{"id":446,"date":"2023-05-11T03:38:37","date_gmt":"2023-05-11T03:38:37","guid":{"rendered":"https:\/\/groups.wallach.com\/?page_id=446"},"modified":"2025-04-29T23:48:23","modified_gmt":"2025-04-29T23:48:23","slug":"application","status":"publish","type":"page","link":"https:\/\/lloydsinsurancebrokerage.com\/de\/application\/","title":{"rendered":"International Medical Insurance | Application"},"content":{"rendered":"<style>.kb-row-layout-id446_d3bc11-0f > .kt-row-column-wrap{align-content:start;}:where(.kb-row-layout-id446_d3bc11-0f > .kt-row-column-wrap) > .wp-block-kadence-column{justify-content:start;}.kb-row-layout-id446_d3bc11-0f > .kt-row-column-wrap{column-gap:var(--global-kb-gap-md, 2rem);row-gap:var(--global-kb-gap-md, 2rem);max-width:600px;margin-left:auto;margin-right:auto;padding-top:var(--global-kb-spacing-xxl, 5rem);padding-right:var(--global-kb-spacing-xs, 1rem);padding-bottom:var(--global-kb-spacing-lg, 3rem);padding-left:var(--global-kb-spacing-xs, 1rem);grid-template-columns:minmax(0, 1fr);}.kb-row-layout-id446_d3bc11-0f > .kt-row-layout-overlay{opacity:0.30;}@media all and (max-width: 1024px){.kb-row-layout-id446_d3bc11-0f > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}@media all and (max-width: 767px){.kb-row-layout-id446_d3bc11-0f > .kt-row-column-wrap{grid-template-columns:minmax(0, 1fr);}}<\/style><div class=\"kb-row-layout-wrap kb-row-layout-id446_d3bc11-0f alignfull has-theme-palette2-background-color kt-row-has-bg wp-block-kadence-rowlayout\"><div class=\"kt-row-column-wrap kt-has-1-columns kt-row-layout-equal kt-tab-layout-inherit kt-mobile-layout-row kt-row-valign-top\">\n<style>.kadence-column446_579405-6d > .kt-inside-inner-col,.kadence-column446_579405-6d > .kt-inside-inner-col:before{border-top-left-radius:0px;border-top-right-radius:0px;border-bottom-right-radius:0px;border-bottom-left-radius:0px;}.kadence-column446_579405-6d > .kt-inside-inner-col{column-gap:var(--global-kb-gap-sm, 1rem);}.kadence-column446_579405-6d > .kt-inside-inner-col{flex-direction:column;}.kadence-column446_579405-6d > .kt-inside-inner-col > .aligncenter{width:100%;}.kadence-column446_579405-6d > .kt-inside-inner-col:before{opacity:0.3;}.kadence-column446_579405-6d{position:relative;}.kadence-column446_579405-6d, .kt-inside-inner-col > .kadence-column446_579405-6d:not(.specificity){margin-top:0px;margin-right:0px;margin-bottom:0px;margin-left:0px;}@media all and (max-width: 1024px){.kadence-column446_579405-6d > .kt-inside-inner-col{flex-direction:column;}}@media all and (max-width: 767px){.kadence-column446_579405-6d > .kt-inside-inner-col{flex-direction:column;}}<\/style>\n<div class=\"wp-block-kadence-column kadence-column446_579405-6d inner-column-1\"><div class=\"kt-inside-inner-col\"><style>.wp-block-kadence-advancedheading.kt-adv-heading446_72d800-25, .wp-block-kadence-advancedheading.kt-adv-heading446_72d800-25[data-kb-block=\"kb-adv-heading446_72d800-25\"]{margin-bottom:var(--global-kb-spacing-lg, 3rem);text-align:center;font-size:var(--global-kb-font-size-xl, 3rem);font-weight:normal;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading446_72d800-25 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading446_72d800-25[data-kb-block=\"kb-adv-heading446_72d800-25\"] mark.kt-highlight{font-weight:normal;font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}<\/style>\n<h2 class=\"kt-adv-heading446_72d800-25 wp-block-kadence-advancedheading has-theme-palette-9-color has-text-color\" data-kb-block=\"kb-adv-heading446_72d800-25\"><strong>Purchase Now<\/strong><\/h2>\n\n\n<style>.wp-block-kadence-advancedheading.kt-adv-heading446_e040b8-82, .wp-block-kadence-advancedheading.kt-adv-heading446_e040b8-82[data-kb-block=\"kb-adv-heading446_e040b8-82\"]{margin-top:-20px;text-align:center;font-weight:normal;font-style:normal;}.wp-block-kadence-advancedheading.kt-adv-heading446_e040b8-82 mark.kt-highlight, .wp-block-kadence-advancedheading.kt-adv-heading446_e040b8-82[data-kb-block=\"kb-adv-heading446_e040b8-82\"] mark.kt-highlight{font-weight:normal;font-style:normal;color:#f76a0c;-webkit-box-decoration-break:clone;box-decoration-break:clone;padding-top:0px;padding-right:0px;padding-bottom:0px;padding-left:0px;}<\/style>\n<p class=\"kt-adv-heading446_e040b8-82 wp-block-kadence-advancedheading has-theme-palette-9-color has-text-color\" data-kb-block=\"kb-adv-heading446_e040b8-82\">Fill out the form below and your policy will be issued immediately upon payment.<\/p>\n<\/div><\/div>\n\n<\/div><\/div>\n\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var 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class=\"gfield gfield--type-uid field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_21_150\"><label class='gfield_label gform-field-label' for='input_21_150' >ID Number<\/label><div class='ginput_container ginput_container_hidden'><input name='input_150' id='input_21_150' type='hidden' value=''  \/><\/div><\/div><div id=\"field_21_192\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_21_192\"><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_21_192' >Affiliate<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_192' id='input_21_192' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_21_203\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_21_203\"><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_21_203' >Producer<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_203' id='input_21_203' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_21_204\"  