{"id":66,"date":"2023-02-27T13:28:45","date_gmt":"2023-02-27T13:28:45","guid":{"rendered":"http:\/\/www.pureconceptions.com\/smithlaw\/?page_id=66"},"modified":"2023-02-27T13:59:23","modified_gmt":"2023-02-27T13:59:23","slug":"client-intake","status":"publish","type":"page","link":"https:\/\/www.pureconceptions.com\/smithlaw\/client-intake\/","title":{"rendered":"Client Intake"},"content":{"rendered":"<script type=\"text\/javascript\">var 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height='640'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gform-theme-control-border-color: #abb8c3;--gform-theme-control-size: var(--gform-theme-control-size-md);--gform-theme-control-label-color-primary: #112337;--gform-theme-control-label-color-secondary: #112337;--gform-theme-control-choice-size: var(--gform-theme-control-choice-size-md);--gform-theme-control-checkbox-check-size: var(--gform-theme-control-checkbox-check-size-md);--gform-theme-control-radio-check-size: var(--gform-theme-control-radio-check-size-md);--gform-theme-control-button-font-size: var(--gform-theme-control-button-font-size-md);--gform-theme-control-button-padding-inline: var(--gform-theme-control-button-padding-inline-md);--gform-theme-control-button-size: var(--gform-theme-control-button-size-md);--gform-theme-control-button-border-color-secondary: #abb8c3;--gform-theme-control-file-button-background-color-hover: #EBEBEB;--gform-theme-field-page-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_48' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_48'  action='\/smithlaw\/wp-json\/wp\/v2\/pages\/66#gf_48' data-formid='48' >\n        <div id='gf_progressbar_wrapper_48' class='gf_progressbar_wrapper'>\n        \t<p class=\"gf_progressbar_title\">Step <span class='gf_step_current_page'>1<\/span> of <span class='gf_step_page_count'>8<\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_blue' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_blue percentbar_12' style='width:12%;'><span>12%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_48_1' class='gform_page ' data-js='page-field-id-1' >\n                                    <div class='gform_page_fields'><div id='gform_fields_48' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_48_129\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_hidden\"  data-js-reload=\"field_48_129\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label gform-field-label' for='input_48_129' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_129' id='input_48_129' type='text' value='06\/18\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_48_129_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_48_129_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_48_129' class='gform_hidden' value='https:\/\/www.pureconceptions.com\/smithlaw\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_48_113\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_113\"><h3 class=\"gsection_title\">Client Information<\/h3><\/div><fieldset id=\"field_48_1\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_1\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Your Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_48_1'>\n                            \n                            <span id='input_48_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_48_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_48_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_48_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_48_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_48_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_48_3\"  class=\"gfield gfield--type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_3\"><label class='gfield_label gform-field-label' for='input_48_3' >Your Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_3' id='input_48_3' type='text' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_48_5\"  class=\"gfield gfield--type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_5\"><label class='gfield_label gform-field-label' for='input_48_5' >Your Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_5' id='input_48_5' type='text' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><fieldset id=\"field_48_4\"  class=\"gfield gfield--type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_4\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Your Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \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_48_4' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_48_4_1_container' >\n                                        <input type='text' name='input_4.1' id='input_48_4_1' value=''    aria-required='true'    \/>\n                                        <label for='input_48_4_1' id='input_48_4_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_48_4_2_container' >\n                                        <input type='text' name='input_4.2' id='input_48_4_2' value=''     aria-required='false'   \/>\n                                        <label for='input_48_4_2' id='input_48_4_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_48_4_3_container' >\n                                    <input type='text' name='input_4.3' id='input_48_4_3' value=''    aria-required='true'    \/>\n                                    <label for='input_48_4_3' id='input_48_4_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_48_4_4_container' >\n                                        <select name='input_4.4' id='input_48_4_4'     aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/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='Northern Mariana Islands' >Northern Mariana Islands<\/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' selected='selected'>Texas<\/option><option value='Utah' >Utah<\/option><option value='U.S. Virgin Islands' >U.S. Virgin Islands<\/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_48_4_4' id='input_48_4_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_48_4_5_container' >\n                                    <input type='text' name='input_4.5' id='input_48_4_5' value=''    aria-required='true'    \/>\n                                    <label for='input_48_4_5' id='input_48_4_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_4.6' id='input_48_4_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_48_6\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_6\"><label class='gfield_label gform-field-label' for='input_48_6' >Your Birthday<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_6' id='input_48_6' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_48_6_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_48_6_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_48_6' class='gform_hidden' value='https:\/\/www.pureconceptions.com\/smithlaw\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_48_151\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_151\"><label class='gfield_label gform-field-label' for='input_48_151' >What&#039;s your Instagram handle?<\/label><div class='ginput_container ginput_container_text'><input name='input_151' id='input_48_151' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_154\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_154\"><label class='gfield_label gform-field-label' for='input_48_154' >What&#039;s your Facebook name?<\/label><div class='ginput_container ginput_container_text'><input name='input_154' id='input_48_154' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_152\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_152\"><label class='gfield_label gform-field-label' for='input_48_152' >What&#039;s your Twitter handle?<\/label><div class='ginput_container ginput_container_text'><input name='input_152' id='input_48_152' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_153\"  class=\"gfield gfield--type-text gfield--width-half field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_153\"><label class='gfield_label gform-field-label' for='input_48_153' >What&#039;s your TikTok handle?<\/label><div class='ginput_container ginput_container_text'><input name='input_153' id='input_48_153' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_128\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_128\"><label class='gfield_label gform-field-label' for='input_48_128' >Your Driver&#039;s License Number<\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_48_128' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_141\"  class=\"gfield gfield--type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_141\"><label class='gfield_label gform-field-label' for='input_48_141' >Which state issued your driver&#039;s license<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_141' id='input_48_141' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/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='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/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='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/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='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><\/select><\/div><\/div><div id=\"field_48_142\"  class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_142\"><label class='gfield_label gform-field-label' for='input_48_142' >Upload photo of front of driver&#039;s license<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='33554432' \/><input name='input_142' id='input_48_142' type='file' class='large' aria-describedby=\"gfield_upload_rules_48_142\" onchange='javascript:gformValidateFileSize( this, 33554432 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_48_142'>Max. file size: 32 