{"id":501,"date":"2020-05-13T20:23:24","date_gmt":"2020-05-13T20:23:24","guid":{"rendered":"https:\/\/vivasegurosinc.com\/?page_id=501"},"modified":"2020-05-13T21:21:07","modified_gmt":"2020-05-13T21:21:07","slug":"claims-2","status":"publish","type":"page","link":"https:\/\/vivasegurosinc.com\/index.php\/claims-2\/","title":{"rendered":"Claims"},"content":{"rendered":"<div id=\"pl-501\"  class=\"panel-layout\" ><div id=\"pg-501-0\"  class=\"panel-grid panel-no-style\" ><div id=\"pgc-501-0-0\"  class=\"panel-grid-cell\" ><div id=\"panel-501-0-0-0\" class=\"so-panel widget widget_sow-headline panel-first-child\" data-index=\"0\" ><div class=\"panel-widget-style panel-widget-style-for-501-0-0-0\" ><div\n\t\t\t\n\t\t\tclass=\"so-widget-sow-headline so-widget-sow-headline-default-bdbb15312494-501\"\n\t\t\t\n\t\t><div class=\"sow-headline-container \">\n\t\t\t\t\t\t\t<h1 class=\"sow-headline\">\n\t\t\t\t\t\tClaims\t\t\t\t\t\t<\/h1>\n\t\t\t\t\t\t\t\t\t\t\t\t<h3 class=\"sow-sub-headline\">\n\t\t\t\t\t\tSuperior claims services requires efficient and detailed claims handling. We act quickly to record and investigate all reported incidents. Claims can be reported to our claims department by phone at (877) 807-8482. Our fax number is (773) 569-3394. It is important to immediately report all incidents to the proper authorities and the insurance company.\t\t\t\t\t\t<\/h3>\n\t\t\t\t\t\t<\/div>\n<\/div><\/div><\/div><div id=\"panel-501-0-0-1\" class=\"so-panel widget widget_gform_widget gform_widget panel-last-child\" data-index=\"1\" ><div id=\"claim-left\" class=\"panel-widget-style panel-widget-style-for-501-0-0-1\" ><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_7' style='display:none'><div id='gf_7' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_7'  action='\/index.php\/wp-json\/wp\/v2\/pages\/501?lang=es#gf_7' data-formid='7' novalidate>\n        <div id='gf_progressbar_wrapper_7' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<h3 class=\"gf_progressbar_title\">Paso <span class='gf_step_current_page'>1<\/span> de <span class='gf_step_page_count'>14<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/h3>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_7' style='width:7%;'><span>7%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_7_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><ul id='gform_fields_7' class='gform_fields left_label form_sublabel_below description_below validation_below'><li id=\"field_7_2\" 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\"  ><label class='gfield_label gform-field-label' >Are you an insured or representing an insured with Viva Seguros?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_2'>\n\t\t\t<li class='gchoice gchoice_7_2_0'>\n\t\t\t\t<input name='input_2' type='radio' value='Yes'  id='choice_7_2_0' tabindex='1'   \/>\n\t\t\t\t<label for='choice_7_2_0' id='label_7_2_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_2_1'>\n\t\t\t\t<input name='input_2' type='radio' value='No'  id='choice_7_2_1' tabindex='2'   \/>\n\t\t\t\t<label for='choice_7_2_1' id='label_7_2_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_309\" 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\"  ><label class='gfield_label gform-field-label screen-reader-text' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_309'>\n\t\t\t<li class='gchoice gchoice_7_309_0'>\n\t\t\t\t<input name='input_309' type='radio' value='Insured'  id='choice_7_309_0' tabindex='3'   \/>\n\t\t\t\t<label for='choice_7_309_0' id='label_7_309_0' class='gform-field-label gform-field-label--type-inline'>I was the person involved in an accident<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_309_1'>\n\t\t\t\t<input name='input_309' type='radio' value='Attorney'  id='choice_7_309_1' tabindex='4'   \/>\n\t\t\t\t<label for='choice_7_309_1' id='label_7_309_1' class='gform-field-label gform-field-label--type-inline'>I am an attorney representing an insured<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_309_2'>\n\t\t\t\t<input name='input_309' type='radio' value='Agent'  id='choice_7_309_2' tabindex='5'   \/>\n\t\t\t\t<label for='choice_7_309_2' id='label_7_309_2' class='gform-field-label gform-field-label--type-inline'>I am an agent representing an insured<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_309_3'>\n\t\t\t\t<input name='input_309' type='radio' value='gf_other_choice'  id='choice_7_309_3' tabindex='6'  onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_7_309_other' name='input_309_other' type='text' value='Otro' aria-label='Otro' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Otro\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Otro\"); }' tabindex='6'  \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_310\" 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\"  ><label class='gfield_label gform-field-label screen-reader-text' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_310'>\n\t\t\t<li class='gchoice gchoice_7_310_0'>\n\t\t\t\t<input name='input_310' type='radio' value='Claimant'  id='choice_7_310_0' tabindex='7'   \/>\n\t\t\t\t<label for='choice_7_310_0' id='label_7_310_0' class='gform-field-label gform-field-label--type-inline'>I am a person who was involved in an accident with a Viva insured<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_310_1'>\n\t\t\t\t<input name='input_310' type='radio' value='Attorney'  id='choice_7_310_1' tabindex='8'   \/>\n\t\t\t\t<label for='choice_7_310_1' id='label_7_310_1' class='gform-field-label gform-field-label--type-inline'>I am an attorney representing a person who was involved in an accident with a Viva insured<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_310_2'>\n\t\t\t\t<input name='input_310' type='radio' value='Agent'  id='choice_7_310_2' tabindex='9'   \/>\n\t\t\t\t<label for='choice_7_310_2' id='label_7_310_2' class='gform-field-label gform-field-label--type-inline'>I am an agent representing a person who was involved in an accident with a Viva insured<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_310_3'>\n\t\t\t\t<input name='input_310' type='radio' value='gf_other_choice'  id='choice_7_310_3' tabindex='10'  onfocus=\"jQuery(this).next('input').focus();\" \/>\n\t\t\t\t<input class='small' id='input_7_310_other' name='input_310_other' type='text' value='Otro' aria-label='Otro' onfocus='jQuery(this).prev(\"input\")[0].click(); if(jQuery(this).val() == \"Otro\") { jQuery(this).val(\"\"); }' onblur='if(jQuery(this).val().replace(\" \", \"\") == \"\") { jQuery(this).val(\"Otro\"); }' tabindex='10'  \/>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_3\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Reporter&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><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_7_3'>\n                            \n                            <span id='input_7_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_7_3_3' value='' tabindex='12'  aria-required='true'     \/>\n                                                    <label for='input_7_3_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_3_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.4' id='input_7_3_4' value='' tabindex='13'  aria-required='false'     \/>\n                                                    <label for='input_7_3_4' class='gform-field-label gform-field-label--type-sub '>Segundo nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_7_3_6' value='' tabindex='14'  aria-required='true'     \/>\n                                                    <label for='input_7_3_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_7_4\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_4'>Reporter&#039;s Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_7_4' type='tel' value='' class='medium' tabindex='16'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_5\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_5'>Reporter&#039;s Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_7_5' type='email' value='' class='medium' tabindex='17'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer left_label'>\n                         <input type='button' id='gform_next_button_7_1' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='18' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_2' class='gform_page' data-js='page-field-id-1' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_2' class='gform_fields left_label form_sublabel_below description_below validation_below'><li id=\"field_7_12\" class=\"gfield gfield--type-section gsection header-fnol field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">General Information<\/h2><\/li><li id=\"field_7_6\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_6'>Viva Seguros Policy Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_7_6' type='text' value='' class='medium'   tabindex='19'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_7\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_7'>Date of Accident<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_7' id='input_7_7' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='20'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_7_7_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_7_7_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_7' class='gform_hidden' value='https:\/\/vivasegurosinc.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_7_8\" class=\"gfield gfield--type-time gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Time of Accident<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"clear-multi\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_7_8'>\n                            <input type='number' name='input_8[]' id='input_7_8_1' value='' tabindex='21' min='0' max='12' step='1'  placeholder='HH' aria-required='true'   \/> <i>:<\/i>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_7_8_1'>Horas<\/label>\n                        <\/div>\n                        \n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_8[]' id='input_7_8_2' value='' tabindex='22' min='0' max='59' step='1'  placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_7_8_2'>Minutos<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_8[]' id='input_7_8_3' tabindex='23' >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_7_8_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/div><\/li><li id=\"field_7_9\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Location of Loss<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city ginput_container_address gform-grid-row' id='input_7_9' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_9_1_container' >\n                                        <input type='text' name='input_9.1' id='input_7_9_1' value='' tabindex='24'   aria-required='false'    \/>\n                                        <label for='input_7_9_1' id='input_7_9_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_9_3_container' >\n                                    <input type='text' name='input_9.3' id='input_7_9_3' value='' tabindex='25'   aria-required='false'    \/>\n                                    <label for='input_7_9_3' id='input_7_9_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_9.4' id='input_7_9_4' value=''\/><input type='hidden' class='gform_hidden' name='input_9.6' id='input_7_9_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_13\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_state ginput_container_address gform-grid-row' id='input_7_13' >\n                        <span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_13_4_container' >\n                                        <select name='input_13.4' id='input_7_13_4' tabindex='29'    aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_13_4' id='input_7_13_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><input type='hidden' class='gform_hidden' name='input_13.6' id='input_7_13_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer left_label'>\n                        <input type='button' id='gform_previous_button_7_10' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='32' \/> <input type='button' id='gform_next_button_7_10' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='33' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_3' class='gform_page' data-js='page-field-id-10' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_3' class='gform_fields left_label form_sublabel_below description_below validation_below'><li id=\"field_7_11\" class=\"gfield gfield--type-section gsection header-fnol field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Viva&#039;s Insured Vehicle Information<\/h2><\/li><li id=\"field_7_263\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_263'>Vehicle Year<\/label><div class='ginput_container ginput_container_text'><input name='input_263' id='input_7_263' type='text' value='' class='medium'   tabindex='34'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_15\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_15'>Vehicle Make<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_7_15' type='text' value='' class='medium'   tabindex='35'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_16\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_16'>Vehicle Model<\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_7_16' type='text' value='' class='medium'   tabindex='36'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_17\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_17'>License Plate Number<\/label><div class='ginput_container ginput_container_text'><input name='input_17' id='input_7_17' type='text' value='' class='medium'   tabindex='37'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_19\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_19'>Vehicle Color<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_7_19' type='text' value='' class='medium'   tabindex='38'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_268\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_268'>Vehicle Identification Number - VIN<\/label><div class='ginput_container ginput_container_text'><input name='input_268' id='input_7_268' type='text' value='' class='medium'   tabindex='39'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_317\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_317'>Choose the option that most applies<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_317' id='input_7_317' class='medium gfield_select' tabindex='40'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Collision with animal' >Collision with animal<\/option><option value='Theft' >Theft<\/option><option value='Fire' >Fire<\/option><option value='Vandalism' >Vandalism<\/option><option value='Weather\/Natural Disasters' >Weather\/Natural Disasters<\/option><option value='Falling Objects' >Falling Objects<\/option><option value='Glass Breakage' >Glass Breakage<\/option><option value='Collision Damage' >Collision Damage<\/option><\/select><\/div><\/li><li id=\"field_7_318\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_318'>Is there damage to this vehicle?