{"id":48463,"date":"2025-08-26T13:37:29","date_gmt":"2025-08-26T19:37:29","guid":{"rendered":"https:\/\/bestpolicy.co\/?page_id=48463"},"modified":"2025-08-26T13:41:25","modified_gmt":"2025-08-26T19:41:25","slug":"aca-form-v3-short","status":"publish","type":"page","link":"https:\/\/developer.bestpolicy.co\/es\/aca-form-v3-short\/","title":{"rendered":"ACA form"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"48463\" class=\"elementor elementor-48463\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-6a0c32a2 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"6a0c32a2\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\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-2d2b57d7\" data-id=\"2d2b57d7\" 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-08e4f0b elementor-widget elementor-widget-shortcode\" data-id=\"08e4f0b\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});<\/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_65' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Do You Qualify for Health Insurance?<\/h2>\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_65'  action='\/es\/wp-json\/wp\/v2\/pages\/48463' data-formid='65' novalidate data-trp-original-action=\"\/es\/wp-json\/wp\/v2\/pages\/48463\"><input id=\"partial_entry_id_65\" class=\"partial_entry_id\" type=\"hidden\" name=\"partial_entry_id\" value=\"pending\" data-form_id=\"65\"\/>\n                        <div class='gform-body gform_body'><div id='gform_fields_65' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_65_319\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_319\" ><div class='ginput_container ginput_container_text'><input name='input_319' id='input_65_319' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_65_216\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_216\" ><div class='ginput_container ginput_container_text'><input name='input_216' id='input_65_216' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_65_274\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_274\" ><div class='ginput_container ginput_container_text'><input name='input_274' id='input_65_274' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_65_230\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_230\" ><div class='ginput_container ginput_container_text'><input name='input_230' id='input_65_230' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_65_275\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_275\" ><div class='ginput_container ginput_container_text'><input name='input_275' id='input_65_275' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_65_272\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_272\" ><div class='ginput_container ginput_container_text'><input name='input_272' id='input_65_272' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_65_276\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_276\" ><div class='ginput_container ginput_container_text'><input name='input_276' id='input_65_276' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_65_266\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_266\" ><div class='ginput_container ginput_container_text'><input name='input_266' id='input_65_266' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='partial' \/><\/div><\/div><div id=\"field_65_215\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_215\" ><div class='ginput_container ginput_container_text'><input name='input_215' id='input_65_215' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='none' \/><\/div><\/div><div id=\"field_65_227\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_227\" ><div class='ginput_container ginput_container_text'><input name='input_227' id='input_65_227' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='internal' \/><\/div><\/div><div id=\"field_65_126\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_126\" ><!-- TrustedForm -->\n<script type=\"text\/javascript\">\n(function() {\nvar tf = document.createElement('script');\ntf.type = 'text\/javascript'; tf.async = true;\ntf.src = (\"https:\" == document.location.protocol ? 'https' : 'http') + \":\/\/api.trustedform.com\/trustedform.js?field=xxTrustedFormCertUrl&ping_field=xxTrustedFormPingUrl&l=\" + new Date().getTime() + Math.random();\n\nvar s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(tf, s);\n})(); \n<\/script>\n<noscript>\n<img decoding=\"async\" src=\"https:\/\/api.trustedform.com\/ns.gif\" \/>\n<\/noscript>\n<!-- End TrustedForm -->\n<\/div><fieldset id=\"field_65_254\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full consent mb--5 gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_254\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent Acknowledgement:*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_65_254'>Yes, I give permission to Best Policy, LLC, My Health Insurance, LLC, and Insurely, LLC and their affiliates to access and to renew my 2025 insurance policy on the Federally Facilitated Marketplace (FFM), Short-term medical plans or the best option that suits needs outside of the marketplace, based on the information provided. I also give them consent to contact me through: email, SMS, phone, automated dialing systems, and AI-generated or pre-recorded calls. Consent is not required to purchase.*<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_65_254'><div class='gchoice gchoice_65_254_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_254.1' type='checkbox'  value='Yes, I give permission.'  