{"id":9244,"date":"2020-09-17T08:40:46","date_gmt":"2020-09-17T08:40:46","guid":{"rendered":"https:\/\/263host.co.zw\/projects\/firstmutual\/?page_id=9244"},"modified":"2021-02-03T15:28:23","modified_gmt":"2021-02-03T15:28:23","slug":"nicoz-motor-claims-from","status":"publish","type":"page","link":"https:\/\/263host.co.zw\/projects\/firstmutual\/nicoz-diamond-products\/nicoz-motor-claims-from\/","title":{"rendered":"Nicoz motor claims from"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"9244\" class=\"elementor elementor-9244\" data-elementor-settings=\"{&quot;ha_cmc_init_switcher&quot;:&quot;no&quot;,&quot;element_pack_global_tooltip_width&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;element_pack_global_tooltip_width_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;element_pack_global_tooltip_width_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;size&quot;:&quot;&quot;,&quot;sizes&quot;:[]},&quot;element_pack_global_tooltip_padding&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_padding_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_padding_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_border_radius&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_border_radius_tablet&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true},&quot;element_pack_global_tooltip_border_radius_mobile&quot;:{&quot;unit&quot;:&quot;px&quot;,&quot;top&quot;:&quot;&quot;,&quot;right&quot;:&quot;&quot;,&quot;bottom&quot;:&quot;&quot;,&quot;left&quot;:&quot;&quot;,&quot;isLinked&quot;:true}}\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-e5c4d50 elementor-section-stretched elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"e5c4d50\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-38de1be\" data-id=\"38de1be\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-d5e179d elementor-widget elementor-widget-spacer\" data-id=\"d5e179d\" data-element_type=\"widget\" data-widget_type=\"spacer.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-spacer\">\n\t\t\t<div class=\"elementor-spacer-inner\"><\/div>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-1358368 elementor-widget elementor-widget-heading\" data-id=\"1358368\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Motor Accident Claim Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2a327b7 elementor-widget-divider--view-line elementor-widget elementor-widget-divider\" data-id=\"2a327b7\" data-element_type=\"widget\" data-widget_type=\"divider.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-divider\">\n\t\t\t<span class=\"elementor-divider-separator\">\n\t\t\t\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-abeead2\" data-id=\"abeead2\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap\">\n\t\t\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-6a280f4 elementor-section-stretched elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"6a280f4\" data-element_type=\"section\" data-settings=\"{&quot;stretch_section&quot;:&quot;section-stretched&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-top-column elementor-element elementor-element-7c123f1\" data-id=\"7c123f1\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-144c97f elementor-widget elementor-widget-text-editor\" data-id=\"144c97f\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-9079\"><form id=\"wpforms-form-9079\" class=\"wpforms-validate wpforms-form\" data-formid=\"9079\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/projects\/firstmutual\/wp-json\/wp\/v2\/pages\/9244\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-page-indicator progress\" data-indicator=\"progress\" data-indicator-color=\"#ec1f27\" data-scroll=\"1\"><span class=\"wpforms-page-indicator-page-title\" ><\/span><span class=\"wpforms-page-indicator-page-title-sep\" style=\"display:none;\"> &#8211; <\/span><span class=\"wpforms-page-indicator-steps\">Step <span class=\"wpforms-page-indicator-steps-current\">1<\/span> of 7<\/span><div class=\"wpforms-page-indicator-page-progress-wrap\"><div class=\"wpforms-page-indicator-page-progress\" style=\"width:14.285714285714%;background-color:#ec1f27;\"><\/div><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \"><div id=\"wpforms-9079-field_17-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"17\"><\/div><div id=\"wpforms-9079-field_1-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_1\">Policy No <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-9079-field_1\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][1]\" required><\/div><div id=\"wpforms-9079-field_2-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_2\">INSURED\u2019S NAME <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-9079-field_2\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][2]\" required><\/div><div id=\"wpforms-9079-field_3-container\" class=\"wpforms-field wpforms-field-email wpforms-one-half\" data-field-id=\"3\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_3\">Email <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-9079-field_3\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][3]\" required><\/div><div id=\"wpforms-9079-field_4-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"4\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_4\">Address and (Day) Phone No.