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_318' id='input_7_318' class='medium gfield_select' tabindex='41'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Unknown' >Unknown<\/option><\/select><\/div><\/li><li id=\"field_7_20\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_20'>Vehicle Damage<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_20' id='input_7_20' class='textarea medium' tabindex='42'  maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_313\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><img decoding=\"async\" src=\"https:\/\/vivasegurosinc.com\/wp-content\/uploads\/2020\/05\/CarWithNumbers-2.png\" style=\"width:300px;\"><\/li><li id=\"field_7_315\" class=\"gfield gfield--type-select field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_315'>Initial Point of Impact<\/label><div class='ginput_container ginput_container_select'><select name='input_315' id='input_7_315' class='medium gfield_select' tabindex='43' aria-describedby=\"gfield_description_7_315\"   aria-invalid=\"false\" ><option value='N\/A' >N\/A<\/option><option value='Front Right' >1. Front Right<\/option><option value='Front Center' >2. Front Center<\/option><option value='Front Left' >3. Front Left<\/option><option value='Front Right Quarter Panel' >4. Front Right Quarter Panel<\/option><option value='Hood' >5. Hood<\/option><option value='Front Left Quarter Panel' >6. Front Left Quarter Panel<\/option><option value='Right Side' >7. Right Side<\/option><option value='Roof' >8. Roof<\/option><option value='Left Side' >9. Left Side<\/option><option value='Rear Right Quarter Panel' >10. Rear Right Quarter Panel<\/option><option value='Deck Lid\/Trunk' >11. Deck Lid\/Trunk<\/option><option value='Rear Left Quarter Panel' >12. Rear Left Quarter Panel<\/option><option value='Rear Right' >13. Rear Right<\/option><option value='Rear' >14. Rear<\/option><option value='Rear Left' >15. Rear Left<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_7_315'>Please use the above image to assist with this answer.<\/div><\/li><li id=\"field_7_22\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_22'>Unrelated Prior Damage<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_7_22' type='text' value='' class='medium'   tabindex='44'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_23\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Is the Vehicle Drivable?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_23'>\n\t\t\t<li class='gchoice gchoice_7_23_0'>\n\t\t\t\t<input name='input_23' type='radio' value='Yes'  id='choice_7_23_0' tabindex='45'   \/>\n\t\t\t\t<label for='choice_7_23_0' id='label_7_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_23_1'>\n\t\t\t\t<input name='input_23' type='radio' value='Unknown'  id='choice_7_23_1' tabindex='46'   \/>\n\t\t\t\t<label for='choice_7_23_1' id='label_7_23_1' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_23_2'>\n\t\t\t\t<input name='input_23' type='radio' value='No'  id='choice_7_23_2' tabindex='47'   \/>\n\t\t\t\t<label for='choice_7_23_2' id='label_7_23_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_24\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Where is the vehicle Located?<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_24' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_24_1_container' >\n                                        <input type='text' name='input_24.1' id='input_7_24_1' value='' tabindex='48'   aria-required='false'    \/>\n                                        <label for='input_7_24_1' id='input_7_24_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_7_24_2_container' >\n                                        <input type='text' name='input_24.2' id='input_7_24_2' value='' tabindex='49'    aria-required='false'   \/>\n                                        <label for='input_7_24_2' id='input_7_24_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_24_3_container' >\n                                    <input type='text' name='input_24.3' id='input_7_24_3' value='' tabindex='50'   aria-required='false'    \/>\n                                    <label for='input_7_24_3' id='input_7_24_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_24_4_container' >\n                                        <select name='input_24.4' id='input_7_24_4' tabindex='51'    aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_24_4' id='input_7_24_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_24_5_container' >\n                                    <input type='text' name='input_24.5' id='input_7_24_5' value='' tabindex='53'   aria-required='false'    \/>\n                                    <label for='input_7_24_5' id='input_7_24_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_24.6' id='input_7_24_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_251\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Is this address a business?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_251'>\n\t\t\t<li class='gchoice gchoice_7_251_0'>\n\t\t\t\t<input name='input_251' type='radio' value='Yes'  id='choice_7_251_0' tabindex='54'   \/>\n\t\t\t\t<label for='choice_7_251_0' id='label_7_251_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_251_1'>\n\t\t\t\t<input name='input_251' type='radio' value='No'  id='choice_7_251_1' tabindex='55'   \/>\n\t\t\t\t<label for='choice_7_251_1' id='label_7_251_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_252\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_252'>Business Name<\/label><div class='ginput_container ginput_container_text'><input name='input_252' id='input_7_252' type='text' value='' class='medium'   tabindex='56'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_253\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_253'>Business Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_253' id='input_7_253' type='tel' value='' class='medium' tabindex='57'   aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer left_label'>\n                        <input type='button' id='gform_previous_button_7_25' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='58' \/> <input type='button' id='gform_next_button_7_25' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='59' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_4' class='gform_page' data-js='page-field-id-25' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_4' class='gform_fields left_label form_sublabel_below description_below validation_below'><li id=\"field_7_26\" class=\"gfield gfield--type-section gsection header-fnol field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Viva Policyholder Information<\/h2><div class='gsection_description' id='gfield_description_7_26'>Registered Owner Information<\/div><\/li><li id=\"field_7_28\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><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_7_28'>\n                            \n                            <span id='input_7_28_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_28.3' id='input_7_28_3' value='' tabindex='61'  aria-required='true'     \/>\n                                                    <label for='input_7_28_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_28_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_28.4' id='input_7_28_4' value='' tabindex='62'  aria-required='false'     \/>\n                                                    <label for='input_7_28_4' class='gform-field-label gform-field-label--type-sub '>Segundo nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_28_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_28.6' id='input_7_28_6' value='' tabindex='63'  aria-required='true'     \/>\n                                                    <label for='input_7_28_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_7_29\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_29' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_29_1_container' >\n                                        <input type='text' name='input_29.1' id='input_7_29_1' value='' tabindex='65'   aria-required='false'    \/>\n                                        <label for='input_7_29_1' id='input_7_29_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_7_29_2_container' >\n                                        <input type='text' name='input_29.2' id='input_7_29_2' value='' tabindex='66'    aria-required='false'   \/>\n                                        <label for='input_7_29_2' id='input_7_29_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_29_3_container' >\n                                    <input type='text' name='input_29.3' id='input_7_29_3' value='' tabindex='67'   aria-required='false'    \/>\n                                    <label for='input_7_29_3' id='input_7_29_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_29_4_container' >\n                                        <select name='input_29.4' id='input_7_29_4' tabindex='68'    aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_29_4' id='input_7_29_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_29_5_container' >\n                                    <input type='text' name='input_29.5' id='input_7_29_5' value='' tabindex='70'   aria-required='false'    \/>\n                                    <label for='input_7_29_5' id='input_7_29_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_29.6' id='input_7_29_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_124\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_124'>Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_124' id='input_7_124' type='tel' value='' class='medium' tabindex='71'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_31\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_31'>Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_31' id='input_7_31' type='tel' value='' class='medium' tabindex='72'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_32\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_32'>Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_32' id='input_7_32' type='tel' value='' class='medium' tabindex='73'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_33\" class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_33'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_33' id='input_7_33' type='email' value='' class='medium' tabindex='74'    aria-invalid=\"false\"  \/>\n                        <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer left_label'>\n                        <input type='button' id='gform_previous_button_7_35' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='75' \/> <input type='button' id='gform_next_button_7_35' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='76' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_5' class='gform_page' data-js='page-field-id-35' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_5' class='gform_fields left_label form_sublabel_below description_below validation_below'><li id=\"field_7_34\" class=\"gfield gfield--type-section gsection header-fnol field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Viva Driver Information<\/h2><\/li><li id=\"field_7_36\" 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\"  ><label class='gfield_label gform-field-label' >Same as Vehicle Owner?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_36'>\n\t\t\t<li class='gchoice gchoice_7_36_0'>\n\t\t\t\t<input name='input_36' type='radio' value='Yes'  id='choice_7_36_0' tabindex='77'   \/>\n\t\t\t\t<label for='choice_7_36_0' id='label_7_36_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_36_1'>\n\t\t\t\t<input name='input_36' type='radio' value='No'  id='choice_7_36_1' tabindex='78'   \/>\n\t\t\t\t<label for='choice_7_36_1' id='label_7_36_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_38\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><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_7_38'>\n                            \n                            <span id='input_7_38_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_38.3' id='input_7_38_3' value='' tabindex='80'  aria-required='false'     \/>\n                                                    <label for='input_7_38_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_38_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_38.4' id='input_7_38_4' value='' tabindex='81'  aria-required='false'     \/>\n                                                    <label for='input_7_38_4' class='gform-field-label gform-field-label--type-sub '>Segundo nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_38_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_38.6' id='input_7_38_6' value='' tabindex='82'  aria-required='false'     \/>\n                                                    <label for='input_7_38_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_7_39\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_39' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_39_1_container' >\n                                        <input type='text' name='input_39.1' id='input_7_39_1' value='' tabindex='84'   aria-required='false'    \/>\n                                        <label for='input_7_39_1' id='input_7_39_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_7_39_2_container' >\n                                        <input type='text' name='input_39.2' id='input_7_39_2' value='' tabindex='85'    aria-required='false'   \/>\n                                        <label for='input_7_39_2' id='input_7_39_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_39_3_container' >\n                                    <input type='text' name='input_39.3' id='input_7_39_3' value='' tabindex='86'   aria-required='false'    \/>\n                                    <label for='input_7_39_3' id='input_7_39_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_39_4_container' >\n                                        <select name='input_39.4' id='input_7_39_4' tabindex='87'    aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_39_4' id='input_7_39_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_39_5_container' >\n                                    <input type='text' name='input_39.5' id='input_7_39_5' value='' tabindex='89'   aria-required='false'    \/>\n                                    <label for='input_7_39_5' id='input_7_39_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_39.6' id='input_7_39_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_43\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_43'>Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_43' id='input_7_43' type='tel' value='' class='medium' tabindex='90'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_289\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_289'>Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_289' id='input_7_289' type='tel' value='' class='medium' tabindex='91'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_288\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_288'>Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_288' id='input_7_288' type='tel' value='' class='medium' tabindex='92'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_41\" class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_41'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_41' id='input_7_41' type='email' value='' class='medium' tabindex='93'    aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_7_37\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_37'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_37' id='input_7_37' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='94'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_7_37_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_7_37_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_37' class='gform_hidden' value='https:\/\/vivasegurosinc.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_7_44\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_44'>Drivers License Number<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_7_44' type='text' value='' class='medium'   tabindex='95'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_45\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Drivers License State<\/label>    \n                    <div class='ginput_complex ginput_container has_state ginput_container_address gform-grid-row' id='input_7_45' >\n                        <span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_45_4_container' >\n                                        <select name='input_45.4' id='input_7_45_4' tabindex='98'    aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_45_4' id='input_7_45_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><input type='hidden' class='gform_hidden' name='input_45.6' id='input_7_45_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_242\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did this person receive a ticket?