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_48_142'><\/div><\/div><\/div><div id=\"field_48_143\"  class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_143\"><label class='gfield_label gform-field-label' for='input_48_143' >Upload photo of back of driver&#039;s license<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='33554432' \/><input name='input_143' id='input_48_143' type='file' class='large' aria-describedby=\"gfield_upload_rules_48_143\" onchange='javascript:gformValidateFileSize( this, 33554432 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_48_143'>Max. file size: 32 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_48_143'><\/div><\/div><\/div><fieldset id=\"field_48_114\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_114\"><legend class='gfield_label gform-field-label'  >Your Marital Status<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_114'>\n\t\t\t<div class='gchoice gchoice_48_114_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='Single'  id='choice_48_114_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_114_0' id='label_48_114_0' class='gform-field-label gform-field-label--type-inline'>Single<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_114_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='Married'  id='choice_48_114_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_114_1' id='label_48_114_1' class='gform-field-label gform-field-label--type-inline'>Married<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_114_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_114' type='radio' value='Divorced'  id='choice_48_114_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_114_2' id='label_48_114_2' class='gform-field-label gform-field-label--type-inline'>Divorced<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_48_115\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_115\"><label class='gfield_label gform-field-label' for='input_48_115' >Your Spouse&#039;s Name<\/label><div class='ginput_container ginput_container_text'><input name='input_115' id='input_48_115' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_48_158' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_48\").val(\"2\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_48\").val(\"2\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_48_2_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_48\"]){return false;}  window[\"gf_submitting_48\"]=true; jQuery(\"#gform_save_48\").val(1); jQuery(\"#gform_48\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_48\"]){return false;} window[\"gf_submitting_48\"]=true; jQuery(\"#gform_save_48\").val(1); jQuery(\"#gform_48\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_48_2' class='gform_page' data-js='page-field-id-158' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_48_2' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_48_28\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_28\"><h3 class=\"gsection_title\">Accident Information<\/h3><\/div><div id=\"field_48_117\"  class=\"gfield gfield--type-number gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_117\"><label class='gfield_label gform-field-label' for='input_48_117' >How many vehicles were involved?<\/label><div class='ginput_container ginput_container_number'><input name='input_117' id='input_48_117' type='text'    value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_48_12\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_12\"><label class='gfield_label gform-field-label' for='input_48_12' >Who was driving the car you were in?<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_48_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_118\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_118\"><label class='gfield_label gform-field-label' for='input_48_118' >Date of Incident<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_118' id='input_48_118' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_48_118_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_48_118_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_48_118' class='gform_hidden' value='https:\/\/www.pureconceptions.com\/smithlaw\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_48_11\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_11\"><label class='gfield_label gform-field-label' for='input_48_11' >Location of Incident<\/label><div class='ginput_container ginput_container_text'><input name='input_11' id='input_48_11' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_48_119\"  class=\"gfield gfield--type-time gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_119\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Time of Incident<\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_48_119'>\n                            <input type='text' maxlength='2' name='input_119[]' id='input_48_119_1' value=''    placeholder='HH' aria-required='false'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_48_119_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='text' maxlength='2' name='input_119[]' id='input_48_119_2' value=''    placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_48_119_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_119[]' id='input_48_119_3'  >\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_48_119_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><div id=\"field_48_15\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_15\"><label class='gfield_label gform-field-label' for='input_48_15' >Weather Conditions<\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_48_15' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_17\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_17\"><label class='gfield_label gform-field-label' for='input_48_17' >Please describe the incident in detail.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_17' id='input_48_17' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_48_18\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_48_18\"><legend class='gfield_label gform-field-label'  >Did you take pictures of the incident?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_18'>\n\t\t\t<div class='gchoice gchoice_48_18_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='Yes'  id='choice_48_18_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_18_0' id='label_48_18_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_18_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_18' type='radio' value='No'  id='choice_48_18_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_18_1' id='label_48_18_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_48_125\"  class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_125\"><label class='gfield_label gform-field-label' for='gform_browse_button_48_125' >Upload all of the pictures of the accident scene<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_48_125' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_48_125&quot;,&quot;container&quot;:&quot;gform_multifile_upload_48_125&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_48_125&quot;,&quot;filelist&quot;:&quot;gform_preview_48_125&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.pureconceptions.com\\\/smithlaw\\\/?gf_page=ad5dfdbfec01312&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.pureconceptions.com\\\/smithlaw\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.pureconceptions.com\\\/smithlaw\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;33554432b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:48,&quot;field_id&quot;:125},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_48_125&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_48_125' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_48_125' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_48_125\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_48_125'>Max. file size: 32 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_48_125'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_48_125' class='ginput_preview_list'><\/div><\/div><fieldset id=\"field_48_19\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_48_19\"><legend class='gfield_label gform-field-label'  >Were you working at the time of the incident?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_19'>\n\t\t\t<div class='gchoice gchoice_48_19_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='Yes'  id='choice_48_19_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_19_0' id='label_48_19_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_19_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_19' type='radio' value='No'  id='choice_48_19_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_19_1' id='label_48_19_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_48_20\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_20\"><label class='gfield_label gform-field-label' for='input_48_20' >Where were you driving from?<\/label><div class='ginput_container ginput_container_text'><input name='input_20' id='input_48_20' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_144\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_144\"><label class='gfield_label gform-field-label' for='input_48_144' >Where were you driving to?<\/label><div class='ginput_container ginput_container_text'><input name='input_144' id='input_48_144' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_48_21\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_21\"><legend class='gfield_label gform-field-label'  >Were the police called to the scene?