<\/label><input type=\"text\" id=\"wpforms-9079-field_4\" class=\"wpforms-field-large\" name=\"wpforms[fields][4]\" ><\/div><div id=\"wpforms-9079-field_5-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"5\"><div id=\"wpforms-9079-field_5\"><h1 style=\"font-size:150%\";\"text-align:center\",>VEHICLE DETAILS<\/h1><\/div><\/div><div id=\"wpforms-9079-field_7-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth wpforms-first\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_7\">Make <\/label><input type=\"text\" id=\"wpforms-9079-field_7\" class=\"wpforms-field-large\" name=\"wpforms[fields][7]\" ><\/div><div id=\"wpforms-9079-field_9-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth\" data-field-id=\"9\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_9\">Engine No. , Chassis No<\/label><input type=\"text\" id=\"wpforms-9079-field_9\" class=\"wpforms-field-large\" name=\"wpforms[fields][9]\" ><\/div><div id=\"wpforms-9079-field_10-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth\" data-field-id=\"10\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_10\">Model and Year<\/label><input type=\"text\" id=\"wpforms-9079-field_10\" class=\"wpforms-field-large\" name=\"wpforms[fields][10]\" ><\/div><div id=\"wpforms-9079-field_11-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_11\">Horse power <\/label><input type=\"text\" id=\"wpforms-9079-field_11\" class=\"wpforms-field-large\" name=\"wpforms[fields][11]\" ><\/div><div id=\"wpforms-9079-field_12-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth wpforms-first\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_12\">Kilometers Completed<\/label><input type=\"text\" id=\"wpforms-9079-field_12\" class=\"wpforms-field-large\" name=\"wpforms[fields][12]\" ><\/div><div id=\"wpforms-9079-field_13-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth\" data-field-id=\"13\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_13\">Registration No.<\/label><input type=\"text\" id=\"wpforms-9079-field_13\" class=\"wpforms-field-large\" name=\"wpforms[fields][13]\" ><\/div><div id=\"wpforms-9079-field_14-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth\" data-field-id=\"14\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_14\">Value <\/label><input type=\"text\" id=\"wpforms-9079-field_14\" class=\"wpforms-field-large\" name=\"wpforms[fields][14]\" ><\/div><div id=\"wpforms-9079-field_15-container\" class=\"wpforms-field wpforms-field-text wpforms-one-fourth\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_15\">Date of Purchase  and price paid<\/label><input type=\"text\" id=\"wpforms-9079-field_15\" class=\"wpforms-field-large\" name=\"wpforms[fields][15]\" ><\/div><div id=\"wpforms-9079-field_16-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"16\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"1\" data-formid=\"9079\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  \" style=\"display:none;\"><div id=\"wpforms-9079-field_25-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"25\"><div id=\"wpforms-9079-field_25\"><h1 style=\"font-size:150%\";\"text-align:center\",>VEHICLE DETAILS<\/h1><\/div><\/div><div id=\"wpforms-9079-field_19-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_19\">In Whose Name Is The Vehicle Registered<\/label><input type=\"text\" id=\"wpforms-9079-field_19\" class=\"wpforms-field-large\" name=\"wpforms[fields][19]\" ><\/div><div id=\"wpforms-9079-field_21-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_21\">Description Of Damage To Vehicle<\/label><input type=\"text\" id=\"wpforms-9079-field_21\" class=\"wpforms-field-large\" name=\"wpforms[fields][21]\" ><\/div><div id=\"wpforms-9079-field_22-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"22\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_22\">Estimate For Repairs Attach Quotations<\/label><input type=\"text\" id=\"wpforms-9079-field_22\" class=\"wpforms-field-large\" name=\"wpforms[fields][22]\" ><\/div><div id=\"wpforms-9079-field_23-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"23\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_23\">Proposed Repairer\u2019s Name Address &amp; Telephone Number <\/label><input type=\"text\" id=\"wpforms-9079-field_23\" class=\"wpforms-field-large\" name=\"wpforms[fields][23]\" ><\/div><div id=\"wpforms-9079-field_24-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"24\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_24\">Where Can Your Damaged Vehicle Be Inspected?