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_242'>\n\t\t\t<li class='gchoice gchoice_7_242_0'>\n\t\t\t\t<input name='input_242' type='radio' value='Yes'  id='choice_7_242_0' tabindex='101'   \/>\n\t\t\t\t<label for='choice_7_242_0' id='label_7_242_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_242_1'>\n\t\t\t\t<input name='input_242' type='radio' value='Unknown'  id='choice_7_242_1' tabindex='102'   \/>\n\t\t\t\t<label for='choice_7_242_1' id='label_7_242_1' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_242_2'>\n\t\t\t\t<input name='input_242' type='radio' value='No'  id='choice_7_242_2' tabindex='103'   \/>\n\t\t\t\t<label for='choice_7_242_2' id='label_7_242_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_264\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_264'>Ticket Reason<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_264' id='input_7_264' class='textarea medium' tabindex='104'  maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_246\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Was this person injured?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_246'>\n\t\t\t<li class='gchoice gchoice_7_246_0'>\n\t\t\t\t<input name='input_246' type='radio' value='Yes'  id='choice_7_246_0' tabindex='105'   \/>\n\t\t\t\t<label for='choice_7_246_0' id='label_7_246_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_246_1'>\n\t\t\t\t<input name='input_246' type='radio' value='No'  id='choice_7_246_1' tabindex='106'   \/>\n\t\t\t\t<label for='choice_7_246_1' id='label_7_246_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_247\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_247'>Describe Injuries:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_247' id='input_7_247' class='textarea medium' tabindex='107'  maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_248\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did they seek medical treatment?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_248'>\n\t\t\t<li class='gchoice gchoice_7_248_0'>\n\t\t\t\t<input name='input_248' type='radio' value='Yes'  id='choice_7_248_0' tabindex='108'   \/>\n\t\t\t\t<label for='choice_7_248_0' id='label_7_248_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_248_1'>\n\t\t\t\t<input name='input_248' type='radio' value='No'  id='choice_7_248_1' tabindex='109'   \/>\n\t\t\t\t<label for='choice_7_248_1' id='label_7_248_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_311\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_311'>Purpose of Use<\/label><div class='ginput_container ginput_container_select'><select name='input_311' id='input_7_311' class='medium gfield_select' tabindex='110'    aria-invalid=\"false\" ><option value='Personal' >Personal<\/option><option value='Business' >Business<\/option><option value='Rideshare' >Rideshare<\/option><\/select><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer left_label'>\n                        <input type='button' id='gform_previous_button_7_47' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='111' \/> <input type='button' id='gform_next_button_7_47' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='112' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_6' class='gform_page' data-js='page-field-id-47' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_6' class='gform_fields left_label form_sublabel_below description_below validation_below'><li id=\"field_7_48\" class=\"gfield gfield--type-section gsection header-fnol field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Viva&#039;s Vehicle Passenger Information<\/h2><\/li><li id=\"field_7_100\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_100'>How Many Passengers in Viva&#039;s vehicle(other than the driver)?<\/label><div class='ginput_container ginput_container_select'><select name='input_100' id='input_7_100' class='medium gfield_select' tabindex='113'    aria-invalid=\"false\" ><option value='0' selected='selected'>None<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><\/select><\/div><\/li><li id=\"field_7_54\" class=\"gfield gfield--type-section gsection header-fnol field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Passenger 1<\/h2><\/li><li id=\"field_7_86\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><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_7_86'>\n                            \n                            <span id='input_7_86_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_86.3' id='input_7_86_3' value='' tabindex='115'  aria-required='false'     \/>\n                                                    <label for='input_7_86_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_86_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_86.4' id='input_7_86_4' value='' tabindex='116'  aria-required='false'     \/>\n                                                    <label for='input_7_86_4' class='gform-field-label gform-field-label--type-sub '>Segundo nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_86_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_86.6' id='input_7_86_6' value='' tabindex='117'  aria-required='false'     \/>\n                                                    <label for='input_7_86_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_7_90\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_90' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_90_1_container' >\n                                        <input type='text' name='input_90.1' id='input_7_90_1' value='' tabindex='119'   aria-required='false'    \/>\n                                        <label for='input_7_90_1' id='input_7_90_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_7_90_2_container' >\n                                        <input type='text' name='input_90.2' id='input_7_90_2' value='' tabindex='120'    aria-required='false'   \/>\n                                        <label for='input_7_90_2' id='input_7_90_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_90_3_container' >\n                                    <input type='text' name='input_90.3' id='input_7_90_3' value='' tabindex='121'   aria-required='false'    \/>\n                                    <label for='input_7_90_3' id='input_7_90_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_90_4_container' >\n                                        <select name='input_90.4' id='input_7_90_4' tabindex='122'    aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_90_4' id='input_7_90_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_90_5_container' >\n                                    <input type='text' name='input_90.5' id='input_7_90_5' value='' tabindex='124'   aria-required='false'    \/>\n                                    <label for='input_7_90_5' id='input_7_90_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_90.6' id='input_7_90_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_58\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_58'>Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_58' id='input_7_58' type='tel' value='' class='medium' tabindex='125'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_290\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_290'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_290' id='input_7_290' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='126'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_7_290_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_7_290_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_290' class='gform_hidden' value='https:\/\/vivasegurosinc.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_7_228\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Was this person injured?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_228'>\n\t\t\t<li class='gchoice gchoice_7_228_0'>\n\t\t\t\t<input name='input_228' type='radio' value='Yes'  id='choice_7_228_0' tabindex='127'   \/>\n\t\t\t\t<label for='choice_7_228_0' id='label_7_228_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_228_1'>\n\t\t\t\t<input name='input_228' type='radio' value='No'  id='choice_7_228_1' tabindex='128'   \/>\n\t\t\t\t<label for='choice_7_228_1' id='label_7_228_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_229\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_229'>Describe Injuries:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_229' id='input_7_229' class='textarea medium' tabindex='129'  maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_243\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did this person seek medical treatment?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_243'>\n\t\t\t<li class='gchoice gchoice_7_243_0'>\n\t\t\t\t<input name='input_243' type='radio' value='Yes'  id='choice_7_243_0' tabindex='130'   \/>\n\t\t\t\t<label for='choice_7_243_0' id='label_7_243_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_243_1'>\n\t\t\t\t<input name='input_243' type='radio' value='No'  id='choice_7_243_1' tabindex='131'   \/>\n\t\t\t\t<label for='choice_7_243_1' id='label_7_243_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_243_2'>\n\t\t\t\t<input name='input_243' type='radio' value='Unknown'  id='choice_7_243_2' tabindex='132'   \/>\n\t\t\t\t<label for='choice_7_243_2' id='label_7_243_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_82\" class=\"gfield gfield--type-section gsection header-fnol field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Passenger 2<\/h2><\/li><li id=\"field_7_51\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><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_7_51'>\n                            \n                            <span id='input_7_51_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_51.3' id='input_7_51_3' value='' tabindex='134'  aria-required='false'     \/>\n                                                    <label for='input_7_51_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_51_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_51.4' id='input_7_51_4' value='' tabindex='135'  aria-required='false'     \/>\n                                                    <label for='input_7_51_4' class='gform-field-label gform-field-label--type-sub '>Segundo nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_51_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_51.6' id='input_7_51_6' value='' tabindex='136'  aria-required='false'     \/>\n                                                    <label for='input_7_51_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_7_89\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_89' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_89_1_container' >\n                                        <input type='text' name='input_89.1' id='input_7_89_1' value='' tabindex='138'   aria-required='false'    \/>\n                                        <label for='input_7_89_1' id='input_7_89_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_7_89_2_container' >\n                                        <input type='text' name='input_89.2' id='input_7_89_2' value='' tabindex='139'    aria-required='false'   \/>\n                                        <label for='input_7_89_2' id='input_7_89_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_89_3_container' >\n                                    <input type='text' name='input_89.3' id='input_7_89_3' value='' tabindex='140'   aria-required='false'    \/>\n                                    <label for='input_7_89_3' id='input_7_89_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_89_4_container' >\n                                        <select name='input_89.4' id='input_7_89_4' tabindex='141'    aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_89_4' id='input_7_89_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_89_5_container' >\n                                    <input type='text' name='input_89.5' id='input_7_89_5' value='' tabindex='143'   aria-required='false'    \/>\n                                    <label for='input_7_89_5' id='input_7_89_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_89.6' id='input_7_89_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_286\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_286'>Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_286' id='input_7_286' type='tel' value='' class='medium' tabindex='144'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_291\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_291'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_291' id='input_7_291' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='145'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_7_291_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_7_291_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_291' class='gform_hidden' value='https:\/\/vivasegurosinc.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_7_226\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Was this person injured?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_226'>\n\t\t\t<li class='gchoice gchoice_7_226_0'>\n\t\t\t\t<input name='input_226' type='radio' value='Yes'  id='choice_7_226_0' tabindex='146'   \/>\n\t\t\t\t<label for='choice_7_226_0' id='label_7_226_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_226_1'>\n\t\t\t\t<input name='input_226' type='radio' value='No'  id='choice_7_226_1' tabindex='147'   \/>\n\t\t\t\t<label for='choice_7_226_1' id='label_7_226_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_227\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_227'>Describe the Injuries:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_227' id='input_7_227' class='textarea medium' tabindex='148'  maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_244\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did this person seek medical treatment?