{"id":2033,"date":"2022-04-20T08:54:31","date_gmt":"2022-04-20T15:54:31","guid":{"rendered":"https:\/\/bhmdev.com\/sphilipsins\/?page_id=2033"},"modified":"2022-04-20T08:54:31","modified_gmt":"2022-04-20T15:54:31","slug":"workers-comp-application","status":"publish","type":"page","link":"https:\/\/bhmdev.com\/sphilipsins\/workers-comp-application\/","title":{"rendered":"Workers Comp Application"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; disabled_on=&#8221;off|off|off&#8221; admin_label=&#8221;Feature&#8221; _builder_version=&#8221;3.22&#8243; background_color=&#8221;#eaf7fd&#8221; custom_padding=&#8221;50px||100px||false|false&#8221; bottom_divider_style=&#8221;arrow3&#8243; bottom_divider_color=&#8221;#ffffff&#8221; bottom_divider_flip=&#8221;horizontal&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row padding_top_bottom_link_1=&#8221;true&#8221; _builder_version=&#8221;3.25&#8243; max_width=&#8221;1280px&#8221; custom_margin=&#8221;0px||0px||true&#8221; custom_padding=&#8221;0px||0px||true&#8221; animation_direction=&#8221;bottom&#8221; use_custom_width=&#8221;on&#8221; custom_width_px=&#8221;1280px&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;3.25&#8243; custom_padding=&#8221;0px||0px|&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text _builder_version=&#8221;4.14.8&#8243; text_font=&#8221;Lato||||||||&#8221; text_font_size=&#8221;18px&#8221; text_line_height=&#8221;1.8em&#8221; header_font=&#8221;Kanit|||on|||||&#8221; header_text_align=&#8221;center&#8221; header_text_color=&#8221;#0788CA&#8221; header_font_size=&#8221;44px&#8221; header_line_height=&#8221;1.1em&#8221; header_2_font=&#8221;||||||||&#8221; module_alignment=&#8221;left&#8221; custom_margin=&#8221;0px||10px||false|false&#8221; custom_margin_last_edited=&#8221;off|desktop&#8221; custom_padding=&#8221;|||&#8221; custom_padding_tablet=&#8221;|0vw||0vw||true&#8221; custom_padding_phone=&#8221;|||||false&#8221; custom_padding_last_edited=&#8221;off|desktop&#8221; animation_style=&#8221;fade&#8221; animation_direction=&#8221;bottom&#8221; header_font_size_tablet=&#8221;36px&#8221; header_font_size_phone=&#8221;&#8221; header_font_size_last_edited=&#8221;on|phone&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h1>Workers\u2019 Comp Application<\/h1>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; admin_label=&#8221;About&#8221; _builder_version=&#8221;3.22&#8243; custom_padding=&#8221;40px|0px|0px|0px|false|false&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.14.8&#8243; custom_margin=&#8221;0px||90px||false|false&#8221; custom_margin_tablet=&#8221;||50px||false|false&#8221; custom_margin_phone=&#8221;||50px||false|false&#8221; custom_margin_last_edited=&#8221;on|phone&#8221; custom_padding=&#8221;0px||0px||true&#8221; use_custom_width=&#8221;on&#8221; locked=&#8221;off&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;3.25&#8243; custom_padding=&#8221;|||&#8221; global_colors_info=&#8221;{}&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text _builder_version=&#8221;4.14.8&#8243; text_font=&#8221;Montserrat|300|||||||&#8221; text_text_color=&#8221;#5e7a8a&#8221; text_font_size=&#8221;18px&#8221; text_line_height=&#8221;1.8em&#8221; link_font=&#8221;||||||||&#8221; ul_font=&#8221;||||||||&#8221; ol_font=&#8221;||||||||&#8221; quote_font=&#8221;||||||||&#8221; header_font=&#8221;||||||||&#8221; header_2_font=&#8221;Kanit|300||on|||||&#8221; header_2_text_align=&#8221;center&#8221; header_2_text_color=&#8221;#009285&#8243; header_2_font_size=&#8221;40px&#8221; header_2_letter_spacing=&#8221;0.4px&#8221; header_2_line_height=&#8221;1.5em&#8221; header_3_font=&#8221;||||||||&#8221; header_4_font=&#8221;||||||||&#8221; header_5_font=&#8221;||||||||&#8221; header_6_font=&#8221;Lato|700|||||||&#8221; header_6_font_size=&#8221;18px&#8221; header_6_letter_spacing=&#8221;1px&#8221; header_6_line_height=&#8221;1.8em&#8221; width=&#8221;96%&#8221; max_width=&#8221;800px&#8221; max_width_tablet=&#8221;700px&#8221; max_width_phone=&#8221;&#8221; max_width_last_edited=&#8221;on|phone&#8221; module_alignment=&#8221;center&#8221; custom_margin=&#8221;||||false|false&#8221; custom_padding=&#8221;||||false|false&#8221; text_font_size_tablet=&#8221;&#8221; text_font_size_phone=&#8221;16px&#8221; text_font_size_last_edited=&#8221;on|phone&#8221; header_2_font_size_tablet=&#8221;&#8221; header_2_font_size_phone=&#8221;22px&#8221; header_2_font_size_last_edited=&#8221;on|phone&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2032-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"2032\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/sphilipsins\/wp-json\/wp\/v2\/pages\/2033#wpcf7-f2032-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"2032\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2032-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<div id=\"comp-form\">\n\t<div class=\"comp-form-head\">\n\t\t<p>S. Philips Surety Insurance Services Inc.\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"comp-form-sub\">\n\t\t<p>22647 Ventura Bl #349, Woodland Hills, CA 91364<br \/>\nwww.sphilipsins.com (818) 715-7133\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"comp-form-sub-head\">\n\t\t<p>Workers Compensation Application\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-left\">\n\t\t<p><label> Insured Legal Name*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"legal-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"legal-name\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-right\">\n\t\t<p><label> Insured DBA*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"DBA\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"DBA\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-third-a\">\n\t\t<p><label> Proposed Effective Date*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"effective-date\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"mm-dd-yyyy\" value=\"\" type=\"text\" name=\"effective-date\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-third-b\">\n\t\t<p><label> Policy Expiration Date*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"expiration-date\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"mm-dd-yyyy\" value=\"\" type=\"text\" name=\"expiration-date\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-third-c\">\n\t\t<p><label> X-Mod<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"x-mod\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"x-mod\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-left\">\n\t\t<p><label> Contact Person\/Title*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"contact\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"contact\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-right\">\n\t\t<p><label> Federal Tax ID*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"federal-tax-id\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"federal-tax-id\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-third-a\">\n\t\t<p><label> Phone Number*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Phone-603\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"Phone-603\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-third-b\">\n\t\t<p><label> Fax<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"fax-201\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"fax-201\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-third-c\">\n\t\t<p><label> Email*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-left\">\n\t\t<p><label> Years in Business*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"years-in-business\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"years-in-business\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-right\">\n\t\t<p><label> Number of Locations*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"number-of-locations\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"number-of-locations\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<p><label> Operating Outside of US?