class='gfield_label gform-field-label' >Any losses in the last 5 years?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_103'>\n\t\t\t<div class='gchoice gchoice_10_103_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='Yes'  id='choice_10_103_0' onchange='gformToggleRadioOther( this )'  tabindex='40'  \/>\n\t\t\t\t\t<label for='choice_10_103_0' id='label_10_103_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_10_103_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_103' type='radio' value='No'  id='choice_10_103_1' onchange='gformToggleRadioOther( this )'  tabindex='41'  \/>\n\t\t\t\t\t<label for='choice_10_103_1' id='label_10_103_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_104\" class=\"gfield gfield--type-list 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_10_104\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Loss History<\/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\">Date of Loss<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Loss Description<\/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_104_cell1 gform-grid-col' data-label='Date of Loss'><input aria-invalid='false'   aria-label='Date of Loss, Row 1' data-aria-label-template='Date of Loss, Row {0}' type='text' name='input_104[]' value='' tabindex='42'  \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_104_cell2 gform-grid-col' data-label='Loss Description'><input aria-invalid='false'   aria-label='Loss Description, Row 1' data-aria-label-template='Loss Description, Row {0}' type='text' name='input_104[]' value='' tabindex='43'  \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 5)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 5)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_10_24\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_left o_medium\"  data-field-class=\"gf_half gf_left o_medium\" data-js-reload=\"field_10_24\" ><label class='gfield_label gform-field-label' for='input_10_24'>Liability Limit requested<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_10_24' type='text' value='' class='small'   tabindex='44'   aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_10_25\" 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_list_2col gfsp_dot o_medium\"  data-field-class=\"gf_quarter gf_list_2col gfsp_dot o_medium\" data-js-reload=\"field_10_25\" ><legend class='gfield_label gform-field-label' >Prior Work Comp Coverage<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_25'>\n\t\t\t<div class='gchoice gchoice_10_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Yes'  id='choice_10_25_0' onchange='gformToggleRadioOther( this )'  tabindex='45'  \/>\n\t\t\t\t\t<label for='choice_10_25_0' id='label_10_25_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_10_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='No'  id='choice_10_25_1' onchange='gformToggleRadioOther( this )'  tabindex='46'  \/>\n\t\t\t\t\t<label for='choice_10_25_1' id='label_10_25_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_26\" 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_10_26\" ><label class='gfield_label gform-field-label' for='input_10_26'>Carrier<\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_10_26' type='text' value='' class='small'   tabindex='47'   aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_10_32' class='gform_next_button gform-theme-button button' value='Next' tabindex='48' onclick='jQuery(\"#gform_target_page_number_10\").val(\"2\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_10\").val(\"2\");  jQuery(\"#gform_10\").trigger(\"submit\",[true]); } ' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_10_2' class='gform_page' data-js='page-field-id-32' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_10_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_10_38\" 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_10_38\" ><h3 class=\"gsection_title\">Employee Breakdown<\/h3><\/div><fieldset id=\"field_10_29\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third gf_newline gf_left gf_label_inline gf_list_2col gfsp_dot o_medium\"  data-field-class=\"gf_third gf_newline gf_left gf_label_inline gf_list_2col gfsp_dot o_medium\" data-js-reload=\"field_10_29\" ><legend class='gfield_label gform-field-label' >Including or excluding owner for work comp?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_29'>\n\t\t\t<div class='gchoice gchoice_10_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Including'  id='choice_10_29_0' onchange='gformToggleRadioOther( this )'  tabindex='49'  \/>\n\t\t\t\t\t<label for='choice_10_29_0' id='label_10_29_0' class='gform-field-label gform-field-label--type-inline'>Including<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_10_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Excluding'  id='choice_10_29_1' onchange='gformToggleRadioOther( this )'  tabindex='50'  \/>\n\t\t\t\t\t<label for='choice_10_29_1' id='label_10_29_1' class='gform-field-label gform-field-label--type-inline'>Excluding<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_30\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third gf_label_inline o_medium\"  data-field-class=\"gf_third gf_label_inline o_medium\" data-js-reload=\"field_10_30\" ><label