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_244'>\n\t\t\t<li class='gchoice gchoice_7_244_0'>\n\t\t\t\t<input name='input_244' type='radio' value='Yes'  id='choice_7_244_0' tabindex='149'   \/>\n\t\t\t\t<label for='choice_7_244_0' id='label_7_244_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_244_1'>\n\t\t\t\t<input name='input_244' type='radio' value='No'  id='choice_7_244_1' tabindex='150'   \/>\n\t\t\t\t<label for='choice_7_244_1' id='label_7_244_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_244_2'>\n\t\t\t\t<input name='input_244' type='radio' value='Unknown'  id='choice_7_244_2' tabindex='151'   \/>\n\t\t\t\t<label for='choice_7_244_2' id='label_7_244_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_81\" class=\"gfield gfield--type-section gsection header-fnol field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Passenger 3<\/h2><\/li><li id=\"field_7_85\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><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_7_85'>\n                            \n                            <span id='input_7_85_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_85.3' id='input_7_85_3' value='' tabindex='153'  aria-required='false'     \/>\n                                                    <label for='input_7_85_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_85_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_85.4' id='input_7_85_4' value='' tabindex='154'  aria-required='false'     \/>\n                                                    <label for='input_7_85_4' class='gform-field-label gform-field-label--type-sub '>Segundo nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_85_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_85.6' id='input_7_85_6' value='' tabindex='155'  aria-required='false'     \/>\n                                                    <label for='input_7_85_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_7_287\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_287' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_287_1_container' >\n                                        <input type='text' name='input_287.1' id='input_7_287_1' value='' tabindex='157'   aria-required='false'    \/>\n                                        <label for='input_7_287_1' id='input_7_287_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_7_287_2_container' >\n                                        <input type='text' name='input_287.2' id='input_7_287_2' value='' tabindex='158'    aria-required='false'   \/>\n                                        <label for='input_7_287_2' id='input_7_287_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_287_3_container' >\n                                    <input type='text' name='input_287.3' id='input_7_287_3' value='' tabindex='159'   aria-required='false'    \/>\n                                    <label for='input_7_287_3' id='input_7_287_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_287_4_container' >\n                                        <select name='input_287.4' id='input_7_287_4' tabindex='160'    aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_287_4' id='input_7_287_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_287_5_container' >\n                                    <input type='text' name='input_287.5' id='input_7_287_5' value='' tabindex='162'   aria-required='false'    \/>\n                                    <label for='input_7_287_5' id='input_7_287_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_287.6' id='input_7_287_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_93\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_93'>Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_93' id='input_7_93' type='tel' value='' class='medium' tabindex='163'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_292\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_292'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_292' id='input_7_292' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='164'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_7_292_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_7_292_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_292' class='gform_hidden' value='https:\/\/vivasegurosinc.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_7_230\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Was this person injured?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_230'>\n\t\t\t<li class='gchoice gchoice_7_230_0'>\n\t\t\t\t<input name='input_230' type='radio' value='Yes'  id='choice_7_230_0' tabindex='165'   \/>\n\t\t\t\t<label for='choice_7_230_0' id='label_7_230_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_230_1'>\n\t\t\t\t<input name='input_230' type='radio' value='No'  id='choice_7_230_1' tabindex='166'   \/>\n\t\t\t\t<label for='choice_7_230_1' id='label_7_230_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_231\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_231'>Describe Injuries:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_231' id='input_7_231' class='textarea medium' tabindex='167'  maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_245\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did this person seek medical treatment?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_245'>\n\t\t\t<li class='gchoice gchoice_7_245_0'>\n\t\t\t\t<input name='input_245' type='radio' value='Yes'  id='choice_7_245_0' tabindex='168'   \/>\n\t\t\t\t<label for='choice_7_245_0' id='label_7_245_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_245_1'>\n\t\t\t\t<input name='input_245' type='radio' value='No'  id='choice_7_245_1' tabindex='169'   \/>\n\t\t\t\t<label for='choice_7_245_1' id='label_7_245_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_245_2'>\n\t\t\t\t<input name='input_245' type='radio' value='Unknown'  id='choice_7_245_2' tabindex='170'   \/>\n\t\t\t\t<label for='choice_7_245_2' id='label_7_245_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_80\" class=\"gfield gfield--type-section gsection header-fnol field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Passenger 4<\/h2><\/li><li id=\"field_7_84\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><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_7_84'>\n                            \n                            <span id='input_7_84_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_84.3' id='input_7_84_3' value='' tabindex='172'  aria-required='false'     \/>\n                                                    <label for='input_7_84_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_84_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_84.4' id='input_7_84_4' value='' tabindex='173'  aria-required='false'     \/>\n                                                    <label for='input_7_84_4' class='gform-field-label gform-field-label--type-sub '>Segundo nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_84_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_84.6' id='input_7_84_6' value='' tabindex='174'  aria-required='false'     \/>\n                                                    <label for='input_7_84_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_7_87\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_87' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_87_1_container' >\n                                        <input type='text' name='input_87.1' id='input_7_87_1' value='' tabindex='176'   aria-required='false'    \/>\n                                        <label for='input_7_87_1' id='input_7_87_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_7_87_2_container' >\n                                        <input type='text' name='input_87.2' id='input_7_87_2' value='' tabindex='177'    aria-required='false'   \/>\n                                        <label for='input_7_87_2' id='input_7_87_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_87_3_container' >\n                                    <input type='text' name='input_87.3' id='input_7_87_3' value='' tabindex='178'   aria-required='false'    \/>\n                                    <label for='input_7_87_3' id='input_7_87_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_87_4_container' >\n                                        <select name='input_87.4' id='input_7_87_4' tabindex='179'    aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_87_4' id='input_7_87_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_87_5_container' >\n                                    <input type='text' name='input_87.5' id='input_7_87_5' value='' tabindex='181'   aria-required='false'    \/>\n                                    <label for='input_7_87_5' id='input_7_87_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_87.6' id='input_7_87_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_92\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_92'>Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_92' id='input_7_92' type='tel' value='' class='medium' tabindex='182'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_293\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_293'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_293' id='input_7_293' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='183'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_7_293_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_7_293_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_293' class='gform_hidden' value='https:\/\/vivasegurosinc.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_7_232\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Was this person injured?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_232'>\n\t\t\t<li class='gchoice gchoice_7_232_0'>\n\t\t\t\t<input name='input_232' type='radio' value='Yes'  id='choice_7_232_0' tabindex='184'   \/>\n\t\t\t\t<label for='choice_7_232_0' id='label_7_232_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_232_1'>\n\t\t\t\t<input name='input_232' type='radio' value='No'  id='choice_7_232_1' tabindex='185'   \/>\n\t\t\t\t<label for='choice_7_232_1' id='label_7_232_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_233\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_233'>Describe Injuries:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_233' id='input_7_233' class='textarea medium' tabindex='186'  maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_249\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did this person seek medical treatment?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_249'>\n\t\t\t<li class='gchoice gchoice_7_249_0'>\n\t\t\t\t<input name='input_249' type='radio' value='Yes'  id='choice_7_249_0' tabindex='187'   \/>\n\t\t\t\t<label for='choice_7_249_0' id='label_7_249_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_249_1'>\n\t\t\t\t<input name='input_249' type='radio' value='No'  id='choice_7_249_1' tabindex='188'   \/>\n\t\t\t\t<label for='choice_7_249_1' id='label_7_249_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_249_2'>\n\t\t\t\t<input name='input_249' type='radio' value='Unknown'  id='choice_7_249_2' tabindex='189'   \/>\n\t\t\t\t<label for='choice_7_249_2' id='label_7_249_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer left_label'>\n                        <input type='button' id='gform_previous_button_7_114' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='190' \/> <input type='button' id='gform_next_button_7_114' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='191' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_7' class='gform_page' data-js='page-field-id-114' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_7' class='gform_fields left_label form_sublabel_below description_below validation_below'><li id=\"field_7_55\" class=\"gfield gfield--type-section gsection header-fnol field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Other Vehicle Information<\/h2><\/li><li id=\"field_7_65\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Is there another Vehicle Involved?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_65'>\n\t\t\t<li class='gchoice gchoice_7_65_0'>\n\t\t\t\t<input name='input_65' type='radio' value='Yes'  id='choice_7_65_0' tabindex='192'   \/>\n\t\t\t\t<label for='choice_7_65_0' id='label_7_65_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_65_1'>\n\t\t\t\t<input name='input_65' type='radio' value='No'  id='choice_7_65_1' tabindex='193'   \/>\n\t\t\t\t<label for='choice_7_65_1' id='label_7_65_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_299\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_299'>Vehicle Year<\/label><div class='ginput_container ginput_container_text'><input name='input_299' id='input_7_299' type='text' value='' class='medium'   tabindex='194'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_117\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_117'>Vehicle Make<\/label><div class='ginput_container ginput_container_text'><input name='input_117' id='input_7_117' type='text' value='' class='medium'   tabindex='195'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_118\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_118'>Vehicle Model<\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_7_118' type='text' value='' class='medium'   tabindex='196'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_269\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_269'>Vehicle Identification Number - VIN<\/label><div class='ginput_container ginput_container_text'><input name='input_269' id='input_7_269' type='text' value='' class='medium'   tabindex='197'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_119\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_119'>Plate Number<\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_7_119' type='text' value='' class='medium'   tabindex='198'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_121\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_121'>Vehicle Color<\/label><div class='ginput_container ginput_container_text'><input name='input_121' id='input_7_121' type='text' value='' class='medium'   tabindex='199'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_319\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_319'>Is there damage to this vehicle?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_319' id='input_7_319' class='medium gfield_select' tabindex='200'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' ><\/option><option value='Yes' >Yes<\/option><option value='No' >No<\/option><option value='Unknown' >Unknown<\/option><\/select><\/div><\/li><li id=\"field_7_164\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_164'>Vehicle Damage<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_164' id='input_7_164' class='textarea medium' tabindex='201'  maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_170\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_170'>Initial Point of Impact<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_170' id='input_7_170' class='textarea medium' tabindex='202'  maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_171\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_171'>Unrelated Prior Damage<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_171' id='input_7_171' class='textarea medium' tabindex='203'  maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_172\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Is the Vehicle Drivable?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_172'>\n\t\t\t<li class='gchoice gchoice_7_172_0'>\n\t\t\t\t<input name='input_172' type='radio' value='Yes'  id='choice_7_172_0' tabindex='204'   \/>\n\t\t\t\t<label for='choice_7_172_0' id='label_7_172_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_172_1'>\n\t\t\t\t<input name='input_172' type='radio' value='Unknown'  id='choice_7_172_1' tabindex='205'   \/>\n\t\t\t\t<label for='choice_7_172_1' id='label_7_172_1' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_172_2'>\n\t\t\t\t<input name='input_172' type='radio' value='No'  id='choice_7_172_2' tabindex='206'   \/>\n\t\t\t\t<label for='choice_7_172_2' id='label_7_172_2' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_173\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Where is the Vehicle Located?