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_21'>\n\t\t\t<div class='gchoice gchoice_48_21_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='Yes'  id='choice_48_21_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_21_0' id='label_48_21_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_21_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_21' type='radio' value='No'  id='choice_48_21_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_21_1' id='label_48_21_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_48_22\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_22\"><label class='gfield_label gform-field-label' for='input_48_22' >What county police department reported to the scene?<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_48_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_48_23\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_23\"><legend class='gfield_label gform-field-label'  >Did the other driver receive a ticket?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_23'>\n\t\t\t<div class='gchoice gchoice_48_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Yes'  id='choice_48_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_23_0' id='label_48_23_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='No'  id='choice_48_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_23_1' id='label_48_23_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_23_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='I&#039;m not sure'  id='choice_48_23_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_23_2' id='label_48_23_2' class='gform-field-label gform-field-label--type-inline'>I&#8217;m not sure<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_48_24\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_24\"><label class='gfield_label gform-field-label' for='input_48_24' >Accident\/Incident Report Number<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_48_24' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_48_159' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_48\").val(\"1\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_48\").val(\"1\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_48_159' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_48\").val(\"3\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_48\").val(\"3\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_48_3_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_48\"]){return false;}  window[\"gf_submitting_48\"]=true; jQuery(\"#gform_save_48\").val(1); jQuery(\"#gform_48\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_48\"]){return false;} window[\"gf_submitting_48\"]=true; jQuery(\"#gform_save_48\").val(1); jQuery(\"#gform_48\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_48_3' class='gform_page' data-js='page-field-id-159' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_48_3' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_48_25\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_25\"><h3 class=\"gsection_title\">Injuries to Your Body<\/h3><\/div><fieldset id=\"field_48_29\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_48_29\"><legend class='gfield_label gform-field-label'  >Are you hurt or injured?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_29'>\n\t\t\t<div class='gchoice gchoice_48_29_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='Yes'  id='choice_48_29_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_29_0' id='label_48_29_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_29_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_29' type='radio' value='No'  id='choice_48_29_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_29_1' id='label_48_29_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_48_166\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gf_list_2col field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_166\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Select All That Are True:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_48_166'><div class='gchoice gchoice_48_166_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.1' type='checkbox'  value='My head hurts'  id='choice_48_166_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_166_1' id='label_48_166_1' class='gform-field-label gform-field-label--type-inline'>My head hurts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_166_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.2' type='checkbox'  value='I jerked into the seat in front of me'  id='choice_48_166_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_166_2' id='label_48_166_2' class='gform-field-label gform-field-label--type-inline'>I jerked into the seat in front of me<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_166_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.3' type='checkbox'  value='My knee, ankle, elbow, or other bone(s) hurt'  id='choice_48_166_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_166_3' id='label_48_166_3' class='gform-field-label gform-field-label--type-inline'>My knee, ankle, elbow, or other bone(s) hurt<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_166_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.4' type='checkbox'  value='My back hurts'  id='choice_48_166_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_166_4' id='label_48_166_4' class='gform-field-label gform-field-label--type-inline'>My back hurts<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_166_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.5' type='checkbox'  value='The pain has gotten worse since I went to the ER'  id='choice_48_166_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_166_5' id='label_48_166_5' class='gform-field-label gform-field-label--type-inline'>The pain has gotten worse since I went to the ER<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_166_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.6' type='checkbox'  value='I haven&#039;t talked to a doctor about the new pains I&#039;m experiencing'  id='choice_48_166_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_166_6' id='label_48_166_6' class='gform-field-label gform-field-label--type-inline'>I haven&#8217;t talked to a doctor about the new pains I&#8217;m experiencing<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_166_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.7' type='checkbox'  value='I struggle to do everyday tasks like eat, sleep, think'  id='choice_48_166_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_166_7' id='label_48_166_7' class='gform-field-label gform-field-label--type-inline'>I struggle to do everyday tasks like eat, sleep, think<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_166_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.8' type='checkbox'  value='My airbag deployed'  id='choice_48_166_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_166_8' id='label_48_166_8' class='gform-field-label gform-field-label--type-inline'>My airbag deployed<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_166_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.9' type='checkbox'  value='I hit my head on the steering wheel'  id='choice_48_166_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_166_9' id='label_48_166_9' class='gform-field-label gform-field-label--type-inline'>I hit my head on the steering wheel<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_166_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.11' type='checkbox'  value='My seatbelt hurt me'  id='choice_48_166_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_166_11' id='label_48_166_11' class='gform-field-label gform-field-label--type-inline'>My seatbelt hurt me<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_166_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.12' type='checkbox'  value='I&#039;ve been limping or struggling to walk'  id='choice_48_166_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_166_12' id='label_48_166_12' class='gform-field-label gform-field-label--type-inline'>I&#8217;ve been limping or struggling to walk<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_166_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.13' type='checkbox'  value='My whole body is in pain'  id='choice_48_166_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_166_13' id='label_48_166_13' class='gform-field-label gform-field-label--type-inline'>My whole body is in pain<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_166_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.14' type='checkbox'  value='New parts of my body hurt since my ER visit'  id='choice_48_166_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_166_14' id='label_48_166_14' class='gform-field-label gform-field-label--type-inline'>New parts of my body hurt since my ER visit<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_166_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.15' type='checkbox'  value='I&#039;ve been forgetting simple things'  id='choice_48_166_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_166_15' id='label_48_166_15' class='gform-field-label gform-field-label--type-inline'>I&#8217;ve been forgetting simple things<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_166_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.16' type='checkbox'  value='The ER put me in a boot, sling, cast or other support device'  id='choice_48_166_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_166_16' id='label_48_166_16' class='gform-field-label gform-field-label--type-inline'>The ER put me in a boot, sling, cast or other support device<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_166_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.17' type='checkbox'  value='My passenger&#039;s airbag deployed'  