class='gfield_label gform-field-label' for='input_10_30'>Total number of employees<\/label><div class='ginput_container ginput_container_number'><input name='input_30' id='input_10_30' type='number' step='any'   value='' class='small' tabindex='51'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_31\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_third gf_right gf_label_inline o_medium\"  data-field-class=\"gf_third gf_right gf_label_inline o_medium\" data-js-reload=\"field_10_31\" ><label class='gfield_label gform-field-label' for='input_10_31'>Total payroll excluding owner<\/label><div class='ginput_container ginput_container_number'><input name='input_31' id='input_10_31' type='text' step='any'   value='' class='small' tabindex='52'     aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_10_91\" class=\"gfield gfield--type-list 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_10_91\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Individuals Included\/Excluded<\/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\">Full Name<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">DOB<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Title\/Relationship<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Ownership %<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Duties<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Inc\/Exc<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Class Code<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Remuneration\/Payroll<\/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_91_cell1 gform-grid-col' data-label='Full Name'><input aria-invalid='false'   aria-label='Full Name, Row 1' data-aria-label-template='Full Name, Row {0}' type='text' name='input_91[]' value='' tabindex='53'  \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_91_cell2 gform-grid-col' data-label='DOB'><input aria-invalid='false'   aria-label='DOB, Row 1' data-aria-label-template='DOB, Row {0}' type='text' name='input_91[]' value='' tabindex='54'  \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_91_cell3 gform-grid-col' data-label='Title\/Relationship'><input aria-invalid='false'   aria-label='Title\/Relationship, Row 1' data-aria-label-template='Title\/Relationship, Row {0}' type='text' name='input_91[]' value='' tabindex='55'  \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_91_cell4 gform-grid-col' data-label='Ownership %'><input aria-invalid='false'   aria-label='Ownership %, Row 1' data-aria-label-template='Ownership %, Row {0}' type='text' name='input_91[]' value='' tabindex='56'  \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_91_cell5 gform-grid-col' data-label='Duties'><input aria-invalid='false'   aria-label='Duties, Row 1' data-aria-label-template='Duties, Row {0}' type='text' name='input_91[]' value='' tabindex='57'  \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_91_cell6 gform-grid-col' data-label='Inc\/Exc'><input aria-invalid='false'   aria-label='Inc\/Exc, Row 1' data-aria-label-template='Inc\/Exc, Row {0}' type='text' name='input_91[]' value='' tabindex='58'  \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_91_cell7 gform-grid-col' data-label='Class Code'><input aria-invalid='false'   aria-label='Class Code, Row 1' data-aria-label-template='Class Code, Row {0}' type='text' name='input_91[]' value='' tabindex='59'  \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_91_cell8 gform-grid-col' data-label='Remuneration\/Payroll'><input aria-invalid='false'   aria-label='Remuneration\/Payroll, Row 1' data-aria-label-template='Remuneration\/Payroll, Row {0}' type='text' name='input_91[]' value='' tabindex='60'  \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type=\"button\"  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 6)'>Add<\/button>   <button type=\"button\"  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 6)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><div id=\"field_10_39\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter gf_left o_medium\"  data-field-class=\"gf_quarter gf_left o_medium\" data-js-reload=\"field_10_39\" ><label class='gfield_label gform-field-label' for='input_10_39'>Part Time Clerical\/Office: #<\/label><div class='ginput_container ginput_container_number'><input name='input_39' id='input_10_39' type='number' step='any'   value='' class='small' tabindex='61'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_63\" class=\"gfield gfield--type-number 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_10_63\" ><label class='gfield_label gform-field-label' for='input_10_63'>Full Time Clerical\/Office: #<\/label><div class='ginput_container ginput_container_number'><input name='input_63' id='input_10_63' type='number' step='any'   value='' class='small' tabindex='62'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_40\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_right o_medium\"  data-field-class=\"gf_half gf_right o_medium\" data-js-reload=\"field_10_40\" ><label class='gfield_label gform-field-label' for='input_10_40'>Total payroll this class: $<\/label><div class='ginput_container ginput_container_number'><input name='input_40' id='input_10_40' type='text' step='any'   