id='choice_65_254_1'   aria-describedby=\"gfield_description_65_254\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_65_254_1' id='label_65_254_1' class='gform-field-label gform-field-label--type-inline'>Yes, I give permission.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_65_13\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full mb--5 gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_13\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Su 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_65_13'>\n                            \n                            <span id='input_65_13_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.3' id='input_65_13_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                    <label for='input_65_13_3' class='gform-field-label gform-field-label--type-sub'>First Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_65_13_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.6' id='input_65_13_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                    <label for='input_65_13_6' class='gform-field-label gform-field-label--type-sub'>Last Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_65_15\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full tooltip gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_15\" ><label class='gfield_label gform-field-label' for='input_65_15'>Correo electr\u00f3nico<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_65_15'> <div class=\"tooltip-container\">\n     <span class=\"info-icon\"><img decoding=\"async\" src=\"https:\/\/bestpolicy.co\/wp-content\/uploads\/2024\/09\/info.svg\"\/> &nbsp;Why do you need my personal information? (email, phone number, address, etc)<\/span>\n    <span class=\"tooltip-text\">Your personal information is used only to find you the best health insurance plan and contact you. We value your privacy, store your information securely, and won't use it for other purposes or send you spam.<\/span>\n  <\/div>\n\n<\/div><div class='ginput_container ginput_container_email'>\n                            <input name='input_15' id='input_65_15' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_65_15\" autocomplete=\"email\"\/>\n                        <\/div><\/div><div id=\"field_65_222\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full phone-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_222\" ><label class='gfield_label gform-field-label' for='input_65_222'>Tel\u00e9fono<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_222' id='input_65_222' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_65_32\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datedropdown gfield--width-half date w-full gfield_contains_required field_sublabel_below gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_32\" ><legend class='gfield_label gform-field-label' >Solicitante principal Fecha de nacimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div id='input_65_32' class='ginput_container ginput_complex gform-grid-row'><div class='gfield_date_dropdown_month ginput_container ginput_container_date gform-grid-col' id='input_65_32_1_container'><label for='input_65_32_1' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Mes<\/label><select name='input_32[]' id='input_65_32_1'   aria-required='true'  ><option value=''>Mes<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><\/select><\/div><div class='gfield_date_dropdown_day ginput_container ginput_container_date gform-grid-col' id='input_65_32_2_container'><label for='input_65_32_2' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>D\u00eda<\/label><select name='input_32[]' id='input_65_32_2'   aria-required='true'  ><option value=''>D\u00eda<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><option value='6' >6<\/option><option value='7' >7<\/option><option value='8' >8<\/option><option value='9' >9<\/option><option value='10' >10<\/option><option value='11' >11<\/option><option value='12' >12<\/option><option value='13' >13<\/option><option value='14' >14<\/option><option value='15' >15<\/option><option value='16' >16<\/option><option value='17' >17<\/option><option value='18' >18<\/option><option value='19' >19<\/option><option value='20' >20<\/option><option value='21' >21<\/option><option value='22' >22<\/option><option value='23' >23<\/option><option value='24' >24<\/option><option value='25' >25<\/option><option value='26' >26<\/option><option value='27' >27<\/option><option value='28' >28<\/option><option value='29' >29<\/option><option value='30' >30<\/option><option value='31' >31<\/option><\/select><\/div><div class='gfield_date_dropdown_year ginput_container ginput_container_date gform-grid-col' id='input_65_32_3_container'><label for='input_65_32_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>A\u00f1o<\/label><select name='input_32[]' id='input_65_32_3'   aria-required='true'  ><option value=''>A\u00f1o<\/option><option value='2027' >2027<\/option><option value='2026' >2026<\/option><option value='2025' >2025<\/option><option value='2024' >2024<\/option><option value='2023' >2023<\/option><option value='2022' >2022<\/option><option value='2021' >2021<\/option><option value='2020' >2020<\/option><option value='2019' >2019<\/option><option value='2018' >2018<\/option><option value='2017' >2017<\/option><option value='2016' >2016<\/option><option value='2015' >2015<\/option><option value='2014' >2014<\/option><option value='2013' >2013<\/option><option value='2012' >2012<\/option><option