<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_173' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_173_1_container' >\n                                        <input type='text' name='input_173.1' id='input_7_173_1' value='' tabindex='207'   aria-required='false'    \/>\n                                        <label for='input_7_173_1' id='input_7_173_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_7_173_2_container' >\n                                        <input type='text' name='input_173.2' id='input_7_173_2' value='' tabindex='208'    aria-required='false'   \/>\n                                        <label for='input_7_173_2' id='input_7_173_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_173_3_container' >\n                                    <input type='text' name='input_173.3' id='input_7_173_3' value='' tabindex='209'   aria-required='false'    \/>\n                                    <label for='input_7_173_3' id='input_7_173_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_173_4_container' >\n                                        <select name='input_173.4' id='input_7_173_4' tabindex='210'    aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_173_4' id='input_7_173_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_173_5_container' >\n                                    <input type='text' name='input_173.5' id='input_7_173_5' value='' tabindex='212'   aria-required='false'    \/>\n                                    <label for='input_7_173_5' id='input_7_173_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_173.6' id='input_7_173_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_254\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Is this address a business?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_254'>\n\t\t\t<li class='gchoice gchoice_7_254_0'>\n\t\t\t\t<input name='input_254' type='radio' value='Yes'  id='choice_7_254_0' tabindex='213'   \/>\n\t\t\t\t<label for='choice_7_254_0' id='label_7_254_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_254_1'>\n\t\t\t\t<input name='input_254' type='radio' value='No'  id='choice_7_254_1' tabindex='214'   \/>\n\t\t\t\t<label for='choice_7_254_1' id='label_7_254_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_255\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_255'>Business Name<\/label><div class='ginput_container ginput_container_text'><input name='input_255' id='input_7_255' type='text' value='' class='medium'   tabindex='215'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_257\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_257'>Business Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_257' id='input_7_257' type='tel' value='' class='medium' tabindex='216'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_168\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_168'>Insurance Company Name<\/label><div class='ginput_container ginput_container_text'><input name='input_168' id='input_7_168' type='text' value='' class='medium'   tabindex='217'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_169\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_169'>Insurance Company Policy Number<\/label><div class='ginput_container ginput_container_text'><input name='input_169' id='input_7_169' type='text' value='' class='medium'   tabindex='218'   aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer left_label'>\n                        <input type='button' id='gform_previous_button_7_297' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='219' \/> <input type='button' id='gform_next_button_7_297' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='220' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_8' class='gform_page' data-js='page-field-id-297' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_8' class='gform_fields left_label form_sublabel_below description_below validation_below'><li id=\"field_7_174\" class=\"gfield gfield--type-section gsection header-fnol field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Other Vehicle Owner Information<\/h2><\/li><li id=\"field_7_175\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><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_7_175'>\n                            \n                            <span id='input_7_175_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_175.3' id='input_7_175_3' value='' tabindex='222'  aria-required='false'     \/>\n                                                    <label for='input_7_175_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_175_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_175.4' id='input_7_175_4' value='' tabindex='223'  aria-required='false'     \/>\n                                                    <label for='input_7_175_4' class='gform-field-label gform-field-label--type-sub '>Segundo nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_175_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_175.6' id='input_7_175_6' value='' tabindex='224'  aria-required='false'     \/>\n                                                    <label for='input_7_175_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_7_176\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_176' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_176_1_container' >\n                                        <input type='text' name='input_176.1' id='input_7_176_1' value='' tabindex='226'   aria-required='false'    \/>\n                                        <label for='input_7_176_1' id='input_7_176_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_7_176_2_container' >\n                                        <input type='text' name='input_176.2' id='input_7_176_2' value='' tabindex='227'    aria-required='false'   \/>\n                                        <label for='input_7_176_2' id='input_7_176_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_176_3_container' >\n                                    <input type='text' name='input_176.3' id='input_7_176_3' value='' tabindex='228'   aria-required='false'    \/>\n                                    <label for='input_7_176_3' id='input_7_176_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_176_4_container' >\n                                        <select name='input_176.4' id='input_7_176_4' tabindex='229'    aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_176_4' id='input_7_176_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_176_5_container' >\n                                    <input type='text' name='input_176.5' id='input_7_176_5' value='' tabindex='231'   aria-required='false'    \/>\n                                    <label for='input_7_176_5' id='input_7_176_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_176.6' id='input_7_176_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_177\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_177'>Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_177' id='input_7_177' type='tel' value='' class='medium' tabindex='232'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_178\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_178'>Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_178' id='input_7_178' type='tel' value='' class='medium' tabindex='233'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_179\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_179'>Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_179' id='input_7_179' type='tel' value='' class='medium' tabindex='234'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_180\" class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_180'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_180' id='input_7_180' type='email' value='' class='medium' tabindex='235'    aria-invalid=\"false\"  \/>\n                        <\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer left_label'>\n                        <input type='button' id='gform_previous_button_7_265' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='236' \/> <input type='button' id='gform_next_button_7_265' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='237' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_9' class='gform_page' data-js='page-field-id-265' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_9' class='gform_fields left_label form_sublabel_below description_below validation_below'><li id=\"field_7_181\" class=\"gfield gfield--type-section gsection header-fnol field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Other Vehicle Driver Information<\/h2><\/li><li id=\"field_7_182\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Is the Driver the Same as the Vehicle Owner?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_182'>\n\t\t\t<li class='gchoice gchoice_7_182_0'>\n\t\t\t\t<input name='input_182' type='radio' value='Yes'  id='choice_7_182_0' tabindex='238'   \/>\n\t\t\t\t<label for='choice_7_182_0' id='label_7_182_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_182_1'>\n\t\t\t\t<input name='input_182' type='radio' value='No'  id='choice_7_182_1' tabindex='239'   \/>\n\t\t\t\t<label for='choice_7_182_1' id='label_7_182_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_186\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><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_7_186'>\n                            \n                            <span id='input_7_186_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_186.3' id='input_7_186_3' value='' tabindex='241'  aria-required='false'     \/>\n                                                    <label for='input_7_186_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_186_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_186.4' id='input_7_186_4' value='' tabindex='242'  aria-required='false'     \/>\n                                                    <label for='input_7_186_4' class='gform-field-label gform-field-label--type-sub '>Segundo nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_186_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_186.6' id='input_7_186_6' value='' tabindex='243'  aria-required='false'     \/>\n                                                    <label for='input_7_186_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_7_187\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_187' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_187_1_container' >\n                                        <input type='text' name='input_187.1' id='input_7_187_1' value='' tabindex='245'   aria-required='false'    \/>\n                                        <label for='input_7_187_1' id='input_7_187_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_7_187_2_container' >\n                                        <input type='text' name='input_187.2' id='input_7_187_2' value='' tabindex='246'    aria-required='false'   \/>\n                                        <label for='input_7_187_2' id='input_7_187_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_187_3_container' >\n                                    <input type='text' name='input_187.3' id='input_7_187_3' value='' tabindex='247'   aria-required='false'    \/>\n                                    <label for='input_7_187_3' id='input_7_187_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_187_4_container' >\n                                        <select name='input_187.4' id='input_7_187_4' tabindex='248'    aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_187_4' id='input_7_187_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_187_5_container' >\n                                    <input type='text' name='input_187.5' id='input_7_187_5' value='' tabindex='250'   aria-required='false'    \/>\n                                    <label for='input_7_187_5' id='input_7_187_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_187.6' id='input_7_187_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_188\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_188'>Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_188' id='input_7_188' type='tel' value='' class='medium' tabindex='251'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_189\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_189'>Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_189' id='input_7_189' type='tel' value='' class='medium' tabindex='252'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_190\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_190'>Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_190' id='input_7_190' type='tel' value='' class='medium' tabindex='253'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_191\" class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_191'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_191' id='input_7_191' type='email' value='' class='medium' tabindex='254'    aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_7_183\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_183'>Driver&#039;s Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_183' id='input_7_183' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='255'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_7_183_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_7_183_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_183' class='gform_hidden' value='https:\/\/vivasegurosinc.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_7_184\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_184'>Driver&#039;s License Number<\/label><div class='ginput_container ginput_container_text'><input name='input_184' id='input_7_184' type='text' value='' class='medium'   tabindex='256'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_185\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Driver&#039;s License State<\/label>    \n                    <div class='ginput_complex ginput_container has_state ginput_container_address gform-grid-row' id='input_7_185' >\n                        <span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_185_4_container' >\n                                        <select name='input_185.4' id='input_7_185_4' tabindex='259'    aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_185_4' id='input_7_185_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><input type='hidden' class='gform_hidden' name='input_185.6' id='input_7_185_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_234\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Were there any injuries to the driver?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_234'>\n\t\t\t<li class='gchoice gchoice_7_234_0'>\n\t\t\t\t<input name='input_234' type='radio' value='Yes'  id='choice_7_234_0' tabindex='262'   \/>\n\t\t\t\t<label for='choice_7_234_0' id='label_7_234_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_234_1'>\n\t\t\t\t<input name='input_234' type='radio' value='No'  id='choice_7_234_1' tabindex='263'   \/>\n\t\t\t\t<label for='choice_7_234_1' id='label_7_234_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_235\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_235'>Describe Injuries:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_235' id='input_7_235' class='textarea medium' tabindex='264'  maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_250\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did this person seek medical treatment?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_250'>\n\t\t\t<li class='gchoice gchoice_7_250_0'>\n\t\t\t\t<input name='input_250' type='radio' value='Yes'  id='choice_7_250_0' tabindex='265'   \/>\n\t\t\t\t<label for='choice_7_250_0' id='label_7_250_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_250_1'>\n\t\t\t\t<input name='input_250' type='radio' value='No'  id='choice_7_250_1' tabindex='266'   \/>\n\t\t\t\t<label for='choice_7_250_1' id='label_7_250_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_241\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Were any tickets issued to this driver?