value='' class='small' tabindex='63'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_64\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter gf_left o_medium\"  data-field-class=\"gf_quarter gf_left o_medium\" data-js-reload=\"field_10_64\" ><label class='gfield_label gform-field-label' for='input_10_64'>Part Time Labor: #<\/label><div class='ginput_container ginput_container_number'><input name='input_64' id='input_10_64' type='number' step='any'   value='' class='small' tabindex='64'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_65\" class=\"gfield gfield--type-number 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_10_65\" ><label class='gfield_label gform-field-label' for='input_10_65'>Full Time Labor: #<\/label><div class='ginput_container ginput_container_number'><input name='input_65' id='input_10_65' type='number' step='any'   value='' class='small' tabindex='65'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_66\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_right o_medium\"  data-field-class=\"gf_half gf_right o_medium\" data-js-reload=\"field_10_66\" ><label class='gfield_label gform-field-label' for='input_10_66'>Total payroll this class: $<\/label><div class='ginput_container ginput_container_number'><input name='input_66' id='input_10_66' type='text' step='any'   value='' class='small' tabindex='66'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_67\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter gf_left o_medium\"  data-field-class=\"gf_quarter gf_left o_medium\" data-js-reload=\"field_10_67\" ><label class='gfield_label gform-field-label' for='input_10_67'>Part Time Other: #<\/label><div class='ginput_container ginput_container_number'><input name='input_67' id='input_10_67' type='number' step='any'   value='' class='small' tabindex='67'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_68\" class=\"gfield gfield--type-number 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_10_68\" ><label class='gfield_label gform-field-label' for='input_10_68'>Full Time Other: #<\/label><div class='ginput_container ginput_container_number'><input name='input_68' id='input_10_68' type='number' step='any'   value='' class='small' tabindex='68'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_69\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_right o_medium\"  data-field-class=\"gf_half gf_right o_medium\" data-js-reload=\"field_10_69\" ><label class='gfield_label gform-field-label' for='input_10_69'>Total payroll this class: $<\/label><div class='ginput_container ginput_container_number'><input name='input_69' id='input_10_69' type='text' step='any'   value='' class='small' tabindex='69'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_70\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter gf_left o_medium\"  data-field-class=\"gf_quarter gf_left o_medium\" data-js-reload=\"field_10_70\" ><label class='gfield_label gform-field-label' for='input_10_70'>Part Time Other: #<\/label><div class='ginput_container ginput_container_number'><input name='input_70' id='input_10_70' type='number' step='any'   value='' class='small' tabindex='70'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_71\" class=\"gfield gfield--type-number 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_10_71\" ><label class='gfield_label gform-field-label' for='input_10_71'>Full Time Other: #<\/label><div class='ginput_container ginput_container_number'><input name='input_71' id='input_10_71' type='number' step='any'   value='' class='small' tabindex='71'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_72\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_right o_medium\"  data-field-class=\"gf_half gf_right o_medium\" data-js-reload=\"field_10_72\" ><label class='gfield_label gform-field-label' for='input_10_72'>Total payroll this class: $<\/label><div class='ginput_container ginput_container_number'><input name='input_72' id='input_10_72' type='text' step='any'   value='' class='small' tabindex='72'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_73\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_quarter gf_left o_medium\"  data-field-class=\"gf_quarter gf_left o_medium\" data-js-reload=\"field_10_73\" ><label class='gfield_label gform-field-label' for='input_10_73'>Part Time Other: #<\/label><div class='ginput_container ginput_container_number'><input name='input_73' id='input_10_73' type='number' step='any'   value='' class='small' tabindex='73'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_74\" class=\"gfield gfield--type-number 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_10_74\" ><label class='gfield_label gform-field-label' for='input_10_74'>Full Time Other: #<\/label><div class='ginput_container ginput_container_number'><input name='input_74' id='input_10_74' type='number' step='any'   value='' class='small' tabindex='74'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_75\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_right o_medium\"  data-field-class=\"gf_half gf_right o_medium\" data-js-reload=\"field_10_75\" ><label class='gfield_label gform-field-label' for='input_10_75'>Total payroll this class: $<\/label><div class='ginput_container ginput_container_number'><input name='input_75' id='input_10_75' type='text' step='any'   value='' class='small' tabindex='75'     aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_10_50\" 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_10_50\" ><legend class='gfield_label gform-field-label' >Will you use uninsured subs\/casual labor?