class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_21_204\"><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_21_204' >Broker<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_204' id='input_21_204' type='text' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_21_18\"  class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_18\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/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_21_18'>\n                            \n                            <span id='input_21_18_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_18.3' id='input_21_18_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_21_18_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_21_18_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_18.6' id='input_21_18_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_21_18_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_21_3\"  class=\"gfield gfield--type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_3\"><legend class='gfield_label gform-field-label'  >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_21_3_container'>\n                                <span id='input_21_3_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_3' id='input_21_3' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_21_3' class='gform-field-label gform-field-label--type-sub '>Enter Email<\/label>\n                                <\/span>\n                                <span id='input_21_3_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_3_2' id='input_21_3_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                                    <label for='input_21_3_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><div id=\"field_21_151\"  class=\"gfield gfield--type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_151\"><label class='gfield_label gform-field-label' for='input_21_151' >Country of Residency<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_151' id='input_21_151' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value=''  class='gf_placeholder'>Select<\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brazil' >Brazil<\/option><option value='Brunei' >Brunei<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='East Timor' >East Timor<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='North Korea' >North Korea<\/option><option value='South Korea' >South Korea<\/option><option value='Kosovo' >Kosovo<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Laos' >Laos<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Sudan, South' >Sudan, South<\/option><option value='Suriname' >Suriname<\/option><option value='Swaziland (Eswatini)' >Swaziland (Eswatini)<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Togo' >Togo<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' selected='selected'>United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Vatican City' >Vatican City<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/div><div id=\"field_21_5\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gcldf-field gcldf-field-date gcldf-date-format-mdy gfield_trigger_change gfield_contains_required field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_5\"><label class='gfield_label gform-field-label' for='input_21_5' >Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_5' id='input_21_5' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_21_5_date_format gfield_description_21_5\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_21_5_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_21_5' class='gform_hidden' value='https:\/\/lloydsinsurancebrokerage.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_21_5'>Must be under age 71 on Desired Effective Date<\/div><\/div><div id=\"field_21_6\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gcldf-field gcldf-field-date gcldf-date-format-mdy gfield_trigger_change gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_6\"><label class='gfield_label gform-field-label' for='input_21_6' >Desired Effective Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_6' id='input_21_6' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_21_6_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_21_6_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_21_6' class='gform_hidden' value='https:\/\/lloydsinsurancebrokerage.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_21_168\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gcldf-field gcldf-field-date gcldf-date-format-mdy gfield_trigger_change gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_21_168\"><label class='gfield_label gform-field-label' for='input_21_168' >Last Day of Coverage<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_168' id='input_21_168' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_21_168_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_21_168_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_21_168' class='gform_hidden' value='https:\/\/lloydsinsurancebrokerage.