id='choice_48_166_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_166_17' id='label_48_166_17' class='gform-field-label gform-field-label--type-inline'>My passenger&#8217;s airbag deployed<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_48_30\"  class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_30\"><label class='gfield_label gform-field-label' for='input_48_30' >Please describe your injuries. (Soreness, aches, numbness, tingling, and or\/ radiating pain)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_30' id='input_48_30' class='textarea small'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_48_126\"  class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_126\"><label class='gfield_label gform-field-label' for='gform_browse_button_48_126' >Upload pictures of your injuries, if you have any:<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_48_126' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_48_126&quot;,&quot;container&quot;:&quot;gform_multifile_upload_48_126&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_48_126&quot;,&quot;filelist&quot;:&quot;gform_preview_48_126&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.pureconceptions.com\\\/smithlaw\\\/?gf_page=ad5dfdbfec01312&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.pureconceptions.com\\\/smithlaw\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.pureconceptions.com\\\/smithlaw\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;33554432b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:48,&quot;field_id&quot;:126},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_48_126&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_48_126' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_48_126' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_48_126\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_48_126'>Max. file size: 32 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_48_126'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_48_126' class='ginput_preview_list'><\/div><\/div><fieldset id=\"field_48_31\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_48_31\"><legend class='gfield_label gform-field-label'  >Did you go to the hospital?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_31'>\n\t\t\t<div class='gchoice gchoice_48_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_48_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_31_0' id='label_48_31_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_48_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_31_1' id='label_48_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_48_32\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_32\"><label class='gfield_label gform-field-label' for='input_48_32' >If yes, what hospital?<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_48_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_48_33\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_48_33\"><legend class='gfield_label gform-field-label'  >Were you transported by ambulance?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_33'>\n\t\t\t<div class='gchoice gchoice_48_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Yes'  id='choice_48_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_33_0' id='label_48_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='No'  id='choice_48_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_33_1' id='label_48_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_48_160' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_48\").val(\"2\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_48\").val(\"2\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_48_160' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_48\").val(\"4\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_48\").val(\"4\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_48_4_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_48\"]){return false;}  window[\"gf_submitting_48\"]=true; jQuery(\"#gform_save_48\").val(1); jQuery(\"#gform_48\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_48\"]){return false;} window[\"gf_submitting_48\"]=true; jQuery(\"#gform_save_48\").val(1); jQuery(\"#gform_48\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_48_4' class='gform_page' data-js='page-field-id-160' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_48_4' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_48_34\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_34\"><h3 class=\"gsection_title\">Property Damage<\/h3><\/div><fieldset id=\"field_48_35\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_48_35\"><legend class='gfield_label gform-field-label'  >Is the vehicle drivable?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_35'>\n\t\t\t<div class='gchoice gchoice_48_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_48_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_35_0' id='label_48_35_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_48_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_35_1' id='label_48_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_48_127\"  class=\"gfield gfield--type-number gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_127\"><label class='gfield_label gform-field-label' for='input_48_127' >Estimated Damage<\/label><div class='ginput_container ginput_container_number'><input name='input_127' id='input_48_127' type='text'    value='' class='large'      aria-invalid=\"false\" aria-describedby=\"gfield_instruction_48_127\" \/><div class='gfield_description instruction ' id='gfield_instruction_48_127'>Please enter a number greater than or equal to <strong>100<\/strong>.<\/div><\/div><\/div><div id=\"field_48_37\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_37\"><label class='gfield_label gform-field-label' for='input_48_37' >Where is your vehicle located?<\/label><div class='ginput_container ginput_container_text'><input name='input_37' id='input_48_37' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_38\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_38\"><label class='gfield_label gform-field-label' for='input_48_38' >Your Vehicle&#039;s Year, Make, &amp; Model<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_48_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_39\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_39\"><label class='gfield_label gform-field-label' for='input_48_39' >Your Vehicle&#039;s License Plate Number<\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_48_39' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_155\"  class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_155\"><label class='gfield_label gform-field-label' for='input_48_155' >Which state is on your license plate?<\/label><div class='ginput_container ginput_container_select'><select name='input_155' id='input_48_155' class='large gfield_select'     aria-invalid=\"false\" ><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/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='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/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='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/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='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><\/select><\/div><\/div><div id=\"field_48_40\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_40\"><label class='gfield_label gform-field-label' for='input_48_40' >VIN<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_48_40' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_41\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_41\"><label class='gfield_label gform-field-label' for='input_48_41' >Full Name of Registered Owner of Vehicle<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_48_41' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_48_161' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_48\").val(\"3\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_48\").val(\"3\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_48_161' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_48\").val(\"5\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_48\").val(\"5\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_48_5_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_48\"]){return false;}  window[\"gf_submitting_48\"]=true; jQuery(\"#gform_save_48\").val(1); jQuery(\"#gform_48\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_48\"]){return false;} window[\"gf_submitting_48\"]=true; jQuery(\"#gform_save_48\").val(1); jQuery(\"#gform_48\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_48_5' class='gform_page' data-js='page-field-id-161' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_48_5' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_48_42\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_42\"><h3 class=\"gsection_title\">Other Vehicle Insurance Information<\/h3><\/div><div id=\"field_48_43\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_43\"><label class='gfield_label gform-field-label' for='input_48_43' >Other Driver&#039;s Name<\/label><div class='ginput_container ginput_container_text'><input name='input_43' id='input_48_43' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_44\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_44\"><label class='gfield_label gform-field-label' for='input_48_44' >Other Driver&#039;s License\/State ID Number<\/label><div class='ginput_container ginput_container_text'><input name='input_44' id='input_48_44' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_156\"  class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_156\"><label class='gfield_label gform-field-label' for='input_48_156' >Which state issued the other driver&#039;s license\/ID?