*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"outside-US\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"outside-US\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span> <\/label>\n\t<\/p>\n\t<p><label> Mailing Address*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mailing-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mailing-address\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>Location 1*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"location-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"location-1\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>Location 2<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"location-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"location-2\" \/><\/span><\/label>\n\t<\/p>\n\t<div style=\"overflow-x:auto;\">\n\t\t<table style=\"table:border:1px solid black;\">\n\t\t\t<tr>\n\t\t\t\t<th>\n\t\t\t\t\t<p>Officer Name\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t\t<th>\n\t\t\t\t\t<p>Title\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t\t<th>\n\t\t\t\t\t<p>% of Stock\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t\t<th>\n\t\t\t\t\t<p>Included\/Excluded\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"officer-name-one\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"officer-name-one\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"title-one\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"title-one\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"stock-one\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"stock-one\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"included-one\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"included-one\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"officer-name-two\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"officer-name-two\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"title-two\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"title-two\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"stock-two\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"stock-two\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"included-two\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"included-two\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"officer-name-three\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"officer-name-three\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"title-three\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"title-three\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"stock-three\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"stock-three\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"included-three\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"included-three\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"officer-name-four\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"officer-name-four\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"title-four\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"title-four\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"stock-four\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"stock-four\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"included-four\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"included-four\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t<\/table>\n\t<\/div>\n\t<p><label> Operation\/Nature of Business*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"operation-business\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"operation-business\" \/><\/span> <\/label>\n\t<\/p>\n\t<div id=\"sb-left\">\n\t\t<p><label>Operation includes driving?*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"opp-q1\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"opp-q1\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-right\">\n\t\t<p><label>Driving Frequency?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"opp-q2\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"opp-q2\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Daily\">Daily<\/option><option value=\"Weekly\">Weekly<\/option><option value=\"Monthly\">Monthly<\/option><\/select><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-left\">\n\t\t<p><label>Driving Radius?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"opp-q3\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"opp-q3\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"10-25mi\">10-25mi<\/option><option value=\"25-50mi\">25-50mi<\/option><option value=\"50-100mi\">50-100mi<\/option><option value=\"+100mi\">+100mi<\/option><\/select><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-right\">\n\t\t<p><label># of Drivers?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"drivers-690\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"drivers-690\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10+\">10+<\/option><option value=\"15+\">15+<\/option><option value=\"20+\">20+<\/option><option value=\"25+\">25+<\/option><option value=\"30+\">30+<\/option><option value=\"35+\">35+<\/option><option value=\"40+\">40+<\/option><option value=\"45+\">45+<\/option><option value=\"50+\">50+<\/option><option value=\"55+\">55+<\/option><option value=\"60+\">60+<\/option><option value=\"65+\">65+<\/option><option value=\"70+\">70+<\/option><option value=\"75+\">75+<\/option><option value=\"80+\">80+<\/option><option value=\"85+\">85+<\/option><option value=\"90+\">90+<\/option><option value=\"95+\">95+<\/option><option value=\"100+\">100+<\/option><\/select><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<p><label>Any losses in the past 5 years?*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"opp-q4\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"opp-q4\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/label>\n\t<\/p>\n\t<p><label>Do you provide group health coverage for your employees?