value='2011' >2011<\/option><option value='2010' >2010<\/option><option value='2009' >2009<\/option><option value='2008' >2008<\/option><option value='2007' >2007<\/option><option value='2006' >2006<\/option><option value='2005' >2005<\/option><option value='2004' >2004<\/option><option value='2003' >2003<\/option><option value='2002' >2002<\/option><option value='2001' >2001<\/option><option value='2000' >2000<\/option><option value='1999' >1999<\/option><option value='1998' >1998<\/option><option value='1997' >1997<\/option><option value='1996' >1996<\/option><option value='1995' >1995<\/option><option value='1994' >1994<\/option><option value='1993' >1993<\/option><option value='1992' >1992<\/option><option value='1991' >1991<\/option><option value='1990' >1990<\/option><option value='1989' >1989<\/option><option value='1988' >1988<\/option><option value='1987' >1987<\/option><option value='1986' >1986<\/option><option value='1985' >1985<\/option><option value='1984' >1984<\/option><option value='1983' >1983<\/option><option value='1982' >1982<\/option><option value='1981' >1981<\/option><option value='1980' >1980<\/option><option value='1979' >1979<\/option><option value='1978' >1978<\/option><option value='1977' >1977<\/option><option value='1976' >1976<\/option><option value='1975' >1975<\/option><option value='1974' >1974<\/option><option value='1973' >1973<\/option><option value='1972' >1972<\/option><option value='1971' >1971<\/option><option value='1970' >1970<\/option><option value='1969' >1969<\/option><option value='1968' >1968<\/option><option value='1967' >1967<\/option><option value='1966' >1966<\/option><option value='1965' >1965<\/option><option value='1964' >1964<\/option><option value='1963' >1963<\/option><option value='1962' >1962<\/option><option value='1961' >1961<\/option><option value='1960' >1960<\/option><option value='1959' >1959<\/option><option value='1958' >1958<\/option><option value='1957' >1957<\/option><option value='1956' >1956<\/option><option value='1955' >1955<\/option><option value='1954' >1954<\/option><option value='1953' >1953<\/option><option value='1952' >1952<\/option><option value='1951' >1951<\/option><option value='1950' >1950<\/option><option value='1949' >1949<\/option><option value='1948' >1948<\/option><option value='1947' >1947<\/option><option value='1946' >1946<\/option><option value='1945' >1945<\/option><option value='1944' >1944<\/option><option value='1943' >1943<\/option><option value='1942' >1942<\/option><option value='1941' >1941<\/option><option value='1940' >1940<\/option><option value='1939' >1939<\/option><option value='1938' >1938<\/option><option value='1937' >1937<\/option><option value='1936' >1936<\/option><option value='1935' >1935<\/option><option value='1934' >1934<\/option><option value='1933' >1933<\/option><option value='1932' >1932<\/option><option value='1931' >1931<\/option><option value='1930' >1930<\/option><option value='1929' >1929<\/option><option value='1928' >1928<\/option><option value='1927' >1927<\/option><option value='1926' >1926<\/option><option value='1925' >1925<\/option><option value='1924' >1924<\/option><option value='1923' >1923<\/option><option value='1922' >1922<\/option><option value='1921' >1921<\/option><option value='1920' >1920<\/option><\/select><\/div><\/div><\/fieldset><div id=\"field_65_225\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half age gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_225\" ><label class='gfield_label gform-field-label' for='input_65_225'>Edad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_225' id='input_65_225' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_65_16\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_16\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n<\/legend>    \n                    <div class='ginput_complex ginput_container has_street ginput_container_address gform-grid-row' id='input_65_16' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_65_16_1_container' >\n                                        <input type='text' name='input_16.1' id='input_65_16_1' value=''    aria-required='false'   autocomplete=\"address-line1\" \/>\n                                        <label for='input_65_16_1' id='input_65_16_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><input type='hidden' class='gform_hidden' name='input_16.4' id='input_65_16_4' value=''\/><input type='hidden' class='gform_hidden' name='input_16.6' id='input_65_16_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_65_76\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half state w-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_76\" ><label class='gfield_label gform-field-label' for='input_65_76'>Seleccionar Estado<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_76' id='input_65_76' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Seleccionar Estado<\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' >California<\/option><option value='Colorado' >Colorado<\/option><option value='Connecticut' >Connecticut<\/option><option value='Delaware' >Delaware<\/option><option value='District of Columbia' >Distrito de Columbia<\/option><option value='Florida' >Florida<\/option><option value='Georgia' >Georgia<\/option><option value='Guam' >Guam<\/option><option value='Hawaii' >Hawai<\/option><option value='Idaho' >Idaho<\/option><option value='Illinois' >Illinois<\/option><option value='Indiana' >Indiana<\/option><option value='Iowa' >Iowa<\/option><option