<\/label><div class='ginput_container ginput_container_select'><select name='input_156' id='input_48_156' class='large gfield_select'     aria-invalid=\"false\" ><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/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='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/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='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/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='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><\/select><\/div><\/div><div id=\"field_48_120\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_120\"><label class='gfield_label gform-field-label' for='input_48_120' >Date of Birth of the Other Driver<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_120' id='input_48_120' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_48_120_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_48_120_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_48_120' class='gform_hidden' value='https:\/\/www.pureconceptions.com\/smithlaw\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_48_46\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_46\"><label class='gfield_label gform-field-label' for='input_48_46' >Year, Make, &amp; Model of the Other Vehicle<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_48_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_47\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_47\"><label class='gfield_label gform-field-label' for='input_48_47' >Vehicle Color for the Other Vehicle<\/label><div class='ginput_container ginput_container_text'><input name='input_47' id='input_48_47' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_48\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_48\"><label class='gfield_label gform-field-label' for='input_48_48' >License Plate Number on the Other Vehicle<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_48_48' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_157\"  class=\"gfield gfield--type-select gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_157\"><label class='gfield_label gform-field-label' for='input_48_157' >Which state is on the other vehicle&#039;s license plate?<\/label><div class='ginput_container ginput_container_select'><select name='input_157' id='input_48_157' class='large gfield_select'     aria-invalid=\"false\" ><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/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='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/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='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/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='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><\/select><\/div><\/div><div id=\"field_48_49\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_49\"><label class='gfield_label gform-field-label' for='input_48_49' >Auto Insurance Provider for Other Driver<\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_48_49' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_131\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_131\"><label class='gfield_label gform-field-label' for='input_48_131' >Policy Number for Other Driver<\/label><div class='ginput_container ginput_container_text'><input name='input_131' id='input_48_131' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_51\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_51\"><label class='gfield_label gform-field-label' for='input_48_51' >Claim Number for Other Driver<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_48_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_52\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_52\"><label class='gfield_label gform-field-label' for='input_48_52' >Adjuster&#039;s Name for Other Driver<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_48_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_53\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_53\"><label class='gfield_label gform-field-label' for='input_48_53' >Adjuster&#039;s Phone Number for Other Driver<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_48_53' type='text' value='' class='small'      aria-invalid=\"false\"   \/> <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_48_162' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_48\").val(\"4\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_48\").val(\"4\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_48_162' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_48\").val(\"6\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_48\").val(\"6\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_48_6_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_48\"]){return false;}  window[\"gf_submitting_48\"]=true; jQuery(\"#gform_save_48\").val(1); jQuery(\"#gform_48\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_48\"]){return false;} window[\"gf_submitting_48\"]=true; jQuery(\"#gform_save_48\").val(1); jQuery(\"#gform_48\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_48_6' class='gform_page' data-js='page-field-id-162' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_48_6' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_48_54\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_54\"><h3 class=\"gsection_title\">Your Auto Insurance Coverage<\/h3><\/div><fieldset id=\"field_48_55\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_55\"><legend class='gfield_label gform-field-label'  >Do you have any auto insurance policy?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_55'>\n\t\t\t<div class='gchoice gchoice_48_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Yes'  id='choice_48_55_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_55_0' id='label_48_55_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='No'  id='choice_48_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_55_1' id='label_48_55_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_48_56\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_56\"><label class='gfield_label gform-field-label' for='input_48_56' >Your Auto Insurance Provider<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_48_56' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_132\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_132\"><label class='gfield_label gform-field-label' for='input_48_132' >Your Auto Insurance Policy Number<\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_48_132' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_48_58\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_58\"><legend class='gfield_label gform-field-label'  >Medical Payment Coverage included in your auto policy?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_58'>\n\t\t\t<div class='gchoice gchoice_48_58_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='PIP'  id='choice_48_58_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_58_0' id='label_48_58_0' class='gform-field-label gform-field-label--type-inline'>PIP<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_58_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='MedPay'  id='choice_48_58_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_58_1' id='label_48_58_1' class='gform-field-label gform-field-label--type-inline'>MedPay<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_58_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_58' type='radio' value='None'  id='choice_48_58_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_58_2' id='label_48_58_2' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_48_165\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_165\"><legend class='gfield_label gform-field-label'  >Do You Have Uninsured\/underinsured Motorist Coverage?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_165'>\n\t\t\t<div class='gchoice gchoice_48_165_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_165' type='radio' value='Yes'  id='choice_48_165_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_165_0' id='label_48_165_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_165_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_165' type='radio' value='No'  id='choice_48_165_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_165_1' id='label_48_165_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_48_61\"  class=\"gfield gfield--type-number gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_61\"><label class='gfield_label gform-field-label' for='input_48_61' >Under\/Uninsured Motorist Coverage Amount<\/label><div class='ginput_container ginput_container_number'><input name='input_61' id='input_48_61' type='text'    value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_48_62\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_62\"><legend class='gfield_label gform-field-label'  >Did you file a claim with your auto insurance company?