<\/label><input type=\"text\" id=\"wpforms-9079-field_24\" class=\"wpforms-field-large\" name=\"wpforms[fields][24]\" ><\/div><div id=\"wpforms-9079-field_26-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"26\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"2\" data-formid=\"9079\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3  \" style=\"display:none;\"><div id=\"wpforms-9079-field_20-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"20\"><div id=\"wpforms-9079-field_20\"><h1 style=\"font-size:150%\";\"text-align:center\",>Details of Driver<\/h1><\/div><\/div><div id=\"wpforms-9079-field_27-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_27\">Full name <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-9079-field_27\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][27]\" required><\/div><div id=\"wpforms-9079-field_28-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"28\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_28\">Occupation <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-9079-field_28\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][28]\" required><\/div><div id=\"wpforms-9079-field_29-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_29\">Address<\/label><input type=\"text\" id=\"wpforms-9079-field_29\" class=\"wpforms-field-large\" name=\"wpforms[fields][29]\" ><\/div><div id=\"wpforms-9079-field_30-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-half\" data-field-id=\"30\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_30\">Date Of Birth<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-9079-field_30\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-large\" data-date-format=\"d\/m\/Y\" data-input=\"true\" name=\"wpforms[fields][30][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-9079-field_39-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"39\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_39\">Driving Licence I.D. No.<\/label><ul id=\"wpforms-9079-field_39\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_39_1\" name=\"wpforms[fields][39][]\" value=\"No.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_39_1\">No.<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_39_2\" name=\"wpforms[fields][39][]\" value=\"Date\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_39_2\">Date<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_39_3\" name=\"wpforms[fields][39][]\" value=\"Place \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_39_3\">Place <\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_39_5\" name=\"wpforms[fields][39][]\" value=\"Full\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_39_5\">Full<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_39_4\" name=\"wpforms[fields][39][]\" value=\"Learner\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_39_4\">Learner<\/label><\/li><\/ul><\/div><div id=\"wpforms-9079-field_48-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"48\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_48\">Driving Licence I.D. No.<\/label><input type=\"text\" id=\"wpforms-9079-field_48\" class=\"wpforms-field-medium\" name=\"wpforms[fields][48]\" ><\/div><div id=\"wpforms-9079-field_33-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"33\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_33\">Date<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-9079-field_33\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"d\/m\/Y\" data-input=\"true\" name=\"wpforms[fields][33][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-9079-field_35-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"35\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_35\">Place<\/label><input type=\"text\" id=\"wpforms-9079-field_35\" class=\"wpforms-field-medium\" name=\"wpforms[fields][35]\" ><\/div><div id=\"wpforms-9079-field_40-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"40\"><div id=\"wpforms-9079-field_40\"><h1 style=\"font-size:150%\";\"text-align:center\",>If Learner Details Of Instructor<\/h1><\/div><\/div><div id=\"wpforms-9079-field_41-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"41\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_41\">State fully the purpose for which the vehicle was being used<\/label><input type=\"text\" id=\"wpforms-9079-field_41\" class=\"wpforms-field-large\" name=\"wpforms[fields][41]\" ><\/div><div id=\"wpforms-9079-field_43-container\" class=\"wpforms-field wpforms-field-payment-multiple wpforms-one-half wpforms-first wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"43\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_43\">Was he\/she driving with your permission?<\/label><ul id=\"wpforms-9079-field_43\"><li class=\"choice-1\"><input type=\"radio\" id=\"wpforms-9079-field_43_1\" class=\"wpforms-payment-price\" data-amount=\"0.00\" name=\"wpforms[fields][43]\" value=\"1\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_43_1\">Yes<\/label><\/li><li class=\"choice-2\"><input type=\"radio\" id=\"wpforms-9079-field_43_2\" class=\"wpforms-payment-price\" data-amount=\"0.00\" name=\"wpforms[fields][43]\" value=\"2\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_43_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-9079-field_42-container\" class=\"wpforms-field wpforms-field-payment-multiple wpforms-one-half wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"42\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_42\">Was he\/she in your employ?