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_21_20\"  class=\"gfield gfield--type-multiselect gfield--width-full copy-20-to-206 gwcopy gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_20\"><label class='gfield_label gform-field-label' for='input_21_20' >Destination Countries<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple' data-placeholder='Click to select...' size='7' name='input_20[]' id='input_21_20' class='large gfield_select'   aria-invalid=\"false\" aria-required=\"true\" ><option value='Area A' >Albania<\/option><option value='Area B' >Algeria<\/option><option value='Area C' >American Samoa<\/option><option value='Area A' >Andorra<\/option><option value='Area B' >Angola<\/option><option value='Area C' >Antigua and Barbuda<\/option><option value='Area A' >Argentina<\/option><option value='Area B' >Armenia<\/option><option value='Area C' >Aruba<\/option><option value='Area B' >Australia<\/option><option value='Area A' >Austria<\/option><option value='Area B' >Azerbaijan<\/option><option value='Area C' >Bahamas<\/option><option value='Area B' >Bahrain<\/option><option value='Area B' >Bangladesh<\/option><option value='Area C' >Barbados<\/option><option value='Area B' >Belarus<\/option><option value='Area A' >Belgium<\/option><option value='Area A' >Belize<\/option><option value='Area B' >Benin<\/option><option value='Area C' >Bermuda<\/option><option value='Area B' >Bhutan<\/option><option value='Area A' >Bolivia<\/option><option value='Area A' >Bosnia and Herzegovina<\/option><option value='Area B' >Botswana<\/option><option value='Area A' >Brazil<\/option><option value='Area B' >Brunei<\/option><option value='Area B' >Bulgaria<\/option><option value='Area B' >Burkina Faso<\/option><option value='Area B' >Burundi<\/option><option value='Area B' >Cambodia<\/option><option value='Area B' >Cameroon<\/option><option value='Area C' >Canada<\/option><option value='Area B' >Cape Verde<\/option><option value='Area C' >Cayman Islands<\/option><option value='Area B' >Central African Republic<\/option><option value='Area B' >Chad<\/option><option value='Area A' >Chile<\/option><option value='Area B' >China<\/option><option value='Area A' >Colombia<\/option><option value='Area B' >Comoros<\/option><option value='Area B' >Congo, Democratic Republic of the<\/option><option value='Area B' >Congo, Republic of the<\/option><option value='Area A' >Costa Rica<\/option><option value='Area B' >C\u00f4te d&#039;Ivoire<\/option><option value='Area A' >Croatia<\/option><option value='Area C' >Cuba<\/option><option value='Area C' >Cura\u00e7ao<\/option><option value='Area B' >Cyprus<\/option><option value='Area A' >Czech Republic<\/option><option value='Area A' >Denmark<\/option><option value='Area B' >Djibouti<\/option><option value='Area C' >Dominica<\/option><option value='Area C' >Dominican Republic<\/option><option value='Area B' >East Timor<\/option><option value='Area A' >Ecuador<\/option><option value='Area B' >Egypt<\/option><option value='Area A' >El Salvador<\/option><option value='Area B' >Equatorial Guinea<\/option><option value='Area B' >Eritrea<\/option><option value='Area B' >Estonia<\/option><option value='Area B' >Ethiopia<\/option><option value='Area A' >Faroe Islands<\/option><option value='Area B' >Fiji<\/option><option value='Area A' >Finland<\/option><option value='Area A' >France<\/option><option value='Area B' >French Polynesia<\/option><option value='Area B' >Gabon<\/option><option value='Area B' >Gambia<\/option><option value='Area B' >Georgia<\/option><option value='Area A' >Germany<\/option><option value='Area B' >Ghana<\/option><option value='Area A' >Greece<\/option><option value='Area A' >Greenland<\/option><option value='Area C' >Grenada<\/option><option value='Area C' >Guam<\/option><option value='Area A' >Guatemala<\/option><option value='Area B' >Guinea<\/option><option value='Area B' >Guinea-Bissau<\/option><option value='Area A' >Guyana<\/option><option value='Area C' >Haiti<\/option><option value='Area A' >Honduras<\/option><option value='Area B' >Hong Kong<\/option><option value='Area B' >Hungary<\/option><option value='Area A' >Iceland<\/option><option value='Area B' >India<\/option><option value='Area B' >Indonesia<\/option><option value='Area B' >Iran<\/option><option value='Area B' >Iraq<\/option><option value='Area A' >Ireland<\/option><option value='Area B' >Israel (exc. Gaza &amp; West Bank) (Tel Aviv)<\/option><option value='Area B' >Israel (inc. Gaza &amp; West Bank) (Jerusalem\/Dead Sea)<\/option><option value='Area A' >Italy<\/option><option value='Area C' >Jamaica<\/option><option value='Area B' >Japan<\/option><option value='Area B' >Jordan<\/option><option value='Area B' >Kazakhstan<\/option><option value='Area B' >Kenya<\/option><option value='Area B' >Kiribati<\/option><option value='Area B' >North Korea<\/option><option value='Area B' >South Korea<\/option><option value='Area A' >Kosovo<\/option><option value='Area B' >Kuwait<\/option><option value='Area B' >Kyrgyzstan<\/option><option value='Area B' >Laos<\/option><option value='Area B' >Latvia<\/option><option value='Area B' >Lebanon<\/option><option value='Area B' >Lesotho<\/option><option value='Area B' >Liberia<\/option><option value='Area B' >Libya<\/option><option value='Area A' >Liechtenstein<\/option><option value='Area A' >Lithuania<\/option><option value='Area A' >Luxembourg<\/option><option value='Area B' >Macedonia<\/option><option value='Area B' >Madagascar<\/option><option value='Area B' >Malawi<\/option><option value='Area B' >Malaysia<\/option><option value='Area B' >Maldives<\/option><option value='Area B' >Mali<\/option><option value='Area A' >Malta<\/option><option value='Area B' >Marshall Islands<\/option><option value='Area B' >Mauritania<\/option><option value='Area B' >Mauritius<\/option><option value='Area