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_62'>\n\t\t\t<div class='gchoice gchoice_48_62_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='Yes'  id='choice_48_62_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_62_0' id='label_48_62_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_62_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_62' type='radio' value='No'  id='choice_48_62_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_62_1' id='label_48_62_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_48_133\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_133\"><label class='gfield_label gform-field-label' for='input_48_133' >Claim Number from your auto insurance<\/label><div class='ginput_container ginput_container_text'><input name='input_133' id='input_48_133' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_66\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_66\"><label class='gfield_label gform-field-label' for='input_48_66' >Adjuster&#039;s Name from your auto insurance<\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_48_66' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_136\"  class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_136\"><label class='gfield_label gform-field-label' for='input_48_136' >Adjuster&#039;s Phone Number from your auto insurance<\/label><div class='ginput_container ginput_container_phone'><input name='input_136' id='input_48_136' type='text' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_48_69\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_69\"><legend class='gfield_label gform-field-label'  >Are you covered through your employer&#039;s insurance?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_69'>\n\t\t\t<div class='gchoice gchoice_48_69_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='Yes'  id='choice_48_69_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_69_0' id='label_48_69_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_69_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_69' type='radio' value='No'  id='choice_48_69_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_69_1' id='label_48_69_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_48_79\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_79\"><label class='gfield_label gform-field-label' for='input_48_79' >Please provide company &amp; agent:<\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_48_79' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_72\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_72\"><h3 class=\"gsection_title\">Witness Information<\/h3><\/div><div id=\"field_48_78\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_78\"><label class='gfield_label gform-field-label' for='input_48_78' >Witness Full Name<\/label><div class='ginput_container ginput_container_text'><input name='input_78' id='input_48_78' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_135\"  class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_135\"><label class='gfield_label gform-field-label' for='input_48_135' >Witness&#039;s Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_135' id='input_48_135' type='text' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_48_163' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_48\").val(\"5\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_48\").val(\"5\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_48_163' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_48\").val(\"7\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_48\").val(\"7\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_48_7_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_48\"]){return false;}  window[\"gf_submitting_48\"]=true; jQuery(\"#gform_save_48\").val(1); jQuery(\"#gform_48\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_48\"]){return false;} window[\"gf_submitting_48\"]=true; jQuery(\"#gform_save_48\").val(1); jQuery(\"#gform_48\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_48_7' class='gform_page' data-js='page-field-id-163' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_48_7' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_48_77\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_77\"><h3 class=\"gsection_title\">Health Insurance<\/h3><\/div><fieldset id=\"field_48_74\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_74\"><legend class='gfield_label gform-field-label'  >Did you use your health insurance for treatment related to this incident?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_74'>\n\t\t\t<div class='gchoice gchoice_48_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Yes'  id='choice_48_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_74_0' id='label_48_74_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='No'  id='choice_48_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_74_1' id='label_48_74_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_48_75\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_75\"><label class='gfield_label gform-field-label' for='input_48_75' >Name of Your Medical Insurance Carrier<\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_48_75' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_76\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_76\"><label class='gfield_label gform-field-label' for='input_48_76' >What&#039;s Your Medical Insurance Member ID or Group #<\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_48_76' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_48_146\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_146\"><legend class='gfield_label gform-field-label'  >Do you have Medicaid or Medicare?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_146'>\n\t\t\t<div class='gchoice gchoice_48_146_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_146' type='radio' value='Yes'  id='choice_48_146_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_146_0' id='label_48_146_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_146_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_146' type='radio' value='No'  id='choice_48_146_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_146_1' id='label_48_146_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_48_147\"  class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_147\"><label class='gfield_label gform-field-label' for='gform_browse_button_48_147' >Please upload a picture of the Front and back of your Medicaid or Medicare card(s)<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_48_147' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_48_147&quot;,&quot;container&quot;:&quot;gform_multifile_upload_48_147&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_48_147&quot;,&quot;filelist&quot;:&quot;gform_preview_48_147&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.pureconceptions.com\\\/smithlaw\\\/?gf_page=ad5dfdbfec01312&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.pureconceptions.com\\\/smithlaw\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.pureconceptions.com\\\/smithlaw\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;*&quot;}],&quot;max_file_size&quot;:&quot;33554432b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:48,&quot;field_id&quot;:147},&quot;gf_vars&quot;:{&quot;max_files&quot;:&quot;2&quot;,&quot;message_id&quot;:&quot;gform_multifile_messages_48_147&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_48_147' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_48_147' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_48_147\"  >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_48_147'>Max. file size: 32 MB, Max. files: 2.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_48_147'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_48_147' class='ginput_preview_list'><\/div><\/div><div id=\"field_48_81\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_81\"><h3 class=\"gsection_title\">Recorded Statement<\/h3><\/div><fieldset id=\"field_48_82\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_82\"><legend class='gfield_label gform-field-label'  >Have you given a recorded statement to anyone?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_82'>\n\t\t\t<div class='gchoice gchoice_48_82_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Yes'  id='choice_48_82_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_82_0' id='label_48_82_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_82_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='No'  id='choice_48_82_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_82_1' id='label_48_82_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_48_89\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_89\"><label class='gfield_label gform-field-label' for='input_48_89' >If yes, who was it given to?<\/label><div class='ginput_container ginput_container_text'><input name='input_89' id='input_48_89' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_84\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_84\"><h3 class=\"gsection_title\">Passenger 1 Information<\/h3><\/div><div id=\"field_48_85\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_85\"><label class='gfield_label gform-field-label' for='input_48_85' >Passenger 1 Full Name<\/label><div class='ginput_container ginput_container_text'><input name='input_85' id='input_48_85' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_148\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_148\"><label class='gfield_label gform-field-label' for='input_48_148' >What&#039;s your relationship to Passenger 1?