value='Kansas' >Kansas<\/option><option value='Kentucky' >Kentucky<\/option><option value='Louisiana' >Luisiana<\/option><option value='Maine' >Maine<\/option><option value='Maryland' >Maryland<\/option><option value='Massachusetts' >Massachusetts<\/option><option value='Michigan' >Michigan<\/option><option value='Minnesota' >Minnesota<\/option><option value='Mississippi' >Mississippi<\/option><option value='Missouri' >Missouri<\/option><option value='Montana' >Montana<\/option><option value='Nebraska' >Nebraska<\/option><option value='Nevada' >Nevada<\/option><option value='New Hampshire' >Nuevo Hampshire<\/option><option value='New Jersey' >Nueva Jersey<\/option><option value='New Mexico' >Nuevo M\u00e9xico<\/option><option value='New York' >Nueva York<\/option><option value='North Carolina' >Carolina del Norte<\/option><option value='North Dakota' >Dakota del Norte<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oreg\u00f3n<\/option><option value='Pennsylvania' >Pensilvania<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Rhode Island' >Rhode Island<\/option><option value='South Carolina' >Carolina del Sur<\/option><option value='South Dakota' >Dakota del Sur<\/option><option value='Tennessee' >Tennessee<\/option><option value='Texas' >Texas<\/option><option value='Utah' >Utah<\/option><option value='Vermont' >Vermont<\/option><option value='Virginia' >Virginia<\/option><option value='Washington' >Washington<\/option><option value='West Virginia' >Virginia Occidental<\/option><option value='Wisconsin' >Wisconsin<\/option><option value='Wyoming' >Wyoming<\/option><\/select><\/div><\/div><div id=\"field_65_255\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half zip-code w-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_255\" ><label class='gfield_label gform-field-label' for='input_65_255'>Zip Code<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_255' id='input_65_255' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_65_296\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_296\" ><label class='gfield_label gform-field-label' for='input_65_296'>Please select the value closest to your estimated 2024 Anual income<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_296' id='input_65_296' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_65_306\" class=\"gfield gfield--type-slider gfield--input-type-slider gfield--width-full range field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_65_306\" ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_65_306'>Please select the value closest to your estimated 2024 income<\/label><div class='ginput_container ginput_container_slider'><input name='input_306' id='input_65_306' type='text' step='1' min='20800' max='150000' data-value-visibility='show' data-connect=\"false\" value='85400' class='slider large' data-min-relation='' data-max-relation='' data-value-format='currency' data-currency='{\"name\":\"U.S. Dollar\",\"symbol_left\":\"$\",\"symbol_right\":\"\",\"symbol_padding\":\"\",\"thousand_separator\":\",\",\"decimal_separator\":\".\",\"decimals\":2,\"code\":\"USD\"}'    \/><div id='gsfslider_306' class='slider-display gform-theme__disable-reset'><\/div><\/div><\/div><div id=\"field_65_228\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_228\" ><br><\/br>\n<p style=\"color:red; font-weight: bold; font-size: 20px\">Debes tener al menos 19 a\u00f1os para Continuar<\/p> <\/div><div id=\"field_65_142\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_142\" ><script>\n  \/\/ try localStorage first\n  let cid = localStorage.getItem('tdcid');\n  \n  \/\/ if not, check cookie\n  if (!cid) {\n    const match = document.cookie.match(\/(?:^|;\\s*)tdcid=([^;]*)\/);\n    cid = match ? match[1] : \"\";\n  }\n\n  \/\/ set it into hidden input\n  if (cid) {\n    document.getElementById(\"cid\").value = cid;\n  }\n<\/script>\n<\/div><div id=\"field_65_317\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_317\" ><label class='gfield_label gform-field-label' for='input_65_317'>Have you had any surgeries?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_317' id='input_65_317' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Yes' >S\u00ed<\/option><\/select><\/div><\/div><div id=\"field_65_315\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_315\" ><label class='gfield_label gform-field-label' for='input_65_315'>Surgeries<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_315' id='input_65_315' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_65_326\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_326\" ><label class='gfield_label gform-field-label' for='input_65_326'>Are you currently taking any prescription medications?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_326' id='input_65_326' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Yes' >S\u00ed<\/option><\/select><\/div><\/div><div id=\"field_65_318\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_318\" ><label class='gfield_label gform-field-label' for='input_65_318'>Prescription medications<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_318' id='input_65_318' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_65_321\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_321\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you ever been diagnosed with, received advice for, or been treated for any of the conditions listed below?