A' >Mexico<\/option><option value='Area B' >Micronesia<\/option><option value='Area B' >Moldova<\/option><option value='Area A' >Monaco<\/option><option value='Area B' >Mongolia<\/option><option value='Area A' >Montenegro<\/option><option value='Area B' >Morocco<\/option><option value='Area B' >Mozambique<\/option><option value='Area B' >Myanmar<\/option><option value='Area B' >Namibia<\/option><option value='Area B' >Nauru<\/option><option value='Area B' >Nepal<\/option><option value='Area A' >Netherlands<\/option><option value='Area B' >New Zealand<\/option><option value='Area A' >Nicaragua<\/option><option value='Area B' >Niger<\/option><option value='Area B' >Nigeria<\/option><option value='Area B' >Northern Mariana Islands<\/option><option value='Area A' >Norway<\/option><option value='Area B' >Oman<\/option><option value='Area B' >Pakistan<\/option><option value='Area B' >Palau<\/option><option value='Area B' >Palestine, State of<\/option><option value='Area A' >Panama<\/option><option value='Area B' >Papua New Guinea<\/option><option value='Area A' >Paraguay<\/option><option value='Area A' >Peru<\/option><option value='Area B' >Philippines<\/option><option value='Area A' >Poland<\/option><option value='Area A' >Portugal<\/option><option value='Area C' >Puerto Rico<\/option><option value='Area B' >Qatar<\/option><option value='Area B' >Romania<\/option><option value='Area B' >Russia<\/option><option value='Area B' >Rwanda<\/option><option value='Area C' >Saint Kitts and Nevis<\/option><option value='Area C' >Saint Lucia<\/option><option value='Area C' >Saint Vincent and the Grenadines<\/option><option value='Area C' >Saint Martin<\/option><option value='Area B' >Samoa<\/option><option value='Area A' >San Marino<\/option><option value='Area B' >Sao Tome and Principe<\/option><option value='Area B' >Saudi Arabia<\/option><option value='Area B' >Senegal<\/option><option value='Area A' >Serbia<\/option><option value='Area B' >Seychelles<\/option><option value='Area B' >Sierra Leone<\/option><option value='Area B' >Singapore<\/option><option value='Area C' >Sint Maarten<\/option><option value='Area A' >Slovakia<\/option><option value='Area A' >Slovenia<\/option><option value='Area B' >Solomon Islands<\/option><option value='Area B' >Somalia<\/option><option value='Area B' >South Africa<\/option><option value='Area A' >Spain<\/option><option value='Area B' >Sri Lanka<\/option><option value='Area B' >Sudan<\/option><option value='Area B' >Sudan, South<\/option><option value='Area B' >Suriname<\/option><option value='Area B' >Swaziland (Eswatini)<\/option><option value='Area A' >Sweden<\/option><option value='Area A' >Switzerland<\/option><option value='Area B' >Syria<\/option><option value='Area B' >Taiwan<\/option><option value='Area B' >Tajikistan<\/option><option value='Area B' >Tanzania<\/option><option value='Area B' >Thailand<\/option><option value='Area B' >Togo<\/option><option value='Area B' >Tonga<\/option><option value='Area C' >Trinidad and Tobago<\/option><option value='Area B' >Tunisia<\/option><option value='Area A' >Turkey<\/option><option value='Area B' >Turkmenistan<\/option><option value='Area B' >Tuvalu<\/option><option value='Area B' >Uganda<\/option><option value='Area B' >Ukraine<\/option><option value='Area B' >United Arab Emirates<\/option><option value='Area A' >United Kingdom<\/option><option value='Area C' >United States<\/option><option value='Area A' >Uruguay<\/option><option value='Area B' >Uzbekistan<\/option><option value='Area B' >Vanuatu<\/option><option value='Area A' >Vatican City<\/option><option value='Area A' >Venezuela<\/option><option value='Area B' >Vietnam<\/option><option value='Area C' >Virgin Islands, British<\/option><option value='Area C' >Virgin Islands, U.S.<\/option><option value='Yemen' >Yemen<\/option><option value='Area B' >Zambia<\/option><option value='Area B' >Zimbabwe<\/option><\/select><\/div><\/div><div id=\"field_21_206\"  class=\"gfield gfield--type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_21_206\"><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_21_206' >Destination Country Name<\/label><div class='ginput_container ginput_container_text'><input name='input_206' id='input_21_206' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_21_205\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_205\"><script>\ngform.addFilter( 'gppc_copied_value', function( value, $elem, data ) {\n    $source = jQuery( '#input_' + data.sourceFormId + '_' + data.source );\n    if( $source.is( 'select' ) ) {\n        value = $source.find( 'option:selected' ).text();\n    }\n    return value;\n} );\n<\/script><\/div><div id=\"field_21_199\"  class=\"gfield gfield--type-text gfield--width-full gf-hidetemp, gf_invisible field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_199\"><label class='gfield_label gform-field-label' for='input_21_199' >Countries &#8211; Admin<\/label><div class='ginput_container ginput_container_text'><input name='input_199' id='input_21_199' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_21_200\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_200\"><script>\n$( document ).ready(function() {\n    $( \"#input_18_3\" ).click(function() {\n        $(\"#input_18_20_chosen .search-choice span\").each(function(e) {\n            $('#input_18_199').val($('#input_18_199').val() + $(this).html() + \" \")\n        });\n    });\n});\n<\/script><\/div><fieldset id=\"field_21_198\"  