{"id":19851,"date":"2016-04-15T18:11:59","date_gmt":"2016-04-16T00:11:59","guid":{"rendered":"http:\/\/www.jedwardknight.com\/insurance-maine\/?page_id=19851"},"modified":"2024-07-04T11:18:20","modified_gmt":"2024-07-04T17:18:20","slug":"claims-satisfaction-survey","status":"publish","type":"page","link":"https:\/\/www.jedwardknight.com\/insurance-maine\/contact-us\/claims-satisfaction-survey\/","title":{"rendered":"Claims Satisfaction Survey"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"19851\" class=\"elementor elementor-19851\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d89fa81 e-flex e-con-boxed e-con e-parent\" data-id=\"d89fa81\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-6db7726 e-con-full e-flex e-con e-child\" data-id=\"6db7726\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-8af372a uael-gf-ajax-true uael-gf-style-box uael-gf-input-size-sm uael-gf-enable-classes-no uael-gf-button-left uael-gf-btn-size-sm elementor-widget elementor-widget-uael-gf-styler\" data-id=\"8af372a\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"uael-gf-styler.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"uael-gf-style uael-gf-check-style elementor-clickable\">\n\t<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_4' style='display:none'><div id='gf_4' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data'  id='gform_4'  action='\/insurance-maine\/wp-json\/wp\/v2\/pages\/19851#gf_4' data-formid='4' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_page_4_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_97\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_97'>URL<\/label><div class='ginput_container'><input name='input_97' id='input_4_97' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_4_97'>This field is for validation purposes and should be left unchanged.<\/div><\/div><div id=\"field_4_79\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><table style=\"background-color:#f8f8f8; border:solid 0px; #cacaca; border-radius:20px 20px 20px 20px; width:100%;\"><tr><td style=\"padding:10px 10px 10px 10px;\">\n\n<h2>Claims Satisfaction Survey<\/h2>\n<img decoding=\"async\" border=\"0\" src=\"https:\/\/secure-one.co\/-\/_form-images\/images\/client-renewal-survey-icon.png\" align=\"right\">\n<br \/>\n<blockquote>Please respond to each statement and select the answer that corresponds to your level of agreement or disagreement with the statement.  Comments on any of the statements may be added after the statement or at the bottom of the survey. <\/blockquote>\n<br \/><br \/>\n<\/td><\/table>\n<hr><\/div><div id=\"field_4_84\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-label' >1. J Edward Knight responded quickly and professionally to the first reporting of my claim.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table aria-label='1. J Edward Knight responded quickly and professionally to the first reporting of my claim.' class='gsurvey-likert' id='input_4_84'><thead><tr><th id='likert_col_1_4_84' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Strongly Disagree<\/th><th id='likert_col_2_4_84' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Disagree<\/th><th id='likert_col_3_4_84' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Neutral<\/th><th id='likert_col_4_4_84' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Agree<\/th><th id='likert_col_5_4_84' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Strongly Agree<\/th><\/tr><\/thead><tbody><tr><td data-label='Strongly Disagree' class='gsurvey-likert-choice'><input name='input_84' type='radio' value='glikertcol841d01a63b'  id='choice_4_84_1'  tabindex='1'  aria-labelledby='likert_col_1_4_84'\/><\/td><td data-label='Disagree' class='gsurvey-likert-choice'><input name='input_84' type='radio' value='glikertcol84bbd6b3ba'  id='choice_4_84_2'  tabindex='2'  aria-labelledby='likert_col_2_4_84'\/><\/td><td data-label='Neutral' class='gsurvey-likert-choice'><input name='input_84' type='radio' value='glikertcol84c2b9d900'  id='choice_4_84_3'  tabindex='3'  aria-labelledby='likert_col_3_4_84'\/><\/td><td data-label='Agree' class='gsurvey-likert-choice'><input name='input_84' type='radio' value='glikertcol8443494f24'  id='choice_4_84_4'  tabindex='4'  aria-labelledby='likert_col_4_4_84'\/><\/td><td data-label='Strongly Agree' class='gsurvey-likert-choice'><input name='input_84' type='radio' value='glikertcol843ace7487'  id='choice_4_84_5'  tabindex='5'  aria-labelledby='likert_col_5_4_84'\/><\/td><\/tr><\/tbody><\/table><\/div><\/div><div id=\"field_4_86\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-label' >2. J Edward Knight explained the claim process to me in a clear and concise manner.