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_241'>\n\t\t\t<li class='gchoice gchoice_7_241_0'>\n\t\t\t\t<input name='input_241' type='radio' value='Yes'  id='choice_7_241_0' tabindex='267'   \/>\n\t\t\t\t<label for='choice_7_241_0' id='label_7_241_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_241_1'>\n\t\t\t\t<input name='input_241' type='radio' value='No'  id='choice_7_241_1' tabindex='268'   \/>\n\t\t\t\t<label for='choice_7_241_1' id='label_7_241_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_266\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_266'>Ticket Reason<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_266' id='input_7_266' class='textarea medium' tabindex='269'  maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer left_label'>\n                        <input type='button' id='gform_previous_button_7_267' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='270' \/> <input type='button' id='gform_next_button_7_267' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='271' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_10' class='gform_page' data-js='page-field-id-267' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_10' class='gform_fields left_label form_sublabel_below description_below validation_below'><li id=\"field_7_192\" class=\"gfield gfield--type-section gsection header-fnol field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Other Vehicle Passenger Information<\/h2><\/li><li id=\"field_7_193\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_193'>How many Passengers in the other Vehicle?(other than the driver?)<\/label><div class='ginput_container ginput_container_select'><select name='input_193' id='input_7_193' class='medium gfield_select' tabindex='272'    aria-invalid=\"false\" ><option value='0' >None<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><\/select><\/div><\/li><li id=\"field_7_194\" class=\"gfield gfield--type-section gsection header-fnol field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Passenger 1<\/h2><\/li><li id=\"field_7_201\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><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_7_201'>\n                            \n                            <span id='input_7_201_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_201.3' id='input_7_201_3' value='' tabindex='274'  aria-required='false'     \/>\n                                                    <label for='input_7_201_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_201_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_201.4' id='input_7_201_4' value='' tabindex='275'  aria-required='false'     \/>\n                                                    <label for='input_7_201_4' class='gform-field-label gform-field-label--type-sub '>Segundo nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_201_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_201.6' id='input_7_201_6' value='' tabindex='276'  aria-required='false'     \/>\n                                                    <label for='input_7_201_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_7_202\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_202' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_202_1_container' >\n                                        <input type='text' name='input_202.1' id='input_7_202_1' value='' tabindex='278'   aria-required='false'    \/>\n                                        <label for='input_7_202_1' id='input_7_202_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_7_202_2_container' >\n                                        <input type='text' name='input_202.2' id='input_7_202_2' value='' tabindex='279'    aria-required='false'   \/>\n                                        <label for='input_7_202_2' id='input_7_202_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_202_3_container' >\n                                    <input type='text' name='input_202.3' id='input_7_202_3' value='' tabindex='280'   aria-required='false'    \/>\n                                    <label for='input_7_202_3' id='input_7_202_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_202_4_container' >\n                                        <select name='input_202.4' id='input_7_202_4' tabindex='281'    aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_202_4' id='input_7_202_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_202_5_container' >\n                                    <input type='text' name='input_202.5' id='input_7_202_5' value='' tabindex='283'   aria-required='false'    \/>\n                                    <label for='input_7_202_5' id='input_7_202_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_202.6' id='input_7_202_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_203\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_203'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_203' id='input_7_203' type='tel' value='' class='medium' tabindex='284'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_204\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_204'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_204' id='input_7_204' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='285'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_7_204_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_7_204_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_204' class='gform_hidden' value='https:\/\/vivasegurosinc.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_7_236\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Were there any Injuries?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_236'>\n\t\t\t<li class='gchoice gchoice_7_236_0'>\n\t\t\t\t<input name='input_236' type='radio' value='Yes'  id='choice_7_236_0' tabindex='286'   \/>\n\t\t\t\t<label for='choice_7_236_0' id='label_7_236_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_236_1'>\n\t\t\t\t<input name='input_236' type='radio' value='No'  id='choice_7_236_1' tabindex='287'   \/>\n\t\t\t\t<label for='choice_7_236_1' id='label_7_236_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_224\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_224'>Describe Injuries:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_224' id='input_7_224' class='textarea medium' tabindex='288'  maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_259\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did this person seek medical treatment?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_259'>\n\t\t\t<li class='gchoice gchoice_7_259_0'>\n\t\t\t\t<input name='input_259' type='radio' value='Yes'  id='choice_7_259_0' tabindex='289'   \/>\n\t\t\t\t<label for='choice_7_259_0' id='label_7_259_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_259_1'>\n\t\t\t\t<input name='input_259' type='radio' value='No'  id='choice_7_259_1' tabindex='290'   \/>\n\t\t\t\t<label for='choice_7_259_1' id='label_7_259_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_259_2'>\n\t\t\t\t<input name='input_259' type='radio' value='Unknown'  id='choice_7_259_2' tabindex='291'   \/>\n\t\t\t\t<label for='choice_7_259_2' id='label_7_259_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_195\" class=\"gfield gfield--type-section gsection header-fnol field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Passenger 2<\/h2><\/li><li id=\"field_7_205\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><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_7_205'>\n                            \n                            <span id='input_7_205_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_205.3' id='input_7_205_3' value='' tabindex='293'  aria-required='false'     \/>\n                                                    <label for='input_7_205_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_205_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_205.4' id='input_7_205_4' value='' tabindex='294'  aria-required='false'     \/>\n                                                    <label for='input_7_205_4' class='gform-field-label gform-field-label--type-sub '>Segundo nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_205_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_205.6' id='input_7_205_6' value='' tabindex='295'  aria-required='false'     \/>\n                                                    <label for='input_7_205_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_7_206\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_206' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_206_1_container' >\n                                        <input type='text' name='input_206.1' id='input_7_206_1' value='' tabindex='297'   aria-required='false'    \/>\n                                        <label for='input_7_206_1' id='input_7_206_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_7_206_2_container' >\n                                        <input type='text' name='input_206.2' id='input_7_206_2' value='' tabindex='298'    aria-required='false'   \/>\n                                        <label for='input_7_206_2' id='input_7_206_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_206_3_container' >\n                                    <input type='text' name='input_206.3' id='input_7_206_3' value='' tabindex='299'   aria-required='false'    \/>\n                                    <label for='input_7_206_3' id='input_7_206_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_206_4_container' >\n                                        <select name='input_206.4' id='input_7_206_4' tabindex='300'    aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_206_4' id='input_7_206_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_206_5_container' >\n                                    <input type='text' name='input_206.5' id='input_7_206_5' value='' tabindex='302'   aria-required='false'    \/>\n                                    <label for='input_7_206_5' id='input_7_206_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_206.6' id='input_7_206_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_207\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_207'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_207' id='input_7_207' type='tel' value='' class='medium' tabindex='303'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_208\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_208'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_208' id='input_7_208' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='304'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_7_208_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_7_208_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_208' class='gform_hidden' value='https:\/\/vivasegurosinc.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_7_237\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Were there any injuries?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_237'>\n\t\t\t<li class='gchoice gchoice_7_237_0'>\n\t\t\t\t<input name='input_237' type='radio' value='Yes'  id='choice_7_237_0' tabindex='305'   \/>\n\t\t\t\t<label for='choice_7_237_0' id='label_7_237_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_237_1'>\n\t\t\t\t<input name='input_237' type='radio' value='No'  id='choice_7_237_1' tabindex='306'   \/>\n\t\t\t\t<label for='choice_7_237_1' id='label_7_237_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_225\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_225'>Describe Injuries:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_225' id='input_7_225' class='textarea medium' tabindex='307'  maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_260\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did this person seek medical treatment?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_260'>\n\t\t\t<li class='gchoice gchoice_7_260_0'>\n\t\t\t\t<input name='input_260' type='radio' value='Yes'  id='choice_7_260_0' tabindex='308'   \/>\n\t\t\t\t<label for='choice_7_260_0' id='label_7_260_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_260_1'>\n\t\t\t\t<input name='input_260' type='radio' value='No'  id='choice_7_260_1' tabindex='309'   \/>\n\t\t\t\t<label for='choice_7_260_1' id='label_7_260_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_260_2'>\n\t\t\t\t<input name='input_260' type='radio' value='Unknown'  id='choice_7_260_2' tabindex='310'   \/>\n\t\t\t\t<label for='choice_7_260_2' id='label_7_260_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_196\" class=\"gfield gfield--type-section gsection header-fnol field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Passenger 3<\/h2><\/li><li id=\"field_7_210\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><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_7_210'>\n                            \n                            <span id='input_7_210_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_210.3' id='input_7_210_3' value='' tabindex='312'  aria-required='false'     \/>\n                                                    <label for='input_7_210_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_210_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_210.4' id='input_7_210_4' value='' tabindex='313'  aria-required='false'     \/>\n                                                    <label for='input_7_210_4' class='gform-field-label gform-field-label--type-sub '>Segundo nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_210_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_210.6' id='input_7_210_6' value='' tabindex='314'  aria-required='false'     \/>\n                                                    <label for='input_7_210_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_7_211\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_211' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_211_1_container' >\n                                        <input type='text' name='input_211.1' id='input_7_211_1' value='' tabindex='316'   aria-required='false'    \/>\n                                        <label for='input_7_211_1' id='input_7_211_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_7_211_2_container' >\n                                        <input type='text' name='input_211.2' id='input_7_211_2' value='' tabindex='317'    aria-required='false'   \/>\n                                        <label for='input_7_211_2' id='input_7_211_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_211_3_container' >\n                                    <input type='text' name='input_211.3' id='input_7_211_3' value='' tabindex='318'   aria-required='false'    \/>\n                                    <label for='input_7_211_3' id='input_7_211_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_211_4_container' >\n                                        <select name='input_211.4' id='input_7_211_4' tabindex='319'    aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_211_4' id='input_7_211_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_211_5_container' >\n                                    <input type='text' name='input_211.5' id='input_7_211_5' value='' tabindex='321'   aria-required='false'    \/>\n                                    <label for='input_7_211_5' id='input_7_211_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_211.6' id='input_7_211_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_212\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_212'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_212' id='input_7_212' type='tel' value='' class='medium' tabindex='322'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_213\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_213'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_213' id='input_7_213' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='323'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_7_213_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_7_213_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_213' class='gform_hidden' value='https:\/\/vivasegurosinc.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_7_238\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Were there any injuries?