<\/label><ul id=\"wpforms-9079-field_42\"><li class=\"choice-1\"><input type=\"radio\" id=\"wpforms-9079-field_42_1\" class=\"wpforms-payment-price\" data-amount=\"0.00\" name=\"wpforms[fields][42]\" value=\"1\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_42_1\">Yes<\/label><\/li><li class=\"choice-2\"><input type=\"radio\" id=\"wpforms-9079-field_42_2\" class=\"wpforms-payment-price\" data-amount=\"0.00\" name=\"wpforms[fields][42]\" value=\"2\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_42_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-9079-field_44-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"44\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_44\">Details of any convictions for motoring offences<\/label><input type=\"text\" id=\"wpforms-9079-field_44\" class=\"wpforms-field-large\" name=\"wpforms[fields][44]\" ><\/div><div id=\"wpforms-9079-field_46-container\" class=\"wpforms-field wpforms-field-radio wpforms-one-half wpforms-first wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"46\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_46\">Has licence ever been endorsed?<\/label><ul id=\"wpforms-9079-field_46\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-9079-field_46_1\" name=\"wpforms[fields][46]\" value=\"Yes \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_46_1\">Yes <\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-9079-field_46_2\" name=\"wpforms[fields][46]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_46_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-9079-field_47-container\" class=\"wpforms-field wpforms-field-payment-multiple wpforms-one-half wpforms-list-inline wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"47\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_47\">Has he\/she any physical disability?<\/label><ul id=\"wpforms-9079-field_47\"><li class=\"choice-1\"><input type=\"radio\" id=\"wpforms-9079-field_47_1\" class=\"wpforms-payment-price\" data-amount=\"0.00\" name=\"wpforms[fields][47]\" value=\"1\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_47_1\">Yes<\/label><\/li><li class=\"choice-2\"><input type=\"radio\" id=\"wpforms-9079-field_47_2\" class=\"wpforms-payment-price\" data-amount=\"0.00\" name=\"wpforms[fields][47]\" value=\"2\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_47_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-9079-field_50-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"50\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"3\" data-formid=\"9079\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-4  \" style=\"display:none;\"><div id=\"wpforms-9079-field_49-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"49\"><div id=\"wpforms-9079-field_49\"><h1 style=\"font-size:150%\";\"text align:center\">ACCIDENT\r\n<\/h1><\/div><\/div><div id=\"wpforms-9079-field_51-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"51\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_51\">DESCRIPTION OF ACCIDENT\/THEFT<\/label><ul id=\"wpforms-9079-field_51\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_51_1\" name=\"wpforms[fields][51][]\" value=\"Date And Time\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_51_1\">Date And Time<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_51_3\" name=\"wpforms[fields][51][]\" value=\"Place\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_51_3\">Place<\/label><\/li><\/ul><div class=\"wpforms-field-description\">Click the box for more details.<\/div><\/div><div id=\"wpforms-9079-field_52-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-half wpforms-first wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"52\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_52\">Date \/ Time<\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-9079-field_52\" class=\"wpforms-field-date-time-date wpforms-datepicker\" data-date-format=\"d\/m\/Y\" data-input=\"true\" name=\"wpforms[fields][52][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><label for=\"wpforms-9079-field_52\" class=\"wpforms-field-sublabel after \">Date<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-9079-field_52-time\" class=\"wpforms-field-date-time-time wpforms-timepicker\" data-rule-time24h=\"true\" data-time-format=\"H:i\" data-step=\"30\" name=\"wpforms[fields][52][time]\" ><label for=\"wpforms-9079-field_52-time\" class=\"wpforms-field-sublabel after \">Time<\/label><\/div><\/div><\/div><div id=\"wpforms-9079-field_53-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"53\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_53\">Place<\/label><input type=\"text\" id=\"wpforms-9079-field_53\" class=\"wpforms-field-large\" name=\"wpforms[fields][53]\" ><\/div><div id=\"wpforms-9079-field_54-container\" class=\"wpforms-field wpforms-field-textarea\" data-field-id=\"54\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_54\">SKETCH OF ACCIDENT<\/label><textarea id=\"wpforms-9079-field_54\" class=\"wpforms-field-medium\" name=\"wpforms[fields][54]\" ><\/textarea><div class=\"wpforms-field-description\">Along which road and in which\r\ndirection was the vehicle travelling<\/div><\/div><div id=\"wpforms-9079-field_55-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"55\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_55\">Was vehicle locked?