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table aria-label='2. J Edward Knight explained the claim process to me in a clear and concise manner.' class='gsurvey-likert' id='input_4_86'><thead><tr><th id='likert_col_1_4_86' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Strongly Disagree<\/th><th id='likert_col_2_4_86' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Disagree<\/th><th id='likert_col_3_4_86' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Neutral<\/th><th id='likert_col_4_4_86' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Agree<\/th><th id='likert_col_5_4_86' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Strongly Agree<\/th><\/tr><\/thead><tbody><tr><td data-label='Strongly Disagree' class='gsurvey-likert-choice'><input name='input_86' type='radio' value='glikertcol841d01a63b'  id='choice_4_86_1'  tabindex='6'  aria-labelledby='likert_col_1_4_86'\/><\/td><td data-label='Disagree' class='gsurvey-likert-choice'><input name='input_86' type='radio' value='glikertcol84bbd6b3ba'  id='choice_4_86_2'  tabindex='7'  aria-labelledby='likert_col_2_4_86'\/><\/td><td data-label='Neutral' class='gsurvey-likert-choice'><input name='input_86' type='radio' value='glikertcol84c2b9d900'  id='choice_4_86_3'  tabindex='8'  aria-labelledby='likert_col_3_4_86'\/><\/td><td data-label='Agree' class='gsurvey-likert-choice'><input name='input_86' type='radio' value='glikertcol8443494f24'  id='choice_4_86_4'  tabindex='9'  aria-labelledby='likert_col_4_4_86'\/><\/td><td data-label='Strongly Agree' class='gsurvey-likert-choice'><input name='input_86' type='radio' value='glikertcol843ace7487'  id='choice_4_86_5'  tabindex='10'  aria-labelledby='likert_col_5_4_86'\/><\/td><\/tr><\/tbody><\/table><\/div><\/div><div id=\"field_4_85\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-label' >3. J Edward Knight was available throughout the claims process to answer my questions and concerns.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table aria-label='3. J Edward Knight was available throughout the claims process to answer my questions and concerns.' class='gsurvey-likert' id='input_4_85'><thead><tr><th id='likert_col_1_4_85' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Strongly Disagree<\/th><th id='likert_col_2_4_85' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Disagree<\/th><th id='likert_col_3_4_85' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Neutral<\/th><th id='likert_col_4_4_85' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Agree<\/th><th id='likert_col_5_4_85' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Strongly Agree<\/th><\/tr><\/thead><tbody><tr><td data-label='Strongly Disagree' class='gsurvey-likert-choice'><input name='input_85' type='radio' value='glikertcol841d01a63b'  id='choice_4_85_1'  tabindex='11'  aria-labelledby='likert_col_1_4_85'\/><\/td><td data-label='Disagree' class='gsurvey-likert-choice'><input name='input_85' type='radio' value='glikertcol84bbd6b3ba'  id='choice_4_85_2'  tabindex='12'  aria-labelledby='likert_col_2_4_85'\/><\/td><td data-label='Neutral' class='gsurvey-likert-choice'><input name='input_85' type='radio' value='glikertcol84c2b9d900'  id='choice_4_85_3'  tabindex='13'  aria-labelledby='likert_col_3_4_85'\/><\/td><td data-label='Agree' class='gsurvey-likert-choice'><input name='input_85' type='radio' value='glikertcol8443494f24'  id='choice_4_85_4'  tabindex='14'  aria-labelledby='likert_col_4_4_85'\/><\/td><td data-label='Strongly Agree' class='gsurvey-likert-choice'><input name='input_85' type='radio' value='glikertcol843ace7487'  id='choice_4_85_5'  tabindex='15'  aria-labelledby='likert_col_5_4_85'\/><\/td><\/tr><\/tbody><\/table><\/div><\/div><div id=\"field_4_88\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-label' >4. My insurance policy coverage met my expectations.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table aria-label='4. My insurance policy coverage met my expectations.' class='gsurvey-likert' id='input_4_88'><thead><tr><th id='likert_col_1_4_88' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Strongly Disagree<\/th><th id='likert_col_2_4_88' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Disagree<\/th><th id='likert_col_3_4_88' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Neutral<\/th><th id='likert_col_4_4_88' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Agree<\/th><th id='likert_col_5_4_88' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Strongly Agree<\/th><\/tr><\/thead><tbody><tr><td data-label='Strongly Disagree' class='gsurvey-likert-choice'><input name='input_88' type='radio' value='glikertcol841d01a63b'  id='choice_4_88_1'  tabindex='16'  aria-labelledby='likert_col_1_4_88'\/><\/td><td data-label='Disagree' class='gsurvey-likert-choice'><input name='input_88' type='radio' value='glikertcol84bbd6b3ba'  id='choice_4_88_2'  tabindex='17'  aria-labelledby='likert_col_2_4_88'\/><\/td><td data-label='Neutral' class='gsurvey-likert-choice'><input name='input_88' type='radio' value='glikertcol84c2b9d900'  id='choice_4_88_3'  tabindex='18'  aria-labelledby='likert_col_3_4_88'\/><\/td><td data-label='Agree' class='gsurvey-likert-choice'><input name='input_88' type='radio' value='glikertcol8443494f24'  id='choice_4_88_4'  tabindex='19'  aria-labelledby='likert_col_4_4_88'\/><\/td><td data-label='Strongly Agree' class='gsurvey-likert-choice'><input name='input_88' type='radio' value='glikertcol843ace7487'  id='choice_4_88_5'  tabindex='20'  aria-labelledby='likert_col_5_4_88'\/><\/td><\/tr><\/tbody><\/table><\/div><\/div><div id=\"field_4_87\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-label' >5. I was satisfied with my claims experience.