{"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\/es\/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 e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\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_21' style='display:none'><style>#gform_wrapper_21[data-form-index=\"0\"].gform-theme,[data-parent-form=\"21_0\"]{--gform-theme-color-primary: #204ce5;--gform-theme-color-primary-rgb: 32, 76, 229;--gform-theme-color-primary-contrast: #fff;--gform-theme-color-primary-contrast-rgb: 255, 255, 255;--gform-theme-color-primary-darker: #001AB3;--gform-theme-color-primary-lighter: #527EFF;--gform-theme-color-secondary: #fff;--gform-theme-color-secondary-rgb: 255, 255, 255;--gform-theme-color-secondary-contrast: #112337;--gform-theme-color-secondary-contrast-rgb: 17, 35, 55;--gform-theme-color-secondary-darker: #F5F5F5;--gform-theme-color-secondary-lighter: #FFFFFF;--gform-theme-color-outside-control-light: rgba(17, 35, 55, 0.1);--gform-theme-color-outside-control-light-rgb: 17, 35, 55;--gform-theme-color-outside-control-light-darker: rgba(104, 110, 119, 0.35);--gform-theme-color-outside-control-light-lighter: #F5F5F5;--gform-theme-color-outside-control-dark: #585e6a;--gform-theme-color-outside-control-dark-rgb: 88, 94, 106;--gform-theme-color-outside-control-dark-darker: #112337;--gform-theme-color-outside-control-dark-lighter: rgba(17, 35, 55, 0.65);--gform-theme-color-inside-control: #fff;--gform-theme-color-inside-control-rgb: 255, 255, 255;--gform-theme-color-inside-control-contrast: #112337;--gform-theme-color-inside-control-contrast-rgb: 17, 35, 55;--gform-theme-color-inside-control-darker: #F5F5F5;--gform-theme-color-inside-control-lighter: #FFFFFF;--gform-theme-color-inside-control-primary: #204ce5;--gform-theme-color-inside-control-primary-rgb: 32, 76, 229;--gform-theme-color-inside-control-primary-contrast: #fff;--gform-theme-color-inside-control-primary-contrast-rgb: 255, 255, 255;--gform-theme-color-inside-control-primary-darker: #001AB3;--gform-theme-color-inside-control-primary-lighter: #527EFF;--gform-theme-color-inside-control-light: rgba(17, 35, 55, 0.1);--gform-theme-color-inside-control-light-rgb: 17, 35, 55;--gform-theme-color-inside-control-light-darker: rgba(104, 110, 119, 0.35);--gform-theme-color-inside-control-light-lighter: #F5F5F5;--gform-theme-color-inside-control-dark: #585e6a;--gform-theme-color-inside-control-dark-rgb: 88, 94, 106;--gform-theme-color-inside-control-dark-darker: #112337;--gform-theme-color-inside-control-dark-lighter: rgba(17, 35, 55, 0.65);--gform-theme-border-radius: 3px;--gform-theme-font-size-secondary: 14px;--gform-theme-font-size-tertiary: 13px;--gform-theme-icon-control-number: url(\"data:image\/svg+xml,%3Csvg width='8' height='14' viewBox='0 0 8 14' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M4 0C4.26522 5.96046e-08 4.51957 0.105357 4.70711 0.292893L7.70711 3.29289C8.09763 3.68342 8.09763 4.31658 7.70711 4.70711C7.31658 5.09763 6.68342 5.09763 6.29289 4.70711L4 2.41421L1.70711 4.70711C1.31658 5.09763 0.683417 5.09763 0.292893 4.70711C-0.0976311 4.31658 -0.097631 3.68342 0.292893 3.29289L3.29289 0.292893C3.48043 0.105357 3.73478 0 4 0ZM0.292893 9.29289C0.683417 8.90237 1.31658 8.90237 1.70711 9.29289L4 11.5858L6.29289 9.29289C6.68342 8.90237 7.31658 8.90237 7.70711 9.29289C8.09763 9.68342 8.09763 10.3166 7.70711 10.7071L4.70711 13.7071C4.31658 14.0976 3.68342 14.0976 3.29289 13.7071L0.292893 10.7071C-0.0976311 10.3166 -0.0976311 9.68342 0.292893 9.29289Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gform-theme-icon-control-select: url(\"data:image\/svg+xml,%3Csvg width='10' height='6' viewBox='0 0 10 6' fill='none' xmlns='http:\/\/www.w3.org\/2000\/svg'%3E%3Cpath fill-rule='evenodd' clip-rule='evenodd' d='M0.292893 0.292893C0.683417 -0.097631 1.31658 -0.097631 1.70711 0.292893L5 3.58579L8.29289 0.292893C8.68342 -0.0976311 9.31658 -0.0976311 9.70711 0.292893C10.0976 0.683417 10.0976 1.31658 9.70711 1.70711L5.70711 5.70711C5.31658 6.09763 4.68342 6.09763 4.29289 5.70711L0.292893 1.70711C-0.0976311 1.31658 -0.0976311 0.683418 0.292893 0.292893Z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gform-theme-icon-control-search: url(\"data:image\/svg+xml,%3Csvg version='1.1' xmlns='http:\/\/www.w3.org\/2000\/svg' width='640' height='640'%3E%3Cpath d='M256 128c-70.692 0-128 57.308-128 128 0 70.691 57.308 128 128 128 70.691 0 128-57.309 128-128 0-70.692-57.309-128-128-128zM64 256c0-106.039 85.961-192 192-192s192 85.961 192 192c0 41.466-13.146 79.863-35.498 111.248l154.125 154.125c12.496 12.496 12.496 32.758 0 45.254s-32.758 12.496-45.254 0L367.248 412.502C335.862 434.854 297.467 448 256 448c-106.039 0-192-85.962-192-192z' fill='rgba(17, 35, 55, 0.65)'\/%3E%3C\/svg%3E\");--gform-theme-control-border-color: #686e77;--gform-theme-control-size: var(--gform-theme-control-size-md);--gform-theme-control-label-color-primary: #112337;--gform-theme-control-label-color-secondary: #112337;--gform-theme-control-choice-size: var(--gform-theme-control-choice-size-md);--gform-theme-control-checkbox-check-size: var(--gform-theme-control-checkbox-check-size-md);--gform-theme-control-radio-check-size: var(--gform-theme-control-radio-check-size-md);--gform-theme-control-button-font-size: var(--gform-theme-control-button-font-size-md);--gform-theme-control-button-padding-inline: var(--gform-theme-control-button-padding-inline-md);--gform-theme-control-button-size: var(--gform-theme-control-button-size-md);--gform-theme-control-button-border-color-secondary: #686e77;--gform-theme-control-file-button-background-color-hover: #EBEBEB;--gform-theme-field-page-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_21'  action='\/es\/wp-json\/wp\/v2\/pages\/446' data-formid='21' novalidate data-trp-original-action=\"\/es\/wp-json\/wp\/v2\/pages\/446\">\n                        <div class='gform-body gform_body'><div id='gform_fields_21' class='gform_fields top_label form_sublabel_below description_below'><div id=\"field_21_150\"  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' >N\u00famero de identificaci\u00f3n<\/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>Oculto<\/span><\/div><label class='gfield_label gform-field-label' for='input_21_192' >Afiliado<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>Oculto<\/span><\/div><label class='gfield_label gform-field-label' for='input_21_203' >Productor<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>Oculto<\/span><\/div><label class='gfield_label gform-field-label' for='input_21_204' >Corredor<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'  >Nombre<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'  >Correo Electr\u00f3nico<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'>Correo Electr\u00f3nico<\/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'>Confirmar Correo Electr\u00f3nico<\/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' >Pa\u00eds de residencia<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'>Seleccione<\/option><option value='Afghanistan' >Afganist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Argelia<\/option><option value='American Samoa' >Samoa Americana<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Antigua and Barbuda' >Antigua y 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' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahr\u00e9in<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Bielorrusia<\/option><option value='Belgium' >B\u00e9lgica<\/option><option value='Belize' >Belice<\/option><option value='Benin' >Ben\u00edn<\/option><option value='Bermuda' >Bermudas<\/option><option value='Bhutan' >But\u00e1n<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bosnia and Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botsuana<\/option><option value='Brazil' >Brasil<\/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' >Camboya<\/option><option value='Cameroon' >Camer\u00fan<\/option><option value='Canada' >Canad\u00e1<\/option><option value='Cape Verde' >Cabo Verde<\/option><option value='Cayman Islands' >Islas Caim\u00e1n<\/option><option value='Central African Republic' >Rep\u00fablica Centroafricana<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoras<\/option><option value='Congo, Democratic Republic of the' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Congo, Republic of the' >Congo, Rep\u00fablica del<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Croatia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Chipre<\/option><option value='Czech Republic' >Rep\u00fablica Checa<\/option><option value='Denmark' >Dinamarca<\/option><option value='Djibouti' >Yibuti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Rep\u00fablica Dominicana<\/option><option value='East Timor' >Timor Oriental<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Guinea Ecuatorial<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Ethiopia' >Etiop\u00eda<\/option><option value='Faroe Islands' >Islas Feroe<\/option><option value='Fiji' >Fiyi<\/option><option value='Finland' >Finlandia<\/option><option value='France' >Francia<\/option><option value='French Polynesia' >Polinesia Francesa<\/option><option value='Gabon' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Alemania<\/option><option value='Ghana' >Ghana<\/option><option value='Greece' >Grecia<\/option><option value='Greenland' >Groenlandia<\/option><option value='Grenada' >Granada<\/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' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungr\u00eda<\/option><option