class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_21_198\"><legend class='gfield_label gform-field-label gfield_label_before_complex'  >Please confirm foreign travel<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_21_198'><div class='gchoice gchoice_21_198_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_198.1' type='checkbox'  value='I confirm that my country of residency is not included in my travel itinerary' checked='checked' id='choice_21_198_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_21_198_1' id='label_21_198_1' class='gform-field-label gform-field-label--type-inline'>I confirm that my country of residency is not included in my travel itinerary<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_21_169\"  class=\"gfield gfield--type-number exclude wc-gforms-hide-from-email copy-169-to-171 copy-169-to-57.3 copy-169-to-76.3 copy-169-to-78.3 copy-169-to-176.3 gwcopy gfield_calculation field_sublabel_below gfield--has-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_21_169\"><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_21_169' >Hidden &#8211; Number of Days Calculation<\/label><div class='ginput_container ginput_container_number'><input name='input_169' id='input_21_169' type='text' step='any'   value='' class='small'  readonly=\"readonly\"    aria-invalid=\"false\" aria-describedby=\"gfield_description_21_169\" \/><\/div><div class='gfield_description' id='gfield_description_21_169'>DO NOT DELETE THIS FIELD &#8211; it is used to calculate number of days, however, since it does not pass to cart correctly, it&#8217;s value is copied to the &#8220;Number of Days Coverage&#8221; field and that field is displayed.  This calculated value is also copied to the quantity fields for all premiums. The copied values pass to the cart correctly.<\/div><\/div><div id=\"field_21_157\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon exclude wc-gforms-hide-from-email, gf_invisible gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_21_157\"><label class='gfield_label gform-field-label' for='input_21_157' >Hidden &#8211; Current Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_157' id='input_21_157' type='text' value='10\/05\/2026' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_21_157_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_21_157_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_21_157' class='gform_hidden' value='https:\/\/lloydsinsurancebrokerage.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_21_156\"  class=\"gfield gfield--type-number copy-156-to-172 exclude wc-gforms-hide-from-email gwcopy gfield_calculation field_sublabel_below gfield--has-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_21_156\"><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_21_156' >Hidden &#8211; Age of Applicant on Desired Effective Date Calculation<\/label><div class='ginput_container ginput_container_number'><input name='input_156' id='input_21_156' type='text' step='any'   value='' class='medium'  readonly=\"readonly\"    aria-invalid=\"false\" aria-describedby=\"gfield_description_21_156\" \/><\/div><div class='gfield_description' id='gfield_description_21_156'>DO NOT DELETE THIS FIELD &#8211; it is used to calculate the age of the applicant on Desired Effective date, however, since it does not pass to cart correctly, it&#8217;s value is copied to the &#8220;Age of Applicant on Desired Effective Date&#8221; field and that field is used.  The copied value passes to the cart correctly.<\/div><\/div><div id=\"field_21_172\"  class=\"gfield gfield--type-number exclude wc-gforms-hide-from-email field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_21_172\"><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_21_172' >Hidden &#8211; Age of Applicant on Desired Effective Date<\/label><div class='ginput_container ginput_container_number'><input name='input_172' id='input_21_172' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_21_166\"  class=\"gfield gfield--type-select copy-171-to-76.3 field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_21_166\"><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_21_166' >Optional Spouse Coverage<\/label><div class='ginput_container ginput_container_select'><select name='input_166' id='input_21_166' class='medium gfield_select'     aria-invalid=\"false\" ><option value='None' selected='selected'>None<\/option><option value='Please provide coverage for my spouse' >Please provide coverage for my spouse<\/option><\/select><\/div><\/div><div id=\"field_21_87\"  class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_87\"><label class='gfield_label gform-field-label' for='input_21_87' >Spouse&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_21_87' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_21_88\"  class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_88\"><legend class='gfield_label gform-field-label'  >Spouse&#039;s Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_21_88'>\n\t\t\t<div class='gchoice gchoice_21_88_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='Male'  id='choice_21_88_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_21_88_0' id='label_21_88_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_21_88_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_88' type='radio' value='Female'  id='choice_21_88_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_21_88_1' id='label_21_88_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_21_89\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gf_left_half