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table aria-label='5. I was satisfied with my claims experience.' class='gsurvey-likert' id='input_4_87'><thead><tr><th id='likert_col_1_4_87' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Strongly Disagree<\/th><th id='likert_col_2_4_87' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Disagree<\/th><th id='likert_col_3_4_87' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Neutral<\/th><th id='likert_col_4_4_87' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Agree<\/th><th id='likert_col_5_4_87' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Strongly Agree<\/th><\/tr><\/thead><tbody><tr><td data-label='Strongly Disagree' class='gsurvey-likert-choice'><input name='input_87' type='radio' value='glikertcol841d01a63b'  id='choice_4_87_1'  tabindex='21'  aria-labelledby='likert_col_1_4_87'\/><\/td><td data-label='Disagree' class='gsurvey-likert-choice'><input name='input_87' type='radio' value='glikertcol84bbd6b3ba'  id='choice_4_87_2'  tabindex='22'  aria-labelledby='likert_col_2_4_87'\/><\/td><td data-label='Neutral' class='gsurvey-likert-choice'><input name='input_87' type='radio' value='glikertcol84c2b9d900'  id='choice_4_87_3'  tabindex='23'  aria-labelledby='likert_col_3_4_87'\/><\/td><td data-label='Agree' class='gsurvey-likert-choice'><input name='input_87' type='radio' value='glikertcol8443494f24'  id='choice_4_87_4'  tabindex='24'  aria-labelledby='likert_col_4_4_87'\/><\/td><td data-label='Strongly Agree' class='gsurvey-likert-choice'><input name='input_87' type='radio' value='glikertcol843ace7487'  id='choice_4_87_5'  tabindex='25'  aria-labelledby='likert_col_5_4_87'\/><\/td><\/tr><\/tbody><\/table><\/div><\/div><div id=\"field_4_90\" class=\"gfield gfield--type-survey gfield--input-type-likert gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gsurvey-survey-field \"  data-field-class=\"gsurvey-survey-field\" ><label class='gfield_label gform-field-label' >6. I would recommend J Edward Knight Insurance Agency to my family and friends.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_likert'><table aria-label='6. I would recommend J Edward Knight Insurance Agency to my family and friends.' class='gsurvey-likert' id='input_4_90'><thead><tr><th id='likert_col_1_4_90' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Strongly Disagree<\/th><th id='likert_col_2_4_90' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Disagree<\/th><th id='likert_col_3_4_90' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Neutral<\/th><th id='likert_col_4_4_90' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Agree<\/th><th id='likert_col_5_4_90' scope='col' role='presentation' class='gsurvey-likert-choice-label'>Strongly Agree<\/th><\/tr><\/thead><tbody><tr><td data-label='Strongly Disagree' class='gsurvey-likert-choice'><input name='input_90' type='radio' value='glikertcol841d01a63b'  id='choice_4_90_1'  tabindex='26'  aria-labelledby='likert_col_1_4_90'\/><\/td><td data-label='Disagree' class='gsurvey-likert-choice'><input name='input_90' type='radio' value='glikertcol84bbd6b3ba'  id='choice_4_90_2'  tabindex='27'  aria-labelledby='likert_col_2_4_90'\/><\/td><td data-label='Neutral' class='gsurvey-likert-choice'><input name='input_90' type='radio' value='glikertcol84c2b9d900'  id='choice_4_90_3'  tabindex='28'  aria-labelledby='likert_col_3_4_90'\/><\/td><td data-label='Agree' class='gsurvey-likert-choice'><input name='input_90' type='radio' value='glikertcol8443494f24'  id='choice_4_90_4'  tabindex='29'  aria-labelledby='likert_col_4_4_90'\/><\/td><td data-label='Strongly Agree' class='gsurvey-likert-choice'><input name='input_90' type='radio' value='glikertcol843ace7487'  id='choice_4_90_5'  tabindex='30'  aria-labelledby='likert_col_5_4_90'\/><\/td><\/tr><\/tbody><\/table><\/div><\/div><div id=\"field_4_95\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_4_94\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>ADDITIONAL COMMENTS?<\/h2>\n<hr><\/div><div id=\"field_4_51\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_51'>Any additional information, questions or concerns you would like to have addressed.