value='Iceland' >Islandia<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Ir\u00e1n<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Irlanda<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Jap\u00f3n<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazajst\u00e1n<\/option><option value='Kenya' >Kenia<\/option><option value='Kiribati' >Kiribati<\/option><option value='North Korea' >Corea del Norte<\/option><option value='South Korea' >Corea del Sur<\/option><option value='Kosovo' >Kosovo<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kirguist\u00e1n<\/option><option value='Laos' >Laos<\/option><option value='Latvia' >Letonia<\/option><option value='Lebanon' >L\u00edbano<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lituania<\/option><option value='Luxembourg' >Luxemburgo<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malasia<\/option><option value='Maldives' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Islas Marshall<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauricio<\/option><option value='Mexico' >M\u00e9xico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldavia<\/option><option value='Monaco' >M\u00f3naco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Morocco' >Marruecos<\/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' >Pa\u00edses Bajos<\/option><option value='New Zealand' >Nueva Zelanda<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >N\u00edger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Northern Mariana Islands' >Islas Marianas del Norte<\/option><option value='Norway' >Noruega<\/option><option value='Oman' >Om\u00e1n<\/option><option value='Pakistan' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestina, Estado de<\/option><option value='Panama' >Panam\u00e1<\/option><option value='Papua New Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Per\u00fa<\/option><option value='Philippines' >Filipinas<\/option><option value='Poland' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Ruman\u00eda<\/option><option value='Russia' >Rusia<\/option><option value='Rwanda' >Ruanda<\/option><option value='Saint Kitts and Nevis' >San Crist\u00f3bal y Nieves<\/option><option value='Saint Lucia' >Santa Luc\u00eda<\/option><option value='Saint Vincent and the Grenadines' >San Vicente y las Granadinas<\/option><option value='Saint Martin' >San Mart\u00edn<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Santo Tom\u00e9 y Pr\u00edncipe<\/option><option value='Saudi Arabia' >Arabia Saud\u00ed<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leona<\/option><option value='Singapore' >Singapur<\/option><option value='Sint Maarten' >San Mart\u00edn<\/option><option value='Slovakia' >Eslovaquia<\/option><option value='Slovenia' >Eslovenia<\/option><option value='Solomon Islands' >Islas Salom\u00f3n<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >Sud\u00e1frica<\/option><option value='Spain' >Espa\u00f1a<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sud\u00e1n<\/option><option value='Sudan, South' >Sud\u00e1n del Sur<\/option><option value='Suriname' >Surinam<\/option><option value='Swaziland (Eswatini)' >Suazilandia (Eswatini)<\/option><option value='Sweden' >Suecia<\/option><option value='Switzerland' >Suiza<\/option><option value='Syria' >Siria<\/option><option value='Taiwan' >Taiw\u00e1n<\/option><option value='Tajikistan' >Tayikist\u00e1n<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Tailandia<\/option><option value='Togo' >Togo<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad y Tobago<\/option><option value='Tunisia' >T\u00fanez<\/option><option value='Turkey' >Turqu\u00eda<\/option><option value='Turkmenistan' >Turkmenist\u00e1n<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ucrania<\/option><option value='United Arab Emirates' >Emiratos \u00c1rabes Unidos<\/option><option value='United Kingdom' >Reino Unido<\/option><option value='United States' selected='selected'>Estados Unidos<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Vatican City' >Ciudad del Vaticano<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Virgin Islands, U.S.' >Islas V\u00edrgenes, EE.UU.