readonly gcldf-field gcldf-field-date gcldf-date-format-mdy gfield_trigger_change gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_21_89\"><label class='gfield_label gform-field-label' for='input_21_89' >Spouse&#039;s Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_21_89'>Must be under age 71 on the Desired Effective Date<\/div><div class='ginput_container ginput_container_date'>\n                            <input name='input_89' id='input_21_89' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_21_89_date_format gfield_description_21_89\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_21_89_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_21_89' class='gform_hidden' value='https:\/\/lloydsinsurancebrokerage.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_21_158\"  class=\"gfield gfield--type-number copy-158-to-173 exclude wc-gforms-hide-from-email gwcopy gfield_calculation field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_21_158\"><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_21_158' >Hidden &#8211; Age of Spouse on Desired Effective Date Calculation<\/label><div class='ginput_container ginput_container_number'><input name='input_158' id='input_21_158' type='text' step='any'   value='' class='medium'  readonly=\"readonly\"    aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_21_173\"  class=\"gfield gfield--type-number exclude wc-gforms-hide-from-email field_sublabel_below gfield--no-description field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_21_173\"><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_21_173' >Hidden &#8211; Age of Spouse on Desired Effective Date<\/label><div class='ginput_container ginput_container_number'><input name='input_173' id='input_21_173' type='number' step='any'   value='' class='medium'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_21_143\"  class=\"gfield gfield--type-select copy-171-to-78.3 gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_hidden\"  data-js-reload=\"field_21_143\"><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_21_143' >Optional Unmarried Dependent Children Coverage<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_21_143'>The minimum age is 15 days and the maximum age is 20 years.\n<\/div><div class='ginput_container ginput_container_select'><select name='input_143' id='input_21_143' class='medium gfield_select'  aria-describedby=\"gfield_description_21_143\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='0' selected='selected'>None<\/option><option value='1' >Please provide coverage for 1 child<\/option><option value='2' >Please provide coverage for 2 children<\/option><option value='3' >Please provide coverage for 3 children<\/option><\/select><\/div><\/div><div id=\"field_21_91\"  class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_91\"><label class='gfield_label gform-field-label' for='input_21_91' >Name of First Child<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_91' id='input_21_91' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_21_92\"  class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_92\"><legend class='gfield_label gform-field-label'  >Sex &#8211; First Child<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_21_92'>\n\t\t\t<div class='gchoice gchoice_21_92_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='Male'  id='choice_21_92_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_21_92_0' id='label_21_92_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_21_92_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_92' type='radio' value='Female'  id='choice_21_92_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_21_92_1' id='label_21_92_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_21_93\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon readonly gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_21_93\"><label class='gfield_label gform-field-label' for='input_21_93' >Date of Birth &#8211; First Child<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_21_93'>Must be under age 21 on Desired Effective Date<\/div><div class='ginput_container ginput_container_date'>\n                            <input name='input_93' id='input_21_93' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_21_93_date_format gfield_description_21_93\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_21_93_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_21_93' class='gform_hidden' value='https:\/\/lloydsinsurancebrokerage.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_21_98\"  class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_98\"><label class='gfield_label gform-field-label' for='input_21_98' >Name of Second Child<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_21_98' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_21_99\"  class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_99\"><legend class='gfield_label gform-field-label'  >Sex &#8211; Second Child<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_21_99'>\n\t\t\t<div class='gchoice gchoice_21_99_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='Male'  id='choice_21_99_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_21_99_0' id='label_21_99_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_21_99_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='Female'  