*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"opp-q5\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"opp-q5\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/label>\n\t<\/p>\n\t<div style=\"overflow-x:auto;\">\n\t\t<table style=\"table:border:1px solid black;\">\n\t\t\t<tr>\n\t\t\t\t<th>\n\t\t\t\t\t<p>Class Codes\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t\t<th>\n\t\t\t\t\t<p>Description\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t\t<th>\n\t\t\t\t\t<p>Payroll\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t\t<th>\n\t\t\t\t\t<p># of Full-Time\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t\t<th>\n\t\t\t\t\t<p># of Part-Time\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"class-code-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"class-code-1\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"description-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"description-1\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"payroll-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"payroll-1\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"fulltime-1\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"fulltime-1\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"parttime-1\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"parttime-1\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"class-code-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"class-code-2\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"description-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"description-2\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"payroll-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"payroll-2\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"fulltime-2\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"fulltime-2\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"parttime-2\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"parttime-2\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"class-code-3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"class-code-3\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"description-3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"description-3\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"payroll-3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"payroll-3\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"fulltime-3\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"fulltime-3\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"parttime-3\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"parttime-3\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"class-code-4\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"class-code-4\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"description-4\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"description-4\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"payroll-4\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"payroll-4\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"fulltime-4\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"fulltime-4\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"parttime-4\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"parttime-4\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"class-code-5\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"class-code-5\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"description-5\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"description-5\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"payroll-5\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"payroll-5\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"fulltime-5\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"fulltime-5\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"parttime-5\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"parttime-5\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t<\/table>\n\t<\/div>\n\t<div style=\"overflow-x:auto;\">\n\t\t<table style=\"table:border:1px solid black;\">\n\t\t\t<tr>\n\t\t\t\t<th>\n\t\t\t\t<\/th>\n\t\t\t\t<th>\n\t\t\t\t\t<p>Payroll Information\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t\t<th>\n\t\t\t\t\t<p>Premium Information\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p>Current Year\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"payroll-info-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"payroll-info-1\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"premium-info-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"premium-info-1\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p>Prior Year\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"payroll-info-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"payroll-info-2\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"premium-info-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"premium-info-2\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p>Prior Year\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"payroll-info-3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"payroll-info-3\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"premium-info-3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"premium-info-3\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t<\/table>\n\t<\/div>\n<\/div>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" id=\"sp-form-send\" type=\"submit\" value=\"Submit Application\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Workers\u2019 Comp Application\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2032-o2\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"2032\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/sphilipsins\/wp-json\/wp\/v2\/pages\/2033#wpcf7-f2032-o2\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"2032\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.5\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2032-o2\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/fieldset>\n<div id=\"comp-form\">\n\t<div class=\"comp-form-head\">\n\t\t<p>S. Philips Surety Insurance Services Inc.