<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabue<\/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' >Fecha de nacimiento<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'>Debe tener menos de 71 a\u00f1os en la fecha de entrada en vigor deseada<\/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' >Fecha de vigencia deseada<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' >\u00daltimo d\u00eda de cobertura<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' >Pa\u00edses de destino<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' >Argelia<\/option><option value='Area C' >Samoa Americana<\/option><option value='Area A' >Andorra<\/option><option value='Area B' >Angola<\/option><option value='Area C' >Antigua y 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' >Azerbaiy\u00e1n<\/option><option value='Area C' >Bahamas<\/option><option value='Area B' >Bahr\u00e9in<\/option><option value='Area B' >Bangladesh<\/option><option value='Area C' >Barbados<\/option><option value='Area B' >Bielorrusia<\/option><option value='Area A' >B\u00e9lgica<\/option><option value='Area A' >Belice<\/option><option value='Area B' >Ben\u00edn<\/option><option value='Area C' >Bermudas<\/option><option value='Area B' >But\u00e1n<\/option><option value='Area A' >Bolivia<\/option><option value='Area A' >Bosnia y Herzegovina<\/option><option value='Area B' >Botsuana<\/option><option value='Area A' >Brasil<\/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' >Camboya<\/option><option value='Area B' >Camer\u00fan<\/option><option value='Area C' >Canad\u00e1<\/option><option value='Area B' >Cabo Verde<\/option><option value='Area C' >Islas Caim\u00e1n<\/option><option value='Area B' >Rep\u00fablica Centroafricana<\/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' >Comoras<\/option><option value='Area B' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Area B' >Congo, Rep\u00fablica del<\/option><option value='Area A' >Costa Rica<\/option><option value='Area B' >C\u00f4te d&#039;Ivoire<\/option><option value='Area A' >Croacia<\/option><option value='Area C' >Cuba<\/option><option value='Area C' >Cura\u00e7ao<\/option><option value='Area B' >Chipre<\/option><option value='Area A' >Rep\u00fablica Checa<\/option><option value='Area A' >Dinamarca<\/option><option value='Area B' >Yibuti<\/option><option value='Area C' >Dominica<\/option><option value='Area C' >Rep\u00fablica Dominicana<\/option><option value='Area B' >Timor Oriental<\/option><option value='Area A' >Ecuador<\/option><option value='Area B' >Egipto<\/option><option value='Area A' >El Salvador<\/option><option value='Area B' >Guinea Ecuatorial<\/option><option value='Area B' >Eritrea<\/option><option value='Area B' >Estonia<\/option><option value='Area B' >Etiop\u00eda<\/option><option value='Area A' >Islas Feroe<\/option><option value='Area B' >Fiyi<\/option><option value='Area A' >Finlandia<\/option><option value='Area A' >Francia<\/option><option value='Area B' >Polinesia Francesa<\/option><option value='Area B' >Gab\u00f3n<\/option><option value='Area B' >Gambia<\/option><option value='Area B' >Georgia<\/option><option value='Area A' >Alemania<\/option><option value='Area B' >Ghana<\/option><option value='Area A' >Grecia<\/option><option value='Area A' >Groenlandia<\/option><option value='Area C' >Granada<\/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' >Hait\u00ed<\/option><option value='Area A' >Honduras<\/option><option value='Area B' >Hong Kong<\/option><option value='Area B' >Hungr\u00eda<\/option><option value='Area A' >Islandia<\/option><option value='Area B' >India<\/option><option value='Area B' >Indonesia<\/option><option value='Area B' >Ir\u00e1n<\/option><option value='Area B' >Iraq<\/option><option value='Area A' >Irlanda<\/option><option value='Area B' >Israel (exc. Gaza y Cisjordania) (Tel Aviv)<\/option><option value='Area B' >Israel (incl. Gaza y Cisjordania) (Jerusal\u00e9n\/Mar Muerto)<\/option><option value='Area A' >Italia<\/option><option value='Area C' >Jamaica<\/option><option value='Area B' >Jap\u00f3n<\/option><option value='Area B' >Jordan<\/option><option value='Area B' >Kazajst\u00e1n<\/option><option value='Area B' >Kenia<\/option><option value='Area B' >Kiribati<\/option><option value='Area B' >Corea del Norte<\/option><option value='Area B' >Corea del Sur<\/option><option value='Area A' >Kosovo<\/option><option value='Area B' >Kuwait<\/option><option value='Area B' >Kirguist\u00e1n<\/option><option value='Area B' >Laos<\/option><option value='Area B' >Letonia<\/option><option value='Area B' >L\u00edbano<\/option><option value='Area B' >Lesotho<\/option><option value='Area B' >Liberia<\/option><option value='Area B' >Libia<\/option><option value='Area A' >Liechtenstein<\/option><option value='Area A' >Lituania<\/option><option value='Area A' >Luxemburgo<\/option><option value='Area B' >Macedonia<\/option><option value='Area B' >Madagascar<\/option><option value='Area B' >Malawi<\/option><option value='Area B' >Malasia<\/option><option value='Area B' >Maldivas<\/option><option value='Area B' >Mali<\/option><option value='Area A' >Malta<\/option><option value='Area B' >Islas Marshall<\/option><option value='Area B' >Mauritania<\/option><option value='Area B' >Mauricio<\/option><option value='Area A' >M\u00e9xico<\/option><option value='Area B' >Micronesia<\/option><option value='Area B' >Moldavia<\/option><option value='Area A' >M\u00f3naco<\/option><option value='Area B' >Mongolia<\/option><option value='Area