id='choice_21_99_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_21_99_1' id='label_21_99_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_21_100\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon readonly gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_21_100\"><label class='gfield_label gform-field-label' for='input_21_100' >Date of Birth &#8211; Second Child<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_21_100'>Must be under age 21 on Desired Effective Date<\/div><div class='ginput_container ginput_container_date'>\n                            <input name='input_100' id='input_21_100' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_21_100_date_format gfield_description_21_100\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_21_100_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_21_100' class='gform_hidden' value='https:\/\/lloydsinsurancebrokerage.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_21_103\"  class=\"gfield gfield--type-text gf_left_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_103\"><label class='gfield_label gform-field-label' for='input_21_103' >Name of Third Child<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_21_103' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><fieldset id=\"field_21_104\"  class=\"gfield gfield--type-radio gfield--type-choice gf_right_half gf_list_inline gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_104\"><legend class='gfield_label gform-field-label'  >Sex &#8211; Third Child<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_21_104'>\n\t\t\t<div class='gchoice gchoice_21_104_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='Male'  id='choice_21_104_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_21_104_0' id='label_21_104_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_21_104_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_104' type='radio' value='Female'  id='choice_21_104_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_21_104_1' id='label_21_104_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_21_105\"  class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon readonly gfield_contains_required field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  data-js-reload=\"field_21_105\"><label class='gfield_label gform-field-label' for='input_21_105' >Date of Birth &#8211; Third Child<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_21_105'>Must be under age 21 on Desired Effective Date<\/div><div class='ginput_container ginput_container_date'>\n                            <input name='input_105' id='input_21_105' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_21_105_date_format gfield_description_21_105\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_21_105_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_21_105' class='gform_hidden' value='https:\/\/lloydsinsurancebrokerage.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_21_57\"  class=\"gfield gfield--type-product gfield--input-type-singleproduct gf_left_half, gf_invisible gfield_price gfield_price_21_57 gfield_product_21_57 gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_57\"><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_21_57_1' ><span class=\"gform-field-label gfield_label_product\">Applicant&#039;s Monthly Premium<\/span> <span class=\"screen-reader-text\">Quantity<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_57.1' value='Applicant&#039;s Monthly Premium' class='gform_hidden' \/>\n\t\t\t\t\t<div id='ginput_product_price_21_57' class='ginput_product_price_wrapper'>\n\t\t\t\t\t\t<span class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/span>\n\t\t\t\t\t\t<span class='gform-field-label gform-field-label--type-sub-large ginput_product_price' id='input_21_57'>$0.00<\/span>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<input type='hidden' name='input_57.2' id='ginput_base_price_21_57' class='gform_hidden' value='$0.00'\/>\n\t\t\t\t\t <span class='ginput_quantity_label gform-field-label' aria-hidden='true'>Quantity<\/span> <input type='number' name='input_57.3' value='' id='input_21_57_1' class='ginput_quantity' size='10' min='0'   aria-label=\"Quantity Applicant&#039;s Monthly Premium\" aria-describedby=\"ginput_product_price_21_57\" \/>\n\t\t\t\t<\/div><\/div><div id=\"field_21_76\"  class=\"gfield gfield--type-product gfield--input-type-singleproduct gf_left_half readonly, gf_invisible gfield--width-half gfield_price gfield_price_21_76 gfield_product_21_76 field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_76\"><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_21_76_1' ><span class=\"gform-field-label gfield_label_product\">Spouse&#039;s Monthly Premium<\/span> <span class=\"screen-reader-text\">Quantity<\/span><\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_76.1' value='Spouse&#039;s Monthly Premium' class='gform_hidden' \/>\n\t\t\t\t\t<div id='ginput_product_price_21_76' class='ginput_product_price_wrapper'>\n\t\t\t\t\t\t<span class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/span>\n\t\t\t\t\t\t<span class='gform-field-label gform-field-label--type-sub-large ginput_product_price' id='input_21_76'>$0.00<\/span>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<input type='hidden' name='input_76.2' id='ginput_base_price_21_76' class='gform_hidden' value='$0.00'\/>\n\t\t\t\t\t <span class='ginput_quantity_label gform-field-label' aria-hidden='true'>Quantity<\/span> <input