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_238'>\n\t\t\t<li class='gchoice gchoice_7_238_0'>\n\t\t\t\t<input name='input_238' type='radio' value='Yes'  id='choice_7_238_0' tabindex='324'   \/>\n\t\t\t\t<label for='choice_7_238_0' id='label_7_238_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_238_1'>\n\t\t\t\t<input name='input_238' type='radio' value='No'  id='choice_7_238_1' tabindex='325'   \/>\n\t\t\t\t<label for='choice_7_238_1' id='label_7_238_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_220\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_220'>Describe Injuries:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_220' id='input_7_220' class='textarea medium' tabindex='326'  maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_261\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did this person seek medical treatment?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_261'>\n\t\t\t<li class='gchoice gchoice_7_261_0'>\n\t\t\t\t<input name='input_261' type='radio' value='Yes'  id='choice_7_261_0' tabindex='327'   \/>\n\t\t\t\t<label for='choice_7_261_0' id='label_7_261_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_261_1'>\n\t\t\t\t<input name='input_261' type='radio' value='No'  id='choice_7_261_1' tabindex='328'   \/>\n\t\t\t\t<label for='choice_7_261_1' id='label_7_261_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_261_2'>\n\t\t\t\t<input name='input_261' type='radio' value='Unknown'  id='choice_7_261_2' tabindex='329'   \/>\n\t\t\t\t<label for='choice_7_261_2' id='label_7_261_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_197\" class=\"gfield gfield--type-section gsection header-fnol field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Passenger 4<\/h2><\/li><li id=\"field_7_214\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><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_7_214'>\n                            \n                            <span id='input_7_214_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_214.3' id='input_7_214_3' value='' tabindex='331'  aria-required='false'     \/>\n                                                    <label for='input_7_214_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_214_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_214.4' id='input_7_214_4' value='' tabindex='332'  aria-required='false'     \/>\n                                                    <label for='input_7_214_4' class='gform-field-label gform-field-label--type-sub '>Segundo nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_214_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_214.6' id='input_7_214_6' value='' tabindex='333'  aria-required='false'     \/>\n                                                    <label for='input_7_214_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_7_215\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_215' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_215_1_container' >\n                                        <input type='text' name='input_215.1' id='input_7_215_1' value='' tabindex='335'   aria-required='false'    \/>\n                                        <label for='input_7_215_1' id='input_7_215_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_7_215_2_container' >\n                                        <input type='text' name='input_215.2' id='input_7_215_2' value='' tabindex='336'    aria-required='false'   \/>\n                                        <label for='input_7_215_2' id='input_7_215_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_215_3_container' >\n                                    <input type='text' name='input_215.3' id='input_7_215_3' value='' tabindex='337'   aria-required='false'    \/>\n                                    <label for='input_7_215_3' id='input_7_215_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_215_4_container' >\n                                        <select name='input_215.4' id='input_7_215_4' tabindex='338'    aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_215_4' id='input_7_215_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_215_5_container' >\n                                    <input type='text' name='input_215.5' id='input_7_215_5' value='' tabindex='340'   aria-required='false'    \/>\n                                    <label for='input_7_215_5' id='input_7_215_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_215.6' id='input_7_215_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_216\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_216'>Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_216' id='input_7_216' type='tel' value='' class='medium' tabindex='341'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_217\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_217'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_217' id='input_7_217' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='342'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_7_217_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_7_217_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_217' class='gform_hidden' value='https:\/\/vivasegurosinc.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_7_239\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Were there any injuries?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_239'>\n\t\t\t<li class='gchoice gchoice_7_239_0'>\n\t\t\t\t<input name='input_239' type='radio' value='Yes'  id='choice_7_239_0' tabindex='343'   \/>\n\t\t\t\t<label for='choice_7_239_0' id='label_7_239_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_239_1'>\n\t\t\t\t<input name='input_239' type='radio' value='No'  id='choice_7_239_1' tabindex='344'   \/>\n\t\t\t\t<label for='choice_7_239_1' id='label_7_239_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_102\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_102'>Describe Injuries:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_102' id='input_7_102' class='textarea medium' tabindex='345'  maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_262\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did this person seek medical treatment?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_262'>\n\t\t\t<li class='gchoice gchoice_7_262_0'>\n\t\t\t\t<input name='input_262' type='radio' value='Yes'  id='choice_7_262_0' tabindex='346'   \/>\n\t\t\t\t<label for='choice_7_262_0' id='label_7_262_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_262_1'>\n\t\t\t\t<input name='input_262' type='radio' value='No'  id='choice_7_262_1' tabindex='347'   \/>\n\t\t\t\t<label for='choice_7_262_1' id='label_7_262_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_262_2'>\n\t\t\t\t<input name='input_262' type='radio' value='Unknown'  id='choice_7_262_2' tabindex='348'   \/>\n\t\t\t\t<label for='choice_7_262_2' id='label_7_262_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer left_label'>\n                        <input type='button' id='gform_previous_button_7_96' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='349' \/> <input type='button' id='gform_next_button_7_96' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='350' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_11' class='gform_page' data-js='page-field-id-96' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_11' class='gform_fields left_label form_sublabel_below description_below validation_below'><li id=\"field_7_129\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Was a pedestrian involved in this accident?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_129'>\n\t\t\t<li class='gchoice gchoice_7_129_0'>\n\t\t\t\t<input name='input_129' type='radio' value='Yes'  id='choice_7_129_0' tabindex='351'   \/>\n\t\t\t\t<label for='choice_7_129_0' id='label_7_129_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_129_1'>\n\t\t\t\t<input name='input_129' type='radio' value='No'  id='choice_7_129_1' tabindex='352'   \/>\n\t\t\t\t<label for='choice_7_129_1' id='label_7_129_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_130\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<\/label><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_7_130'>\n                            \n                            <span id='input_7_130_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_130.3' id='input_7_130_3' value='' tabindex='354'  aria-required='false'     \/>\n                                                    <label for='input_7_130_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_130_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_130.4' id='input_7_130_4' value='' tabindex='355'  aria-required='false'     \/>\n                                                    <label for='input_7_130_4' class='gform-field-label gform-field-label--type-sub '>Segundo nombre<\/label>\n                                                <\/span>\n                            <span id='input_7_130_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_130.6' id='input_7_130_6' value='' tabindex='356'  aria-required='false'     \/>\n                                                    <label for='input_7_130_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_7_131\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_131' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_131_1_container' >\n                                        <input type='text' name='input_131.1' id='input_7_131_1' value='' tabindex='358'   aria-required='false'    \/>\n                                        <label for='input_7_131_1' id='input_7_131_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_7_131_2_container' >\n                                        <input type='text' name='input_131.2' id='input_7_131_2' value='' tabindex='359'    aria-required='false'   \/>\n                                        <label for='input_7_131_2' id='input_7_131_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_131_3_container' >\n                                    <input type='text' name='input_131.3' id='input_7_131_3' value='' tabindex='360'   aria-required='false'    \/>\n                                    <label for='input_7_131_3' id='input_7_131_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_131_4_container' >\n                                        <select name='input_131.4' id='input_7_131_4' tabindex='361'    aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_131_4' id='input_7_131_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_131_5_container' >\n                                    <input type='text' name='input_131.5' id='input_7_131_5' value='' tabindex='363'   aria-required='false'    \/>\n                                    <label for='input_7_131_5' id='input_7_131_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_131.6' id='input_7_131_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_132\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_132'>Cell Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_132' id='input_7_132' type='tel' value='' class='medium' tabindex='364'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_222\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_222'>Work Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_222' id='input_7_222' type='tel' value='' class='medium' tabindex='365'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_221\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_221'>Home Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_221' id='input_7_221' type='tel' value='' class='medium' tabindex='366'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_133\" class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_133'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_133' id='input_7_133' type='email' value='' class='medium' tabindex='367'    aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_7_134\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_134'>Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_134' id='input_7_134' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='368'  placeholder='mm\/dd\/aaaa' aria-describedby=\"input_7_134_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_7_134_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_7_134' class='gform_hidden' value='https:\/\/vivasegurosinc.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_7_223\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Was this person injured?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_223'>\n\t\t\t<li class='gchoice gchoice_7_223_0'>\n\t\t\t\t<input name='input_223' type='radio' value='Yes'  id='choice_7_223_0' tabindex='369'   \/>\n\t\t\t\t<label for='choice_7_223_0' id='label_7_223_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_223_1'>\n\t\t\t\t<input name='input_223' type='radio' value='No'  id='choice_7_223_1' tabindex='370'   \/>\n\t\t\t\t<label for='choice_7_223_1' id='label_7_223_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_219\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_219'>Describe Injuries:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_219' id='input_7_219' class='textarea medium' tabindex='371'  maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_258\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Did this person seek medical treatment?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_258'>\n\t\t\t<li class='gchoice gchoice_7_258_0'>\n\t\t\t\t<input name='input_258' type='radio' value='Yes'  id='choice_7_258_0' tabindex='372'   \/>\n\t\t\t\t<label for='choice_7_258_0' id='label_7_258_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_258_1'>\n\t\t\t\t<input name='input_258' type='radio' value='No'  id='choice_7_258_1' tabindex='373'   \/>\n\t\t\t\t<label for='choice_7_258_1' id='label_7_258_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_258_2'>\n\t\t\t\t<input name='input_258' type='radio' value='Unknown'  id='choice_7_258_2' tabindex='374'   \/>\n\t\t\t\t<label for='choice_7_258_2' id='label_7_258_2' class='gform-field-label gform-field-label--type-inline'>Unknown<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer left_label'>\n                        <input type='button' id='gform_previous_button_7_301' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='375' \/> <input type='button' id='gform_next_button_7_301' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='376' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_12' class='gform_page' data-js='page-field-id-301' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_12' class='gform_fields left_label form_sublabel_below description_below validation_below'><li id=\"field_7_300\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Fixed Object Information<\/h2><\/li><li id=\"field_7_294\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' >Was a fixed object involved?