A' >Montenegro<\/option><option value='Area B' >Marruecos<\/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' >Pa\u00edses Bajos<\/option><option value='Area B' >Nueva Zelanda<\/option><option value='Area A' >Nicaragua<\/option><option value='Area B' >N\u00edger<\/option><option value='Area B' >Nigeria<\/option><option value='Area B' >Islas Marianas del Norte<\/option><option value='Area A' >Noruega<\/option><option value='Area B' >Om\u00e1n<\/option><option value='Area B' >Pakist\u00e1n<\/option><option value='Area B' >Palau<\/option><option value='Area B' >Palestina, Estado de<\/option><option value='Area A' >Panam\u00e1<\/option><option value='Area B' >Pap\u00faa Nueva Guinea<\/option><option value='Area A' >Paraguay<\/option><option value='Area A' >Per\u00fa<\/option><option value='Area B' >Filipinas<\/option><option value='Area A' >Polonia<\/option><option value='Area A' >Portugal<\/option><option value='Area C' >Puerto Rico<\/option><option value='Area B' >Qatar<\/option><option value='Area B' >Ruman\u00eda<\/option><option value='Area B' >Rusia<\/option><option value='Area B' >Ruanda<\/option><option value='Area C' >San Crist\u00f3bal y Nieves<\/option><option value='Area C' >Santa Luc\u00eda<\/option><option value='Area C' >San Vicente y las Granadinas<\/option><option value='Area C' >San Mart\u00edn<\/option><option value='Area B' >Samoa<\/option><option value='Area A' >San Marino<\/option><option value='Area B' >Santo Tom\u00e9 y Pr\u00edncipe<\/option><option value='Area B' >Arabia Saud\u00ed<\/option><option value='Area B' >Senegal<\/option><option value='Area A' >Serbia<\/option><option value='Area B' >Seychelles<\/option><option value='Area B' >Sierra Leona<\/option><option value='Area B' >Singapur<\/option><option value='Area C' >San Mart\u00edn<\/option><option value='Area A' >Eslovaquia<\/option><option value='Area A' >Eslovenia<\/option><option value='Area B' >Islas Salom\u00f3n<\/option><option value='Area B' >Somalia<\/option><option value='Area B' >Sud\u00e1frica<\/option><option value='Area A' >Espa\u00f1a<\/option><option value='Area B' >Sri Lanka<\/option><option value='Area B' >Sud\u00e1n<\/option><option value='Area B' >Sud\u00e1n del Sur<\/option><option value='Area B' >Surinam<\/option><option value='Area B' >Suazilandia (Eswatini)<\/option><option value='Area A' >Suecia<\/option><option value='Area A' >Suiza<\/option><option value='Area B' >Siria<\/option><option value='Area B' >Taiw\u00e1n<\/option><option value='Area B' >Tayikist\u00e1n<\/option><option value='Area B' >Tanzania<\/option><option value='Area B' >Tailandia<\/option><option value='Area B' >Togo<\/option><option value='Area B' >Tonga<\/option><option value='Area C' >Trinidad y Tobago<\/option><option value='Area B' >T\u00fanez<\/option><option value='Area A' >Turqu\u00eda<\/option><option value='Area B' >Turkmenist\u00e1n<\/option><option value='Area B' >Tuvalu<\/option><option value='Area B' >Uganda<\/option><option value='Area B' >Ucrania<\/option><option value='Area B' >Emiratos \u00c1rabes Unidos<\/option><option value='Area A' >Reino Unido<\/option><option value='Area C' >Estados Unidos<\/option><option value='Area A' >Uruguay<\/option><option value='Area B' >Uzbekist\u00e1n<\/option><option value='Area B' >Vanuatu<\/option><option value='Area A' >Ciudad del Vaticano<\/option><option value='Area A' >Venezuela<\/option><option value='Area B' >Vietnam<\/option><option value='Area C' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Area C' >Islas V\u00edrgenes, EE.UU.<\/option><option value='Yemen' >Yemen<\/option><option value='Area B' >Zambia<\/option><option value='Area B' >Zimbabue<\/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>Oculto<\/span><\/div><label class='gfield_label gform-field-label' for='input_21_206' >Nombre del pa\u00eds de destino<\/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 = $source.find( 'option:selected' ).text();\n    }\n    return value;\n} );\n<\/script><\/div><div id=\"field_21_199\"  class=\"gfield gfield--type-text gfield--width-full gf-hidetemp, gf_invisible field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_199\"><label class='gfield_label gform-field-label' for='input_21_199' >Pa\u00edses - Admin<\/label><div class='ginput_container ginput_container_text'><input name='input_199' id='input_21_199' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_21_200\"  class=\"gfield gfield--type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_200\"><script>\n$( 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'  >Por favor confirmar viaje al extranjero<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'>Confirmo que mi pa\u00eds de residencia no est\u00e1 incluido en mi itinerario de viaje<\/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>Oculto<\/span><\/div><label class='gfield_label gform-field-label' for='input_21_169' >Oculto - C\u00e1lculo del n\u00famero de d\u00edas<\/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'>NO ELIMINE ESTE CAMPO - se utiliza para calcular el n\u00famero de d\u00edas, sin embargo, como no pasa al carro correctamente, su valor se copia en el campo \"N\u00famero de d\u00edas de cobertura\" y se muestra ese campo.  