<\/label><div class='ginput_container ginput_container_text'><input name='input_148' id='input_48_148' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_137\"  class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_137\"><label class='gfield_label gform-field-label' for='input_48_137' >Passenger 1 Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_137' id='input_48_137' type='text' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_48_87\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_87\"><label class='gfield_label gform-field-label' for='input_48_87' >Passenger 1 Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_87' id='input_48_87' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_48_87_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_48_87_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_48_87' class='gform_hidden' value='https:\/\/www.pureconceptions.com\/smithlaw\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_48_124\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_124\"><legend class='gfield_label gform-field-label'  >Passenger 1 Position in Vehicle<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_124'>\n\t\t\t<div class='gchoice gchoice_48_124_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Front Seat'  id='choice_48_124_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_124_0' id='label_48_124_0' class='gform-field-label gform-field-label--type-inline'>Front Seat<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_124_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Behind Driver'  id='choice_48_124_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_124_1' id='label_48_124_1' class='gform-field-label gform-field-label--type-inline'>Behind Driver<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_124_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Middle Seat'  id='choice_48_124_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_124_2' id='label_48_124_2' class='gform-field-label gform-field-label--type-inline'>Middle Seat<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_124_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_124' type='radio' value='Behind Front Passenger'  id='choice_48_124_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_124_3' id='label_48_124_3' class='gform-field-label gform-field-label--type-inline'>Behind Front Passenger<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_48_88\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_88\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Passenger 1 Medical Treatment<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_48_88'><div class='gchoice gchoice_48_88_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.1' type='checkbox'  value='Hospital'  id='choice_48_88_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_88_1' id='label_48_88_1' class='gform-field-label gform-field-label--type-inline'>Hospital<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_88_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.2' type='checkbox'  value='Ambulance'  id='choice_48_88_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_88_2' id='label_48_88_2' class='gform-field-label gform-field-label--type-inline'>Ambulance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_88_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_88.3' type='checkbox'  value='None'  id='choice_48_88_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_88_3' id='label_48_88_3' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_48_91\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_91\"><legend class='gfield_label gform-field-label'  >Does he\/she (Passenger 1) have Medicaid?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_91'>\n\t\t\t<div class='gchoice gchoice_48_91_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='Yes'  id='choice_48_91_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_91_0' id='label_48_91_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_91_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_91' type='radio' value='No'  id='choice_48_91_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_91_1' id='label_48_91_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_48_92\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_92\"><h3 class=\"gsection_title\">Passenger 2 Information<\/h3><\/div><div id=\"field_48_93\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_93\"><label class='gfield_label gform-field-label' for='input_48_93' >Passenger 2 Full Name<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_48_93' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_150\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_150\"><label class='gfield_label gform-field-label' for='input_48_150' >What&#039;s your relationship to Passenger 2?<\/label><div class='ginput_container ginput_container_text'><input name='input_150' id='input_48_150' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_138\"  class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_138\"><label class='gfield_label gform-field-label' for='input_48_138' >Passenger 2 Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_138' id='input_48_138' type='text' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_48_103\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_103\"><label class='gfield_label gform-field-label' for='input_48_103' >Passenger 2 Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_103' id='input_48_103' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_48_103_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_48_103_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_48_103' class='gform_hidden' value='https:\/\/www.pureconceptions.com\/smithlaw\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_48_167\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_167\"><legend class='gfield_label gform-field-label'  >Passenger 2 Position in Vehicle<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_167'>\n\t\t\t<div class='gchoice gchoice_48_167_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='Front Seat'  id='choice_48_167_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_167_0' id='label_48_167_0' class='gform-field-label gform-field-label--type-inline'>Front Seat<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_167_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='Behind Driver'  id='choice_48_167_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_167_1' id='label_48_167_1' class='gform-field-label gform-field-label--type-inline'>Behind Driver<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_167_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='Middle Seat'  id='choice_48_167_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_167_2' id='label_48_167_2' class='gform-field-label gform-field-label--type-inline'>Middle Seat<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_167_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_167' type='radio' value='Behind Front Passenger'  id='choice_48_167_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_167_3' id='label_48_167_3' class='gform-field-label gform-field-label--type-inline'>Behind Front Passenger<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_48_98\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_98\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Passenger 2 Medical Treatment<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_48_98'><div class='gchoice gchoice_48_98_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.1' type='checkbox'  value='Hospital'  id='choice_48_98_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_98_1' id='label_48_98_1' class='gform-field-label gform-field-label--type-inline'>Hospital<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_98_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.2' type='checkbox'  value='Ambulance'  id='choice_48_98_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_98_2' id='label_48_98_2' class='gform-field-label gform-field-label--type-inline'>Ambulance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_98_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_98.3' type='checkbox'  value='None'  id='choice_48_98_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_98_3' id='label_48_98_3' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_48_106\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_106\"><legend class='gfield_label gform-field-label'  >Does he\/she (Passenger 2) have Medicaid?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_106'>\n\t\t\t<div class='gchoice gchoice_48_106_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_106' type='radio' value='Yes'  id='choice_48_106_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_106_0' id='label_48_106_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_106_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_106' type='radio' value='No'  id='choice_48_106_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_106_1' id='label_48_106_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_48_100\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_100\"><h3 class=\"gsection_title\">Passenger 3 Information<\/h3><\/div><div id=\"field_48_101\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_101\"><label class='gfield_label gform-field-label' for='input_48_101' >Passenger 3 Full Name<\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_48_101' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_149\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_149\"><label class='gfield_label gform-field-label' for='input_48_149' >What&#039;s your relationship to Passenger 3?