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_294'>\n\t\t\t<li class='gchoice gchoice_7_294_0'>\n\t\t\t\t<input name='input_294' type='radio' value='Yes'  id='choice_7_294_0' tabindex='377'   \/>\n\t\t\t\t<label for='choice_7_294_0' id='label_7_294_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_294_1'>\n\t\t\t\t<input name='input_294' type='radio' value='No'  id='choice_7_294_1' tabindex='378'   \/>\n\t\t\t\t<label for='choice_7_294_1' id='label_7_294_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_295\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_295'>Describe Fixed Object<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_295' id='input_7_295' class='textarea medium' tabindex='379'  maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_296\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_296'>Describe Damage to Fixed Object<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_296' id='input_7_296' class='textarea medium' tabindex='380'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_7_302\" class=\"gfield gfield--type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Fixed Object Owner<\/label><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_7_302'>\n                            \n                            <span id='input_7_302_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_302.3' id='input_7_302_3' value='' tabindex='382'  aria-required='false'     \/>\n                                                    <label for='input_7_302_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_7_302_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_302.6' id='input_7_302_6' value='' tabindex='384'  aria-required='false'     \/>\n                                                    <label for='input_7_302_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_7_303\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Fixed Object Address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_7_303' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_7_303_1_container' >\n                                        <input type='text' name='input_303.1' id='input_7_303_1' value='' tabindex='386'   aria-required='false'    \/>\n                                        <label for='input_7_303_1' id='input_7_303_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_7_303_2_container' >\n                                        <input type='text' name='input_303.2' id='input_7_303_2' value='' tabindex='387'    aria-required='false'   \/>\n                                        <label for='input_7_303_2' id='input_7_303_2_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_7_303_3_container' >\n                                    <input type='text' name='input_303.3' id='input_7_303_3' value='' tabindex='388'   aria-required='false'    \/>\n                                    <label for='input_7_303_3' id='input_7_303_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_7_303_4_container' >\n                                        <select name='input_303.4' id='input_7_303_4' tabindex='389'    aria-required='false'    ><option value='' selected='selected'><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >District of Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawaii<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Louisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >New Hampshire<\/option><option value='New Jersey' >New Jersey<\/option><option value='New Mexico' >New Mexico<\/option><option value='New York' >New York<\/option><option value='North Carolina' >North Carolina<\/option><option value='North Dakota' >North Dakota<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >South Carolina<\/option><option value='South Dakota' >South Dakota<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >West Virginia<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_7_303_4' id='input_7_303_4_label' class='gform-field-label gform-field-label--type-sub '>Provincia<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_7_303_5_container' >\n                                    <input type='text' name='input_303.5' id='input_7_303_5' value='' tabindex='391'   aria-required='false'    \/>\n                                    <label for='input_7_303_5' id='input_7_303_5_label' class='gform-field-label gform-field-label--type-sub '>C\u00f3digo Postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_303.6' id='input_7_303_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_7_305\" class=\"gfield gfield--type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_305'>Fixed Object Owner&#039;s Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_305' id='input_7_305' type='email' value='' class='medium' tabindex='392'    aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_7_304\" class=\"gfield gfield--type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_304'>Fixed Object Owner&#039;s Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_304' id='input_7_304' type='tel' value='' class='medium' tabindex='393'   aria-invalid=\"false\"   \/><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer left_label'>\n                        <input type='button' id='gform_previous_button_7_95' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='394' \/> <input type='button' id='gform_next_button_7_95' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='395' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_13' class='gform_page' data-js='page-field-id-95' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_13' class='gform_fields left_label form_sublabel_below description_below validation_below'><li id=\"field_7_98\" class=\"gfield gfield--type-section gsection header-fnol field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Accident Details<\/h2><\/li><li id=\"field_7_103\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_103'>Describe what happened in the accident:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><div id=\"wp-input_7_103-wrap\" class=\"wp-core-ui wp-editor-wrap tmce-active\"><link rel='stylesheet' id='dashicons-css' href='https:\/\/vivasegurosinc.com\/wp-includes\/css\/dashicons.min.css?ver=6.9.4' type='text\/css' media='all' \/>\n<link rel='stylesheet' id='editor-buttons-css' href='https:\/\/vivasegurosinc.com\/wp-includes\/css\/editor.min.css?ver=6.9.4' type='text\/css' media='all' \/>\n<div id=\"wp-input_7_103-editor-container\" class=\"wp-editor-container\"><textarea class=\"medium wp-editor-area\" style=\"height: 180px\" tabindex=\"397\" autocomplete=\"off\" cols=\"40\" name=\"input_103\" id=\"input_7_103\"><\/textarea><\/div>\n<\/div>\n\n<\/div><\/li><li id=\"field_7_104\" 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\"  ><label class='gfield_label gform-field-label' >Were the police notified?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_104'>\n\t\t\t<li class='gchoice gchoice_7_104_0'>\n\t\t\t\t<input name='input_104' type='radio' value='Yes'  id='choice_7_104_0' tabindex='398'   \/>\n\t\t\t\t<label for='choice_7_104_0' id='label_7_104_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_104_1'>\n\t\t\t\t<input name='input_104' type='radio' value='No'  id='choice_7_104_1' tabindex='399'   \/>\n\t\t\t\t<label for='choice_7_104_1' id='label_7_104_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_108\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_108'>Police Department<\/label><div class='ginput_container ginput_container_text'><input name='input_108' id='input_7_108' type='text' value='' class='medium'   tabindex='400'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_109\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_109'>Police Report Number<\/label><div class='ginput_container ginput_container_text'><input name='input_109' id='input_7_109' type='text' value='' class='medium'   tabindex='401'   aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_7_298\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_298'>Reported through<\/label><div class='ginput_container ginput_container_select'><select name='input_298' id='input_7_298' class='medium gfield_select' tabindex='402'    aria-invalid=\"false\" ><option value='Police On Scene' >Police On Scene<\/option><option value='Report Filed in Station' >Report Filed in Station<\/option><option value='Report Filed on Phone' >Report Filed on Phone<\/option><\/select><\/div><\/li><li id=\"field_7_110\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_7_110'>Any additional Comments?<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_110' id='input_7_110' class='textarea medium' tabindex='403'  maxlength='1000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><\/ul>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer left_label'>\n                        <input type='button' id='gform_previous_button_7_125' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='404' \/> <input type='button' id='gform_next_button_7_125' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next' tabindex='405' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_7_14' class='gform_page' data-js='page-field-id-125' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <ul id='gform_fields_7_14' class='gform_fields left_label form_sublabel_below description_below validation_below'><li id=\"field_7_320\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\">Disclaimers<\/h2><\/li><li id=\"field_7_321\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>If applicable, we may want to send you an email or text message with a link which provides instruction to take photographs of your damaged vehicle.<\/p><\/li><li id=\"field_7_322\" 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\"  ><label class='gfield_label gform-field-label' >Do you give your permission?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_7_322'>\n\t\t\t<li class='gchoice gchoice_7_322_0'>\n\t\t\t\t<input name='input_322' type='radio' value='No'  id='choice_7_322_0' tabindex='406'   \/>\n\t\t\t\t<label for='choice_7_322_0' id='label_7_322_0' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_322_1'>\n\t\t\t\t<input name='input_322' type='radio' value='Yes, send me a text message'  id='choice_7_322_1' tabindex='407'   \/>\n\t\t\t\t<label for='choice_7_322_1' id='label_7_322_1' class='gform-field-label gform-field-label--type-inline'>Yes, send me a text message<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_7_322_2'>\n\t\t\t\t<input name='input_322' type='radio' value='Yes, send me an email'  id='choice_7_322_2' tabindex='408'   \/>\n\t\t\t\t<label for='choice_7_322_2' id='label_7_322_2' class='gform-field-label gform-field-label--type-inline'>Yes, send me an email<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_7_323\" class=\"gfield gfield--type-phone gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_7_323'>We will send a text message to this provided phone number.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_323' id='input_7_323' type='tel' value='' class='medium' tabindex='409'  aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_7_323\"  \/><\/div><div class='gfield_description' id='gfield_description_7_323'>We will send a text message to this provided phone number.<\/div><\/li><li id=\"field_7_324\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_7_324'>We will send an email to this provided email address.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_324' id='input_7_324' type='email' value='' class='medium' tabindex='410'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_7_324\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_7_324'>We will send an email to this provided email address.<\/div><\/li><li id=\"field_7_325\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2 class=\"gsection_title\"><\/h2><\/li><li id=\"field_7_326\" class=\"gfield gfield--type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div style=\"font-size:0.75em; border:1px solid #000; padding: 10px;\">\n<p>Law requires vehicle owners to mitigate their damages, whether the vehicle is disabled or not.  This includes, but is not limited to, protecting the vehicle from further damage and to move the vehicle to a storage free location. \n<br\/>\nIf your vehicle, whether disabled or not, is at any facility incurring charges for any reason, please be advised that you have the duty to move your vehicle to a storage free location.\n<br\/>\nWe will not be responsible for, nor will we pay, any unreasonable towing or storage fees incurred, prior to, during or after our involvement due to your failure to mitigate your loss.\n<\/p>\n<\/div><\/li><li id=\"field_7_308\" class=\"gfield gfield--type-consent gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label gfield_label_before_complex' >Do you understand and accept these conditions?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_consent'><input name='input_308.1' id='input_7_308_1' type='checkbox' value='1' tabindex='411'  aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_7_308_1' >Yes<\/label><input type='hidden' name='input_308.2' value='Yes' class='gform_hidden' \/><input type='hidden' name='input_308.3' value='4' class='gform_hidden' \/><\/div><\/li><\/ul><\/div>\n        <div class='gform-page-footer gform_page_footer left_label'><input type='submit' id='gform_previous_button_7' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous' tabindex='412' \/> <input type='submit' id='gform_submit_button_7' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit' tabindex='413' \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_7' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_7' id='gform_theme_7' value='legacy' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_7' id='gform_style_settings_7' value='' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_7' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='7' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='USD' value='0dVfLD8JwKCFa1w4ntCjrFxybb5tvfMPKIwmAGTfq1Qgk5a9ch5Don+H5r3fGeEWSasyo5QJxr1J9FOgPs1K2uSk\/NtGTg6tpoe1RPeNuLGBafU=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_7' value='WyJ7XCIzMDguMVwiOlwiZTMyYjQ0NmQ3ZmJhMjU3YWRkZDI0NzkwMWZhMDc0ODVcIixcIjMwOC4yXCI6XCI0NzE0NThlNjhkMTk1OGI5NmViZjU5ZTY1MDhmNGI3YlwiLFwiMzA4LjNcIjpcImZlODM4NzdiYWVjOWQzYjY2YTk3OWI2NTlmNGQ1NmQzXCJ9IiwiYWE1MzkyM2Q4NmVkNWZhZjJhMDQyZjJhYzFmNWUxZjciXQ==' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_target_page_number_7' id='gform_target_page_number_7' value='2' \/>\n            <input type='hidden' autocomplete='off' class='gform_hidden' name='gform_source_page_number_7' id='gform_source_page_number_7' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n             <\/div><\/div>\n                        <\/form>\n                        <\/div><script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\n gform.initializeOnLoaded( function() {gformInitSpinner( 7, 'https:\/\/vivasegurosinc.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_7').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_7');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_7').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_7').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_7').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_7').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_7').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_7').val();gformInitSpinner( 7, 'https:\/\/vivasegurosinc.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [7, current_page]);window['gf_submitting_7'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_7').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_7').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [7]);window['gf_submitting_7'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_7').text());}else{jQuery('#gform_7').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"7\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);        if (event && event.defaultPrevented) {                return;        }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_7\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_7\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_7\" );        let postRenderFired = false;        function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            gform.core.triggerPostRenderEvents( 7, current_page );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} ); \n\/* ]]> *\/\n<\/script>\n<\/div><\/div><\/div><\/div><\/div>","protected":false},"excerpt":{"rendered":"<p>Claims Superior claims services requires efficient and detailed claims handling. We act quickly to record and investigate all reported incidents. Claims can be reported to our claims department by phone at (877) 807-8482. Our fax number is (773) 569-3394. 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