<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_51' id='input_4_51' class='textarea medium' tabindex='31'  maxlength='5000'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='image' src='https:\/\/secure-one.co\/-\/_form-images\/images\/next-button-sm.png' id='gform_next_button_4_91' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' class='gform_next_button gform-theme-button button gform_image_button' alt='Next Page' tabindex='32' \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_4_2' class='gform_page' data-js='page-field-id-91' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_4_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_4_82\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>YOUR CONTACT INFORMATION<\/h2>\n<hr><\/div><fieldset id=\"field_4_1\" class=\"gfield gfield--type-name gfield--input-type-name gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >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_4_1'>\n                            <span id='input_4_1_3_container' class='name_first gform-grid-col' >\n                                                    <input type='text' name='input_1.3' id='input_4_1_3' value='' tabindex='33'  aria-required='true'    \/>\n                                                    <label for='input_4_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                               <\/span>\n                            <span id='input_4_1_6_container' class='name_last gform-grid-col' >\n                                                    <input type='text' name='input_1.6' id='input_4_1_6' value='' tabindex='34'  aria-required='true'    \/>\n                                                    <label for='input_4_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            <div class='gf_clear gf_clear_complex'><\/div>\n                        <\/div><\/fieldset><fieldset id=\"field_4_5\" class=\"gfield gfield--type-email gfield--input-type-email gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_4_5_container'>\n                                <span id='input_4_5_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_5' id='input_4_5' value='' tabindex='35'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_4_5' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_4_5_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_5_2' id='input_4_5_2' value='' tabindex='36'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_4_5_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><fieldset id=\"field_4_93\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Please check if you\u2019d like to be contacted to discuss your responses.<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_4_93'><div class='gchoice gchoice_4_93_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_93.1' type='checkbox'  value='YES. Please Contact Me.'  id='choice_4_93_1' tabindex='37'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_4_93_1' id='label_4_93_1' class='gform-field-label gform-field-label--type-inline'>YES. Please Contact Me.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_3\" class=\"gfield gfield--type-text gfield--input-type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_4_3'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_4_3' type='text' value='' class='small'   tabindex='38'  aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_4_80\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_right_half gf_list_inline gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Phone Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_4_80'>\n\t\t\t<div class='gchoice gchoice_4_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Cell'  id='choice_4_80_0' onchange='gformToggleRadioOther( this )'  tabindex='39'  \/>\n\t\t\t\t\t<label for='choice_4_80_0' id='label_4_80_0' class='gform-field-label gform-field-label--type-inline'>Cell<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Work'  id='choice_4_80_1' onchange='gformToggleRadioOther( this )'  tabindex='40'  \/>\n\t\t\t\t\t<label for='choice_4_80_1' id='label_4_80_1' class='gform-field-label gform-field-label--type-inline'>Work<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_80_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Home'  id='choice_4_80_2' onchange='gformToggleRadioOther( this )'  tabindex='41'  \/>\n\t\t\t\t\t<label for='choice_4_80_2' id='label_4_80_2' class='gform-field-label gform-field-label--type-inline'>Home<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_4_80_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Other'  id='choice_4_80_3' onchange='gformToggleRadioOther( this )'  tabindex='42'  \/>\n\t\t\t\t\t<label for='choice_4_80_3' id='label_4_80_3' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_4_53\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below 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tabindex='43' \/> <input type='image' src='https:\/\/secure-one.co\/-\/_form-images\/images\/submit-button-sm.png' id='gform_submit_button_4' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' class='gform_button button gform_image_button' alt='Submit' tabindex='44' \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_4' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_4' id='gform_theme_4' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_4' id='gform_style_settings_4' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_4' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='4' \/>\n            \n            <input type='hidden' class='gform_hidden' 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