<\/label><div class='ginput_container ginput_container_text'><input name='input_149' id='input_48_149' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_139\"  class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_139\"><label class='gfield_label gform-field-label' for='input_48_139' >Passenger 3 Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_139' id='input_48_139' type='text' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_48_104\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_104\"><label class='gfield_label gform-field-label' for='input_48_104' >Passenger 3 Date of Birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_104' id='input_48_104' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_48_104_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_48_104_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_48_104' class='gform_hidden' value='https:\/\/www.pureconceptions.com\/smithlaw\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_48_122\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_122\"><legend class='gfield_label gform-field-label'  >Passenger 3 Position in Vehicle<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_122'>\n\t\t\t<div class='gchoice gchoice_48_122_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='Front Seat'  id='choice_48_122_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_122_0' id='label_48_122_0' class='gform-field-label gform-field-label--type-inline'>Front Seat<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_122_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='Behind Driver'  id='choice_48_122_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_122_1' id='label_48_122_1' class='gform-field-label gform-field-label--type-inline'>Behind Driver<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_122_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='Middle Seat'  id='choice_48_122_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_122_2' id='label_48_122_2' class='gform-field-label gform-field-label--type-inline'>Middle Seat<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_122_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_122' type='radio' value='Behind Front Passenger'  id='choice_48_122_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_122_3' id='label_48_122_3' class='gform-field-label gform-field-label--type-inline'>Behind Front Passenger<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_48_168\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_168\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Passenger 3 Medical Treatment<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_48_168'><div class='gchoice gchoice_48_168_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.1' type='checkbox'  value='Hospital'  id='choice_48_168_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_168_1' id='label_48_168_1' class='gform-field-label gform-field-label--type-inline'>Hospital<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_168_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.2' type='checkbox'  value='Ambulance'  id='choice_48_168_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_168_2' id='label_48_168_2' class='gform-field-label gform-field-label--type-inline'>Ambulance<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_48_168_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.3' type='checkbox'  value='None'  id='choice_48_168_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_48_168_3' id='label_48_168_3' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_48_99\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_99\"><legend class='gfield_label gform-field-label'  >Does he\/she (Passenger 3) have Medicaid?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_99'>\n\t\t\t<div class='gchoice gchoice_48_99_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='Yes'  id='choice_48_99_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_99_0' id='label_48_99_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_99_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='No'  id='choice_48_99_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_99_1' id='label_48_99_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_48_164' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='jQuery(\"#gform_target_page_number_48\").val(\"6\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_48\").val(\"6\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); } ' \/> <input type='button' id='gform_next_button_48_164' class='gform_next_button gform-theme-button button' value='Next'  onclick='jQuery(\"#gform_target_page_number_48\").val(\"8\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); ' onkeypress='if( event.keyCode == 13 ){ jQuery(\"#gform_target_page_number_48\").val(\"8\");  jQuery(\"#gform_48\").trigger(\"submit\",[true]); } ' \/> <button type='button'  id='gform_save_48_8_link' class='gform_save_link gform-theme-button gform-theme-button--secondary button'  onclick='if(window[\"gf_submitting_48\"]){return false;}  window[\"gf_submitting_48\"]=true; jQuery(\"#gform_save_48\").val(1); jQuery(\"#gform_48\").trigger(\"submit\",[true]);' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_48\"]){return false;} window[\"gf_submitting_48\"]=true; jQuery(\"#gform_save_48\").val(1); jQuery(\"#gform_48\").trigger(\"submit\",[true]); }'><svg aria-hidden=\"true\" focusable=\"false\" width=\"16\" height=\"16\" fill=\"none\" xmlns=\"http:\/\/www.w3.org\/2000\/svg\"><path fill-rule=\"evenodd\" clip-rule=\"evenodd\" d=\"M0 8a4 4 0 004 4h3v3a1 1 0 102 0v-3h3a4 4 0 100-8 4 4 0 10-8 0 4 4 0 00-4 4zm9 4H7V7.414L5.707 8.707a1 1 0 01-1.414-1.414l3-3a1 1 0 011.414 0l3 3a1 1 0 01-1.414 1.414L9 7.414V12z\" fill=\"#6B7280\"\/><\/svg> Save and Continue Later<\/button>\n                    <\/div>\n                <\/div>\n                <div id='gform_page_48_8' class='gform_page' data-js='page-field-id-164' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_48_8' class='gform_fields top_label form_sublabel_below description_above'><div id=\"field_48_107\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_107\"><h3 class=\"gsection_title\">Emergency Contact<\/h3><\/div><div id=\"field_48_108\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_108\"><label class='gfield_label gform-field-label' for='input_48_108' >Emergency Contact Full Name<\/label><div class='ginput_container ginput_container_text'><input name='input_108' id='input_48_108' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_48_140\"  class=\"gfield gfield--type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_140\"><label class='gfield_label gform-field-label' for='input_48_140' >Emergency Contact Phone Number<\/label><div class='ginput_container ginput_container_phone'><input name='input_140' id='input_48_140' type='text' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_48_110\"  class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_110\"><h3 class=\"gsection_title\">How Did You Hear About Us?!<\/h3><\/div><fieldset id=\"field_48_111\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_111\"><legend class='gfield_label gform-field-label'  >Please select one:<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_111'>\n\t\t\t<div class='gchoice gchoice_48_111_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='Referral'  id='choice_48_111_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_111_0' id='label_48_111_0' class='gform-field-label gform-field-label--type-inline'>Referral<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_111_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='Instagram'  id='choice_48_111_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_111_1' id='label_48_111_1' class='gform-field-label gform-field-label--type-inline'>Instagram<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_111_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='In Person'  id='choice_48_111_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_111_2' id='label_48_111_2' class='gform-field-label gform-field-label--type-inline'>In Person<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_111_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_111' type='radio' value='Other'  id='choice_48_111_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_111_3' id='label_48_111_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_48_112\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_48_112\"><label class='gfield_label gform-field-label' for='input_48_112' >Name of Person Who Referred You<\/label><div class='ginput_container ginput_container_text'><input name='input_112' id='input_48_112' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_48_130\"  class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_below gfield--no-description field_description_above gfield_visibility_hidden\"  data-js-reload=\"field_48_130\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><legend class='gfield_label gform-field-label'  >How do you want to contact to be generated<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_48_130'>\n\t\t\t<div class='gchoice gchoice_48_130_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Send the contract to the client via email'  id='choice_48_130_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_130_0' id='label_48_130_0' class='gform-field-label gform-field-label--type-inline'>Send the contract to the client via email<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_48_130_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_130' type='radio' value='Generate the contract to be signed right now'  id='choice_48_130_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_48_130_1' id='label_48_130_1' class='gform-field-label gform-field-label--type-inline'>Generate the contract to be signed right now<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><\/div><\/div>\n        <div class='gform_page_footer top_label'><input type='submit' id='gform_previous_button_48' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' value='Previous'  onclick='if(window[\"gf_submitting_48\"]){return false;}  window[\"gf_submitting_48\"]=true;  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_48\"]){return false;} window[\"gf_submitting_48\"]=true;  jQuery(\"#gform_48\").trigger(\"submit\",[true]); }' \/> <input 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