<\/label><input type=\"text\" id=\"wpforms-9079-field_55\" class=\"wpforms-field-large\" name=\"wpforms[fields][55]\" ><\/div><div id=\"wpforms-9079-field_57-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"57\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_57\">Speed<\/label><ul id=\"wpforms-9079-field_57\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_57_1\" name=\"wpforms[fields][57][]\" value=\"Weather conditions\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_57_1\">Weather conditions<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_57_2\" name=\"wpforms[fields][57][]\" value=\"Visibility\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_57_2\">Visibility<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_57_7\" name=\"wpforms[fields][57][]\" value=\"Road surface\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_57_7\">Road surface<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_57_6\" name=\"wpforms[fields][57][]\" value=\"Width of road\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_57_6\">Width of road<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_57_5\" name=\"wpforms[fields][57][]\" value=\"Which vehicle lights were on?\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_57_5\">Which vehicle lights were on?<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_57_4\" name=\"wpforms[fields][57][]\" value=\"Street lighting\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_57_4\">Street lighting<\/label><\/li><\/ul><div class=\"wpforms-field-description\">Click on the boxes to answer all questions.<\/div><\/div><div id=\"wpforms-9079-field_58-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"58\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_58\">State The Weather Conditions<\/label><input type=\"text\" id=\"wpforms-9079-field_58\" class=\"wpforms-field-large\" name=\"wpforms[fields][58]\" ><\/div><div id=\"wpforms-9079-field_59-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"59\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_59\">Visibility<\/label><input type=\"text\" id=\"wpforms-9079-field_59\" class=\"wpforms-field-large\" name=\"wpforms[fields][59]\" ><\/div><div id=\"wpforms-9079-field_60-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"60\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_60\">Road Surface<\/label><input type=\"text\" id=\"wpforms-9079-field_60\" class=\"wpforms-field-large\" name=\"wpforms[fields][60]\" ><\/div><div id=\"wpforms-9079-field_61-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"61\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_61\">Width of road<\/label><input type=\"text\" id=\"wpforms-9079-field_61\" class=\"wpforms-field-large\" name=\"wpforms[fields][61]\" ><\/div><div id=\"wpforms-9079-field_62-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"62\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_62\">Which vehicle lights were on?<\/label><input type=\"text\" id=\"wpforms-9079-field_62\" class=\"wpforms-field-large\" name=\"wpforms[fields][62]\" ><\/div><div id=\"wpforms-9079-field_63-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"63\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_63\">Street lighting?<\/label><input type=\"text\" id=\"wpforms-9079-field_63\" class=\"wpforms-field-large\" name=\"wpforms[fields][63]\" ><\/div><div id=\"wpforms-9079-field_64-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"64\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_64\">Was any warning given by you e,g, hooting, indicator etc<\/label><input type=\"text\" id=\"wpforms-9079-field_64\" class=\"wpforms-field-large\" name=\"wpforms[fields][64]\" ><\/div><div id=\"wpforms-9079-field_65-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"65\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_65\">Were there any witnesses if so give Name and Contact Details<\/label><input type=\"text\" id=\"wpforms-9079-field_65\" class=\"wpforms-field-large\" name=\"wpforms[fields][65]\" ><\/div><div id=\"wpforms-9079-field_66-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"66\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"4\" data-formid=\"9079\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-5  \" style=\"display:none;\"><div id=\"wpforms-9079-field_67-container\" class=\"wpforms-field wpforms-field-html\" data-field-id=\"67\"><div id=\"wpforms-9079-field_67\"><h1 style=\"font-size:150%\";\"text align:center\">THEFT\r\n<\/h1><\/div><\/div><div id=\"wpforms-9079-field_68-container\" class=\"wpforms-field wpforms-field-date-time wpforms-one-half wpforms-first\" data-field-id=\"68\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_68\">Date and Time of Theft <\/label><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-9079-field_68\" class=\"wpforms-field-date-time-date wpforms-datepicker\" data-date-format=\"d\/m\/Y\" data-input=\"true\" name=\"wpforms[fields][68][date]\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><label for=\"wpforms-9079-field_68\" class=\"wpforms-field-sublabel after \">Date<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-9079-field_68-time\" class=\"wpforms-field-date-time-time wpforms-timepicker\" data-rule-time24h=\"true\" data-time-format=\"H:i\" data-step=\"30\" name=\"wpforms[fields][68][time]\" ><label for=\"wpforms-9079-field_68-time\" class=\"wpforms-field-sublabel after \">Time<\/label><\/div><\/div><\/div><div