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_50'>\n\t\t\t<div class='gchoice gchoice_10_50_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='Yes'  id='choice_10_50_0' onchange='gformToggleRadioOther( this )'  tabindex='76'  \/>\n\t\t\t\t\t<label for='choice_10_50_0' id='label_10_50_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_10_50_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_50' type='radio' value='No'  id='choice_10_50_1' onchange='gformToggleRadioOther( this )'  tabindex='77'  \/>\n\t\t\t\t\t<label for='choice_10_50_1' id='label_10_50_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_51\" class=\"gfield gfield--type-number 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_10_51\" ><label class='gfield_label gform-field-label' for='input_10_51'>Amount paid annually<\/label><div class='ginput_container ginput_container_number'><input name='input_51' id='input_10_51' type='text' step='any'   value='' class='small' tabindex='78'     aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_10_85\" 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_10_85\" ><label class='gfield_label gform-field-label' for='input_10_85'>Uninsured Subs<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_10_85' type='text' value='' class='small'   tabindex='79'   aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_10_86\" 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_10_86\" ><label class='gfield_label gform-field-label' for='input_10_86'>Contract Labor<\/label><div class='ginput_container ginput_container_text'><input name='input_86' id='input_10_86' type='text' value='' class='small'   tabindex='80'   aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_10_76\" 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_10_76\" ><legend class='gfield_label gform-field-label' >Will you use insured subs?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_76'>\n\t\t\t<div class='gchoice gchoice_10_76_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='Yes'  id='choice_10_76_0' onchange='gformToggleRadioOther( this )'  tabindex='81'  \/>\n\t\t\t\t\t<label for='choice_10_76_0' id='label_10_76_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_10_76_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_76' type='radio' value='No'  id='choice_10_76_1' onchange='gformToggleRadioOther( this )'  tabindex='82'  \/>\n\t\t\t\t\t<label for='choice_10_76_1' id='label_10_76_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_77\" class=\"gfield gfield--type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gf_half gf_right o_medium\"  data-field-class=\"gf_half gf_right o_medium\" data-js-reload=\"field_10_77\" ><label class='gfield_label gform-field-label' for='input_10_77'>Amount paid annually<\/label><div class='ginput_container ginput_container_number'><input name='input_77' id='input_10_77' type='text' step='any'   value='' class='small' tabindex='83'     aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_10_78\" 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_10_78\" ><legend class='gfield_label gform-field-label' >Collect Certificates for subs?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_78'>\n\t\t\t<div class='gchoice gchoice_10_78_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='Yes'  id='choice_10_78_0' onchange='gformToggleRadioOther( this )'  tabindex='84'  \/>\n\t\t\t\t\t<label for='choice_10_78_0' id='label_10_78_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_10_78_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_78' type='radio' value='No'  id='choice_10_78_1' onchange='gformToggleRadioOther( this )'  tabindex='85'  \/>\n\t\t\t\t\t<label for='choice_10_78_1' id='label_10_78_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_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_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_10_88\" ><legend class='gfield_label gform-field-label' >Required to have equal liability limits?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_10_88'>\n\t\t\t<div class='gchoice gchoice_10_88_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='Yes'  id='choice_10_88_0' onchange='gformToggleRadioOther( this )'  tabindex='86'  \/>\n\t\t\t\t\t<label for='choice_10_88_0' id='label_10_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_10_88_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='No'  id='choice_10_88_1' onchange='gformToggleRadioOther( this )'  tabindex='87'  \/>\n\t\t\t\t\t<label for='choice_10_88_1' id='label_10_88_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_10_107\" 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_10_107\" ><label class='gfield_label gform-field-label' for='input_10_107'>Comments<\/label><div class='ginput_container'><input name='input_107' id='input_10_107' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_10_107'>This field is for validation purposes and 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