Este valor calculado tambi\u00e9n se copia en los campos de cantidad de todas las primas. Los valores copiados pasan al carro correctamente.<\/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' >Oculto - Fecha actual<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='05\/17\/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>Oculto<\/span><\/div><label class='gfield_label gform-field-label' for='input_21_156' >Oculto - C\u00e1lculo de la edad del solicitante en la fecha efectiva deseada<\/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'>NO ELIMINE ESTE CAMPO - se utiliza para calcular la edad del solicitante en la fecha de entrada en vigor deseada, sin embargo, como no pasa al carro correctamente, su valor se copia en el campo \"Edad del solicitante en la fecha de entrada en vigor deseada\" y se utiliza ese campo.  El valor copiado pasa al carro correctamente.<\/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>Oculto<\/span><\/div><label class='gfield_label gform-field-label' for='input_21_172' >Oculto - Edad del solicitante en la fecha efectiva deseada<\/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>Oculto<\/span><\/div><label class='gfield_label gform-field-label' for='input_21_166' >Cobertura opcional del c\u00f3nyuge<\/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'>Ninguno<\/option><option value='Please provide coverage for my spouse' >Por favor, proporcione cobertura para mi c\u00f3nyuge<\/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' >Nombre del c\u00f3nyuge<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'  >Sexo del c\u00f3nyuge<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'>Hombre<\/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'>Mujer<\/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' >C\u00f3nyuge&#039;Fecha de nacimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_21_89'>Debe tener menos de 71 a\u00f1os en la fecha de entrada en vigor deseada<\/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>Oculto<\/span><\/div><label class='gfield_label gform-field-label' for='input_21_158' >Oculto - C\u00e1lculo de la edad del c\u00f3nyuge en la fecha de entrada en vigor deseada<\/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>Oculto<\/span><\/div><label class='gfield_label gform-field-label' for='input_21_173' >Oculto - Edad del c\u00f3nyuge en la fecha de entrada en vigor deseada<\/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>Oculto<\/span><\/div><label class='gfield_label gform-field-label' for='input_21_143' >Cobertura opcional para hijos solteros a cargo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_21_143'>La edad m\u00ednima es de 15 d\u00edas y la m\u00e1xima de 20 a\u00f1os.\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'>Ninguno<\/option><option value='1' >Por favor, proporcione cobertura para 1 ni\u00f1o<\/option><option value='2' >Por favor, proporcione cobertura para 2 ni\u00f1os<\/option><option value='3' >Por favor, proporcione cobertura para 3 ni\u00f1os<\/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' >Nombre del primer hijo<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'  >Sexo - Primer hijo<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'>Hombre<\/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'>Mujer<\/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' >Fecha de nacimiento - Primer hijo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_21_93'>Debe ser menor de 21 a\u00f1os en la fecha de entrada en vigor deseada<\/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' >Nombre del segundo hijo<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'  >Sexo - Segundo hijo<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'>Hombre<\/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'>Mujer<\/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' >Fecha de nacimiento - Segundo hijo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_21_100'>Debe ser menor de 21 a\u00f1os en la fecha de entrada en vigor deseada<\/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' >Nombre del tercer hijo<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'  >Sexo - Tercer hijo<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'>Hombre<\/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'>Mujer<\/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' >Fecha de nacimiento - Tercer hijo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_21_105'>Debe ser menor de 21 a\u00f1os en la fecha de entrada en vigor deseada<\/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\">Prima mensual del solicitante<\/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\">Prima mensual del c\u00f3nyuge<\/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\">Ni\u00f1os&#039;Prima mensual<\/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' >Ajuste Premium (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' >Ajuste Premium (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( this.value, true ) );' \n                    data-amount='7' data-amounttype='percent'\n                    data-productstype='exclude' data-products='[]' \/>\n            <\/div><\/div><div id=\"field_21_197\"  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_197\"><label class='gfield_label gform-field-label' for='input_21_197' >Ajuste Premium (5%)<\/label>\n            <div class='ginput_container'>\n                <span class='ginput_tax ginput_product_price ginput_tax_21_197'\n                \tstyle=''>$0.00<\/span>\n                <input type='hidden' name='input_197' id='input_21_197' class='gform_hidden ginput_tax_input' \n                    onchange='jQuery( this ).prev( \"span\" ).text( gformFormatMoney( this.value, true ) );' \n                    data-amount='5' data-amounttype='percent'\n                    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' >Tasa de inscripci\u00f3n<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 ginput_product_price_label'>Price:<\/label>\n\t\t\t\t\t\t<input type='text' readonly class='ginput_product_price gform-text-input-reset' name='input_202.2' id='ginput_base_price_21_202' value='$9.99' aria-label='Enrollment Fee Price'  \/>\n\t\t\t\t\t<\/div>\n\t\t\t\t\t<input type='hidden' name='input_202.3' value='1' class='ginput_quantity_21_202 gform_hidden' \/>\n\t\t\t\t<\/div><\/div><div id=\"field_21_178\"  class=\"gfield gfield--type-subtotal gfield--width-full gf_invisible field_sublabel_below gfield--no-description field_description_below gfield_visibility_visible\"  data-js-reload=\"field_21_178\"><label class='gfield_label gform-field-label' for='input_21_178' >Prima b\u00e1sica<\/label>\n            <div class='ginput_container'>\n                <span class='ginput_subtotal ginput_product_price ginput_subtotal_21_178'\n                \tstyle=''>$0.00<\/span>\n                <input type='hidden' name='input_178' id='input_21_178' class='gform_hidden ginput_subtotal_input' \n                    onchange='jQuery( this ).prev( \"span\" ).text( gformFormatMoney( this.value, true ) );' \n                    data-amount='0' data-amounttype='flat'\n                    data-productstype='exclude' data-products='[]' \/>\n            <\/div><\/div><div id=\"field_21_159\"  class=\"gfield gfield--type-total gfield_price gfield_price_21_ gfield_total gfield_total_21_ field_sublabel_below gfield--has-description field_description_above gfield_visibility_visible\"  aria-atomic=\"true\" aria-live=\"polite\" data-js-reload=\"field_21_159\"><label class='gfield_label gform-field-label' for='input_21_159' >Total<\/label><div class='gfield_description' id='gfield_description_21_159'>Prima por el n\u00famero total de d\u00edas cubiertos<\/div><div class='ginput_container ginput_container_total'>\n\t\t\t\t\t\t\t<input type='text' readonly name='input_159' id='input_21_159' value='$0.00' class='gform-text-input-reset ginput_total ginput_total_21' \/>\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\">Declaraci\u00f3n del Solicitante<\/h3><div class='gsection_description' id='gfield_description_21_37'>Al hacer clic en el bot\u00f3n \"Continuar\" a continuaci\u00f3n, por la presente solicito la compra del seguro y doy mi consentimiento para la recopilaci\u00f3n, el uso y la divulgaci\u00f3n de mi informaci\u00f3n personal en relaci\u00f3n con HealthCare International para los fines descritos en el <a href=\"https:\/\/wallach.com\/privacy-policy\/\" target=\"_blank\">pol\u00edtica de privacidad<\/a>. Si no doy mi consentimiento para la recopilaci\u00f3n, uso y divulgaci\u00f3n de mi informaci\u00f3n personal en relaci\u00f3n con el <a href=\"https:\/\/wallach.com\/privacy-policy\/\" target=\"_blank\">pol\u00edtica de privacidad<\/a>, Entiendo que no podr\u00e9 adquirir la p\u00f3liza de HealthCare International. Declaro a mi leal saber y entender que la informaci\u00f3n proporcionada en esta Solicitud es verdadera y completa. Reconozco (en nombre de la(s) persona(s) a asegurar) que los beneficios no se aplicar\u00e1n al tratamiento que surja de condiciones m\u00e9dicas preexistentes. Se acuerda que esta declaraci\u00f3n y la informaci\u00f3n contenida en ella constituir\u00e1n la base del contrato entre la Persona Asegurada y la Compa\u00f1\u00eda. Adem\u00e1s, por la presente me suscribo al International Sojourners Insurance Trust y reconozco estar inscrito en esta cobertura grupal para la cual soy elegible seg\u00fan el contrato emitido por la Compa\u00f1\u00eda.