id=\"wpforms-9079-field_69-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"69\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_69\">From which address or exact location was the vehicle <\/label><input type=\"text\" id=\"wpforms-9079-field_69\" class=\"wpforms-field-large\" name=\"wpforms[fields][69]\" ><\/div><div id=\"wpforms-9079-field_71-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"71\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_71\">Where was the vehicle parked (garage\/carport\/driveway\/parking area\/road side or other place)<\/label><input type=\"text\" id=\"wpforms-9079-field_71\" class=\"wpforms-field-large\" name=\"wpforms[fields][71]\" ><\/div><div id=\"wpforms-9079-field_72-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"72\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_72\">When did you last see the vehicle<\/label><input type=\"text\" id=\"wpforms-9079-field_72\" class=\"wpforms-field-large\" name=\"wpforms[fields][72]\" ><\/div><div id=\"wpforms-9079-field_73-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"73\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_73\">Were all doors and windows closed and locked <\/label><input type=\"text\" id=\"wpforms-9079-field_73\" class=\"wpforms-field-large\" name=\"wpforms[fields][73]\" ><\/div><div id=\"wpforms-9079-field_74-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"74\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_74\">Where were the keys to the vehicle when the theft occurred<\/label><input type=\"text\" id=\"wpforms-9079-field_74\" class=\"wpforms-field-large\" name=\"wpforms[fields][74]\" ><\/div><div id=\"wpforms-9079-field_75-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"75\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_75\">When and how did you discover the theft<\/label><input type=\"text\" id=\"wpforms-9079-field_75\" class=\"wpforms-field-large\" name=\"wpforms[fields][75]\" ><\/div><div id=\"wpforms-9079-field_76-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"76\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_76\">Who is now in possession of the keys <\/label><input type=\"text\" id=\"wpforms-9079-field_76\" class=\"wpforms-field-large\" name=\"wpforms[fields][76]\" ><\/div><div id=\"wpforms-9079-field_77-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"77\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_77\">Vehicle, engine and chasiss no. <\/label><input type=\"text\" id=\"wpforms-9079-field_77\" class=\"wpforms-field-large\" name=\"wpforms[fields][77]\" ><\/div><div id=\"wpforms-9079-field_78-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"78\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_78\">If accessories stolen, provide full details<\/label><input type=\"text\" id=\"wpforms-9079-field_78\" class=\"wpforms-field-large\" name=\"wpforms[fields][78]\" ><\/div><div id=\"wpforms-9079-field_79-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"79\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_79\">Any special identification marks <\/label><input type=\"text\" id=\"wpforms-9079-field_79\" class=\"wpforms-field-large\" name=\"wpforms[fields][79]\" ><\/div><div id=\"wpforms-9079-field_80-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"80\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_80\">Police details<\/label><ul id=\"wpforms-9079-field_80\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-9079-field_80_1\" name=\"wpforms[fields][80]\" value=\"Name of Officer \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_80_1\">Name of Officer <\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-9079-field_80_2\" name=\"wpforms[fields][80]\" value=\"Station &amp; Ref #\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_80_2\">Station &amp; Ref #<\/label><\/li><\/ul><\/div><div id=\"wpforms-9079-field_81-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"81\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_81\">Name of Officer<\/label><input type=\"text\" id=\"wpforms-9079-field_81\" class=\"wpforms-field-medium\" name=\"wpforms[fields][81]\" ><\/div><div id=\"wpforms-9079-field_82-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"82\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_82\">Station &amp; Ref #<\/label><input type=\"text\" id=\"wpforms-9079-field_82\" class=\"wpforms-field-medium\" name=\"wpforms[fields][82]\" ><\/div><div id=\"wpforms-9079-field_83-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first\" data-field-id=\"83\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_83\">Date reported to Police Station and name of Station<\/label><input type=\"text\" id=\"wpforms-9079-field_83\" class=\"wpforms-field-large\" name=\"wpforms[fields][83]\" ><\/div><div id=\"wpforms-9079-field_86-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half\" data-field-id=\"86\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_86\">Was driver tested for Alcohol or drugs<\/label><input type=\"text\" id=\"wpforms-9079-field_86\" class=\"wpforms-field-large\" name=\"wpforms[fields][86]\" ><\/div><div id=\"wpforms-9079-field_84-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"84\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"5\" data-formid=\"9079\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-6  \" style=\"display:none;\"><div id=\"wpforms-9079-field_88-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"88\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_88\">PASSENGERS IN INSURED VEHICLE<\/label><ul id=\"wpforms-9079-field_88\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-9079-field_88_1\" name=\"wpforms[fields][88]\" value=\"Name and Occupation \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_88_1\">Name and Occupation <\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-9079-field_88_2\" name=\"wpforms[fields][88]\" value=\"Address &amp; Phone No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_88_2\">Address &amp; Phone No<\/label><\/li><\/ul><\/div><div id=\"wpforms-9079-field_89-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"89\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_89\">Name and Occupation <\/label><textarea id=\"wpforms-9079-field_89\" class=\"wpforms-field-small\" name=\"wpforms[fields][89]\" ><\/textarea><\/div><div id=\"wpforms-9079-field_90-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"90\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_90\">Address &amp; Phone No<\/label><textarea id=\"wpforms-9079-field_90\" class=\"wpforms-field-small\" name=\"wpforms[fields][90]\" ><\/textarea><\/div><div id=\"wpforms-9079-field_91-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"91\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_91\">For what purpose were they carried?<\/label><input type=\"text\" id=\"wpforms-9079-field_91\" class=\"wpforms-field-large\" name=\"wpforms[fields][91]\" ><\/div><div id=\"wpforms-9079-field_93-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline\" data-field-id=\"93\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_93\">Are they employees?<\/label><ul id=\"wpforms-9079-field_93\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_93_1\" name=\"wpforms[fields][93][]\" value=\"Yes\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_93_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_93_2\" name=\"wpforms[fields][93][]\" value=\"No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_93_2\">No<\/label><\/li><\/ul><\/div><div id=\"wpforms-9079-field_101-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"101\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_101\">OTHER VEHICLES<\/label><ul id=\"wpforms-9079-field_101\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_101_1\" name=\"wpforms[fields][101][]\" value=\"Registration No. \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_101_1\">Registration No. <\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_101_2\" name=\"wpforms[fields][101][]\" value=\"Make\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_101_2\">Make<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_101_3\" name=\"wpforms[fields][101][]\" value=\"Name and Address of Owner and Driver\/Phone No\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_101_3\">Name and Address of Owner and Driver\/Phone No<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_101_4\" name=\"wpforms[fields][101][]\" value=\"Damage and Third Party insurers\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_101_4\">Damage and Third Party insurers<\/label><\/li><\/ul><\/div><div id=\"wpforms-9079-field_96-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"96\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_96\">Registration No. <\/label><input type=\"text\" id=\"wpforms-9079-field_96\" class=\"wpforms-field-medium\" name=\"wpforms[fields][96]\" ><\/div><div id=\"wpforms-9079-field_97-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"97\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_97\">Make<\/label><input type=\"text\" id=\"wpforms-9079-field_97\" class=\"wpforms-field-medium\" name=\"wpforms[fields][97]\" ><\/div><div id=\"wpforms-9079-field_98-container\" class=\"wpforms-field wpforms-field-textarea wpforms-one-half wpforms-first wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"98\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_98\">Name and Address of Owner and Driver\/Phone No<\/label><textarea id=\"wpforms-9079-field_98\" class=\"wpforms-field-medium\" name=\"wpforms[fields][98]\" ><\/textarea><\/div><div id=\"wpforms-9079-field_100-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"100\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_100\">Damage and Third Party insurers<\/label><input type=\"text\" id=\"wpforms-9079-field_100\" class=\"wpforms-field-large\" name=\"wpforms[fields][100]\" ><\/div><div id=\"wpforms-9079-field_99-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"99\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><button class=\"wpforms-page-button wpforms-page-next\" data-action=\"next\" data-page=\"6\" data-formid=\"9079\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-7 last \" style=\"display:none;\"><div id=\"wpforms-9079-field_102-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"102\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_102\">PROPERTY OTHER THAN VEHICLES<\/label><ul id=\"wpforms-9079-field_102\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_102_1\" name=\"wpforms[fields][102][]\" value=\"Name and Address of Owner \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_102_1\">Name and Address of Owner <\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_102_2\" name=\"wpforms[fields][102][]\" value=\"Details of Damage\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_102_2\">Details of Damage<\/label><\/li><\/ul><div class=\"wpforms-field-description\">Click all the boxes to answer all questions.