\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"comp-form-sub\">\n\t\t<p>22647 Ventura Bl #349, Woodland Hills, CA 91364<br \/>\nwww.sphilipsins.com (818) 715-7133\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"comp-form-sub-head\">\n\t\t<p>Workers Compensation Application\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-left\">\n\t\t<p><label> Insured Legal Name*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"legal-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"legal-name\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-right\">\n\t\t<p><label> Insured DBA*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"DBA\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"DBA\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-third-a\">\n\t\t<p><label> Proposed Effective Date*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"effective-date\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"mm-dd-yyyy\" value=\"\" type=\"text\" name=\"effective-date\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-third-b\">\n\t\t<p><label> Policy Expiration Date*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"expiration-date\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"mm-dd-yyyy\" value=\"\" type=\"text\" name=\"expiration-date\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-third-c\">\n\t\t<p><label> X-Mod<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"x-mod\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"x-mod\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-left\">\n\t\t<p><label> Contact Person\/Title*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"contact\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"contact\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-right\">\n\t\t<p><label> Federal Tax ID*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"federal-tax-id\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"federal-tax-id\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-third-a\">\n\t\t<p><label> Phone Number*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Phone-603\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"Phone-603\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-third-b\">\n\t\t<p><label> Fax<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"fax-201\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"fax-201\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-third-c\">\n\t\t<p><label> Email*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-left\">\n\t\t<p><label> Years in Business*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"years-in-business\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"years-in-business\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-right\">\n\t\t<p><label> Number of Locations*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"number-of-locations\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"number-of-locations\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<p><label> Operating Outside of US?*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"outside-US\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"outside-US\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span> <\/label>\n\t<\/p>\n\t<p><label> Mailing Address*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"mailing-address\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"mailing-address\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>Location 1*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"location-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"location-1\" \/><\/span><\/label>\n\t<\/p>\n\t<p><label>Location 2<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"location-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"location-2\" \/><\/span><\/label>\n\t<\/p>\n\t<div style=\"overflow-x:auto;\">\n\t\t<table style=\"table:border:1px solid black;\">\n\t\t\t<tr>\n\t\t\t\t<th>\n\t\t\t\t\t<p>Officer Name\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t\t<th>\n\t\t\t\t\t<p>Title\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t\t<th>\n\t\t\t\t\t<p>% of Stock\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t\t<th>\n\t\t\t\t\t<p>Included\/Excluded\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"officer-name-one\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"officer-name-one\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"title-one\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"title-one\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"stock-one\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"stock-one\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"included-one\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"included-one\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"officer-name-two\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"officer-name-two\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"title-two\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"title-two\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"stock-two\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"stock-two\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"included-two\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"included-two\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"officer-name-three\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"officer-name-three\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"title-three\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"title-three\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"stock-three\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"stock-three\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"included-three\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"included-three\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"officer-name-four\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"officer-name-four\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"title-four\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"title-four\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"stock-four\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"stock-four\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"included-four\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"included-four\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t<\/table>\n\t<\/div>\n\t<p><label> Operation\/Nature of Business*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"operation-business\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"operation-business\" \/><\/span> <\/label>\n\t<\/p>\n\t<div id=\"sb-left\">\n\t\t<p><label>Operation includes driving?*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"opp-q1\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"opp-q1\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-right\">\n\t\t<p><label>Driving Frequency?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"opp-q2\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"opp-q2\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Daily\">Daily<\/option><option value=\"Weekly\">Weekly<\/option><option value=\"Monthly\">Monthly<\/option><\/select><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-left\">\n\t\t<p><label>Driving Radius?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"opp-q3\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"opp-q3\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"10-25mi\">10-25mi<\/option><option value=\"25-50mi\">25-50mi<\/option><option value=\"50-100mi\">50-100mi<\/option><option value=\"+100mi\">+100mi<\/option><\/select><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div id=\"sb-right\">\n\t\t<p><label># of Drivers?