type='number' name='input_76.3' value='' id='input_21_76_1' class='ginput_quantity' size='10' min='0'   aria-label=\"Quantity Spouse&#039;s Monthly Premium\" aria-describedby=\"ginput_product_price_21_76\" \/>\n\t\t\t\t<\/div><\/div><div id=\"field_21_78\"  class=\"gfield gfield--type-product gfield--input-type-singleproduct gf_left_half readonly gfield--width-half gfield_price gfield_price_21_78 gfield_product_21_78 field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_78\"><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_21_78_1' ><span class=\"gform-field-label gfield_label_product\">Children&#039;s Monthly Premium<\/span> <span class=\"screen-reader-text\">Quantity<\/span><\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_78.1' value='Children&#039;s Monthly Premium' class='gform_hidden' \/>\n\t\t\t\t\t<div id='ginput_product_price_21_78' class='ginput_product_price_wrapper'>\n\t\t\t\t\t\t<span class='gform-field-label gform-field-label--type-sub-large ginput_product_price_label'>Price:<\/span>\n\t\t\t\t\t\t<span class='gform-field-label gform-field-label--type-sub-large ginput_product_price' id='input_21_78'>$0.00<\/span>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<input type='hidden' name='input_78.2' id='ginput_base_price_21_78' class='gform_hidden' value='$0.00'\/>\n\t\t\t\t\t <span class='ginput_quantity_label gform-field-label' aria-hidden='true'>Quantity<\/span> <input type='number' name='input_78.3' value='' id='input_21_78_1' class='ginput_quantity' size='10' min='0'   aria-label=\"Quantity Children&#039;s Monthly Premium\" aria-describedby=\"ginput_product_price_21_78\" \/>\n\t\t\t\t<\/div><\/div><div id=\"field_21_195\"  class=\"gfield gfield--type-tax gfield--width-full gf_invisible field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_195\"><label class='gfield_label gform-field-label' for='input_21_195' >Premium adjustment (10%)<\/label>\n            <div class='ginput_container'>\n                <span class='ginput_tax ginput_product_price ginput_tax_21_195'\n                \tstyle=''>$0.00<\/span>\n                <input type='hidden' name='input_195' id='input_21_195' class='gform_hidden ginput_tax_input' \n                    onchange='jQuery( this ).prev( \"span\" ).text( gformFormatMoney( this.value, true ) );' \n                    data-amount='10' data-amounttype='percent'\n                    data-productstype='exclude' data-products='[]' \/>\n            <\/div><\/div><div id=\"field_21_196\"  class=\"gfield gfield--type-tax gfield--width-full gf_invisible field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_196\"><label class='gfield_label gform-field-label' for='input_21_196' >Premium adjustment (7%)<\/label>\n            <div class='ginput_container'>\n                <span class='ginput_tax ginput_product_price ginput_tax_21_196'\n                \tstyle=''>$0.00<\/span>\n                <input type='hidden' name='input_196' id='input_21_196' class='gform_hidden ginput_tax_input' \n                    onchange='jQuery( this ).prev( \"span\" ).text( gformFormatMoney( 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data-productstype='exclude' data-products='[]' \/>\n            <\/div><\/div><div id=\"field_21_202\"  class=\"gfield gfield--type-product gfield--input-type-singleproduct gfield--width-full gf_invisible gfield_price gfield_price_21_202 gfield_product_21_202 gfield_contains_required field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_202\"><label class='gfield_label gform-field-label gfield_label_before_complex' for='input_21_202_1' >Enrollment Fee<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_singleproduct'>\n\t\t\t\t\t<input type='hidden' name='input_202.1' value='Enrollment Fee' class='gform_hidden' \/>\n\t\t\t\t\t<div id='ginput_product_price_21_202' class='ginput_product_price_wrapper'>\n\t\t\t\t\t\t<label for='ginput_base_price_21_202' class='gform-field-label gform-field-label--type-sub-large 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\/>\n\t\t\t\t\t\t<\/div><\/div><div id=\"field_21_37\"  class=\"gfield gfield--type-section gsection gf_scroll_text gf_padding_25 field_sublabel_below gfield--has-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_37\"><h3 class=\"gsection_title\">Declaration of Applicant<\/h3><div class='gsection_description' id='gfield_description_21_37'>By clicking the &#8220;Continue&#8221; button below, I hereby apply to purchase the insurance and I consent to the collection, use and disclosure of my personal information in connection with HealthCare International for the purposes outlined in the <a href=\"https:\/\/wallach.com\/privacy-policy\/\" target=\"_blank\">Privacy Policy<\/a>. If I do not consent to the collection, use and disclosure of my personal information in connection with the <a href=\"https:\/\/wallach.com\/privacy-policy\/\" target=\"_blank\">Privacy Policy<\/a>,  I understand that I will not be able to purchase the HealthCare International policy. I declare to the best of my knowledge and belief that the information given in this Application is true and complete. I acknowledge (on behalf of the person(s) to be insured) that benefits will not apply to treatment arising from pre-existing medical conditions. It is agreed that this declaration and the information given herein shall form the basis of the contract between the Insured Person and the Company. 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