<\/div><\/div><div id=\"wpforms-9079-field_103-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"103\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_103\">Name and Address of Owner <\/label><textarea id=\"wpforms-9079-field_103\" class=\"wpforms-field-medium\" name=\"wpforms[fields][103]\" ><\/textarea><\/div><div id=\"wpforms-9079-field_104-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"104\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_104\">Details of Damage<\/label><textarea id=\"wpforms-9079-field_104\" class=\"wpforms-field-medium\" name=\"wpforms[fields][104]\" ><\/textarea><\/div><div id=\"wpforms-9079-field_105-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-list-inline wpforms-conditional-trigger\" data-field-id=\"105\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_105\">PERSONAL INJURIES (OTHER THAN IN INSURED VEHICLE)<\/label><ul id=\"wpforms-9079-field_105\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_105_1\" name=\"wpforms[fields][105][]\" value=\"Name of Injured \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_105_1\">Name of Injured <\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_105_2\" name=\"wpforms[fields][105][]\" value=\"Relationship to accident e.g. driver, passenger etc.\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_105_2\">Relationship to accident e.g. driver, passenger etc.<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_105_3\" name=\"wpforms[fields][105][]\" value=\"Details of Injury\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_105_3\">Details of Injury<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-9079-field_105_4\" name=\"wpforms[fields][105][]\" value=\"Name of Hospital\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-9079-field_105_4\">Name of Hospital<\/label><\/li><\/ul><\/div><div id=\"wpforms-9079-field_106-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"106\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_106\">Name of Injured<\/label><input type=\"text\" id=\"wpforms-9079-field_106\" class=\"wpforms-field-medium\" name=\"wpforms[fields][106]\" ><\/div><div id=\"wpforms-9079-field_107-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"107\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_107\">Relationship to accident e.g. driver, passenger etc.<\/label><input type=\"text\" id=\"wpforms-9079-field_107\" class=\"wpforms-field-medium\" name=\"wpforms[fields][107]\" ><\/div><div id=\"wpforms-9079-field_109-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-first wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"109\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_109\">Details of Injury<\/label><input type=\"text\" id=\"wpforms-9079-field_109\" class=\"wpforms-field-medium\" name=\"wpforms[fields][109]\" ><\/div><div id=\"wpforms-9079-field_108-container\" class=\"wpforms-field wpforms-field-text wpforms-one-half wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"108\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-9079-field_108\">Name of Hospital<\/label><input type=\"text\" id=\"wpforms-9079-field_108\" class=\"wpforms-field-medium\" name=\"wpforms[fields][108]\" ><\/div><div id=\"wpforms-9079-field_18-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"18\"><div class=\"wpforms-clear wpforms-pagebreak-left\"><\/div><\/div><\/div><\/div><div class=\"wpforms-field wpforms-field-hp\"><label for=\"wpforms-9079-field-hp\" class=\"wpforms-field-label\">Website<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-9079-field-hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-submit-container\" style=\"display:none;\"><input type=\"hidden\" name=\"wpforms[id]\" value=\"9079\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"3\"><button type=\"submit\" name=\"wpforms[submit]\" class=\"wpforms-submit \" id=\"wpforms-submit-9079\" value=\"wpforms-submit\" aria-live=\"assertive\" data-alt-text=\"Sending...\" data-submit-text=\"Submit\">Submit<\/button><\/div><\/form><\/div>  <!-- .wpforms-container --><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Motor Accident Claim Form<\/p>\n","protected":false},"author":3,"featured_media":0,"parent":714,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"inline_featured_image":false,"site-sidebar-layout":"no-sidebar","site-content-layout":"page-builder","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"disabled","ast-breadcrumbs-content":"","ast-featured-img":"disabled","footer-sml-layout":"","theme-transparent-header-meta":"disabled","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"var(--ast-global-color-4)","background-image":"","background-repeat":"repeat","background-position":"center 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