<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"drivers-690\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"drivers-690\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><option value=\"5\">5<\/option><option value=\"6\">6<\/option><option value=\"7\">7<\/option><option value=\"8\">8<\/option><option value=\"9\">9<\/option><option value=\"10+\">10+<\/option><option value=\"15+\">15+<\/option><option value=\"20+\">20+<\/option><option value=\"25+\">25+<\/option><option value=\"30+\">30+<\/option><option value=\"35+\">35+<\/option><option value=\"40+\">40+<\/option><option value=\"45+\">45+<\/option><option value=\"50+\">50+<\/option><option value=\"55+\">55+<\/option><option value=\"60+\">60+<\/option><option value=\"65+\">65+<\/option><option value=\"70+\">70+<\/option><option value=\"75+\">75+<\/option><option value=\"80+\">80+<\/option><option value=\"85+\">85+<\/option><option value=\"90+\">90+<\/option><option value=\"95+\">95+<\/option><option value=\"100+\">100+<\/option><\/select><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n\t<p><label>Any losses in the past 5 years?*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"opp-q4\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"opp-q4\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/label>\n\t<\/p>\n\t<p><label>Do you provide group health coverage for your employees?*<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"opp-q5\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"opp-q5\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/label>\n\t<\/p>\n\t<div style=\"overflow-x:auto;\">\n\t\t<table style=\"table:border:1px solid black;\">\n\t\t\t<tr>\n\t\t\t\t<th>\n\t\t\t\t\t<p>Class Codes\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t\t<th>\n\t\t\t\t\t<p>Description\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t\t<th>\n\t\t\t\t\t<p>Payroll\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t\t<th>\n\t\t\t\t\t<p># of Full-Time\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t\t<th>\n\t\t\t\t\t<p># of Part-Time\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"class-code-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"class-code-1\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"description-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"description-1\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"payroll-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"payroll-1\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"fulltime-1\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"fulltime-1\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"parttime-1\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"parttime-1\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"class-code-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"class-code-2\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"description-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"description-2\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"payroll-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"payroll-2\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"fulltime-2\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"fulltime-2\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"parttime-2\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"parttime-2\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"class-code-3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"class-code-3\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"description-3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"description-3\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"payroll-3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"payroll-3\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"fulltime-3\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"fulltime-3\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"parttime-3\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"parttime-3\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"class-code-4\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"class-code-4\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"description-4\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"description-4\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"payroll-4\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"payroll-4\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"fulltime-4\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"fulltime-4\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"parttime-4\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"parttime-4\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"class-code-5\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"class-code-5\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"description-5\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"description-5\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"payroll-5\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"payroll-5\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"fulltime-5\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"fulltime-5\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"parttime-5\"><input size=\"40\" maxlength=\"12\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"parttime-5\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t<\/table>\n\t<\/div>\n\t<div style=\"overflow-x:auto;\">\n\t\t<table style=\"table:border:1px solid black;\">\n\t\t\t<tr>\n\t\t\t\t<th>\n\t\t\t\t<\/th>\n\t\t\t\t<th>\n\t\t\t\t\t<p>Payroll Information\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t\t<th>\n\t\t\t\t\t<p>Premium Information\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/th>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p>Current Year\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"payroll-info-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"payroll-info-1\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"premium-info-1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"premium-info-1\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p>Prior Year\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"payroll-info-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"payroll-info-2\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"premium-info-2\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"premium-info-2\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t\t<tr>\n\t\t\t\t<td>\n\t\t\t\t\t<p>Prior Year\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"payroll-info-3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"payroll-info-3\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t\t<td>\n\t\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"premium-info-3\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"premium-info-3\" \/><\/span>\n\t\t\t\t\t<\/p>\n\t\t\t\t<\/td>\n\t\t\t<\/tr>\n\t\t<\/table>\n\t<\/div>\n<\/div>\n<p><input class=\"wpcf7-form-control 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