\n\n<p style=\"font-weight:bold\">Al enviar esta Solicitud, usted acepta los t\u00e9rminos de la Declaraci\u00f3n del Solicitante.<\/p>\n\n<p style=\"font-weight:bold\">Los documentos de su seguro se enviar\u00e1n a la direcci\u00f3n de correo electr\u00f3nico proporcionada con este formulario de inscripci\u00f3n.<\/p><\/div><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_21' class='gform_button button' value='Enviar solicitud'  onclick='if(window[\"gf_submitting_21\"]){return false;}  if( !jQuery(\"#gform_21\")[0].checkValidity || jQuery(\"#gform_21\")[0].checkValidity()){window[\"gf_submitting_21\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_21\"]){return false;} if( !jQuery(\"#gform_21\")[0].checkValidity || jQuery(\"#gform_21\")[0].checkValidity()){window[\"gf_submitting_21\"]=true;}  jQuery(\"#gform_21\").trigger(\"submit\",[true]); }' \/> \n            <input type='hidden' class='gform_hidden' name='is_submit_21' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='21' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_21' value='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' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_21' id='gform_target_page_number_21' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_21' id='gform_source_page_number_21' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            \n        <\/div>\n                        <p style=\"display: none !important;\" class=\"akismet-fields-container\" data-prefix=\"ak_\"><label>&#916;<textarea name=\"ak_hp_textarea\" cols=\"45\" rows=\"8\" maxlength=\"100\"><\/textarea><\/label><input type=\"hidden\" id=\"ak_js_1\" name=\"ak_js\" value=\"153\"\/><script>\ndocument.getElementById( \"ak_js_1\" ).setAttribute( \"value\", ( new Date() ).getTime() );\n<\/script>\n<\/p><input type=\"hidden\" name=\"trp-form-language\" value=\"es\"\/><\/form>\n                        <\/div><script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 21, 'https:\/\/lloydsinsurancebrokerage.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_21').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_21');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_21').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){jQuery('#gform_wrapper_21').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_21').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_21').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/  }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_21').val();gformInitSpinner( 21, 'https:\/\/lloydsinsurancebrokerage.com\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [21, current_page]);window['gf_submitting_21'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}setTimeout(function(){jQuery('#gform_wrapper_21').replaceWith(confirmation_content);jQuery(document).trigger('gform_confirmation_loaded', [21]);window['gf_submitting_21'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_21').text());}, 50);}else{jQuery('#gform_21').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger('gform_post_render', [21, current_page]);gform.utils.trigger({ event: 'gform\/postRender', native: false, data: { formId: 21, currentPage: current_page } });} );} );\n<\/script>","protected":false},"excerpt":{"rendered":"<p>Fill out the form and your travel medical insurance policy will be issued immediately upon payment.<\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_kad_post_transparent":"","_kad_post_title":"hide","_kad_post_layout":"","_kad_post_sidebar_id":"","_kad_post_content_style":"","_kad_post_vertical_padding":"","_kad_post_feature":"","_kad_post_feature_position":"","_kad_post_header":true,"_kad_post_footer":true,"footnotes":""},"class_list":["post-446","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/lloydsinsurancebrokerage.com\/es\/wp-json\/wp\/v2\/pages\/446","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/lloydsinsurancebrokerage.com\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/lloydsinsurancebrokerage.com\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/lloydsinsurancebrokerage.com\/es\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/lloydsinsurancebrokerage.com\/es\/wp-json\/wp\/v2\/comments?post=446"}],"version-history":[{"count":0,"href":"https:\/\/lloydsinsurancebrokerage.com\/es\/wp-json\/wp\/v2\/pages\/446\/revisions"}],"wp:attachment":[{"href":"https:\/\/lloydsinsurancebrokerage.com\/es\/wp-json\/wp\/v2\/media?parent=446"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}