<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_65_321'><div class='gchoice gchoice_65_321_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_321.1' type='checkbox'  value='None'  id='choice_65_321_1'   aria-describedby=\"gfield_description_65_321\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_65_321_1' id='label_65_321_1' class='gform-field-label gform-field-label--type-inline'>Ninguno<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_65_321_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_321.2' type='checkbox'  value='Major conditions'  id='choice_65_321_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_321_2' id='label_65_321_2' class='gform-field-label gform-field-label--type-inline'>Major conditions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_65_321_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_321.3' type='checkbox'  value='Autoimmune and Immune-Related Disorders'  id='choice_65_321_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_321_3' id='label_65_321_3' class='gform-field-label gform-field-label--type-inline'>Autoimmune and Immune-Related Disorders<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_65_321_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_321.4' type='checkbox'  value='Neurological and Mental Health'  id='choice_65_321_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_321_4' id='label_65_321_4' class='gform-field-label gform-field-label--type-inline'>Neurological and Mental Health<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_65_321_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_321.5' type='checkbox'  value='Other High-Risk Conditions'  id='choice_65_321_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_321_5' id='label_65_321_5' class='gform-field-label gform-field-label--type-inline'>Other High-Risk Conditions<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_65_321'>Select all that appy.<\/div><\/fieldset><fieldset id=\"field_65_322\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_322\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Select all Major Condition that apply:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_65_322'><div class='gchoice gchoice_65_322_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_322.1' type='checkbox'  value='Cancer (current or history of cancer in recent years)'  id='choice_65_322_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_322_1' id='label_65_322_1' class='gform-field-label gform-field-label--type-inline'>Cancer (current or history of cancer in recent years)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_65_322_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_322.2' type='checkbox'  value='Heart disease (coronary artery disease, heart attack, heart surgery, stents, congestive heart failure, etc.)'  id='choice_65_322_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_322_2' id='label_65_322_2' class='gform-field-label gform-field-label--type-inline'>Heart disease (coronary artery disease, heart attack, heart surgery, stents, congestive heart failure, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_65_322_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_322.3' type='checkbox'  value='Stroke or TIA (transient ischemic attack)'  id='choice_65_322_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_322_3' id='label_65_322_3' class='gform-field-label gform-field-label--type-inline'>Stroke or TIA (transient ischemic attack)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_65_322_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_322.4' type='checkbox'  value='Chronic obstructive pulmonary disease (COPD), emphysema, or severe asthma'  id='choice_65_322_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_322_4' id='label_65_322_4' class='gform-field-label gform-field-label--type-inline'>Chronic obstructive pulmonary disease (COPD), emphysema, or severe asthma<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_65_322_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_322.5' type='checkbox'  value='Diabetes (especially insulin-dependent)'  id='choice_65_322_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_322_5' id='label_65_322_5' class='gform-field-label gform-field-label--type-inline'>Diabetes (especially insulin-dependent)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_65_322_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_322.6' type='checkbox'  value='Chronic kidney disease or kidney failure'  id='choice_65_322_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_322_6' id='label_65_322_6' class='gform-field-label gform-field-label--type-inline'>Chronic kidney disease or kidney failure<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_65_322_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_322.7' type='checkbox'  value='Liver disease (hepatitis, cirrhosis)'  id='choice_65_322_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_322_7' id='label_65_322_7' class='gform-field-label gform-field-label--type-inline'>Liver disease (hepatitis, cirrhosis)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_65_323\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_323\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Select all Autoimmune Condition that apply:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_65_323'><div class='gchoice gchoice_65_323_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_323.1' type='checkbox'  value='HIV\/AIDS'  id='choice_65_323_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_323_1' id='label_65_323_1' class='gform-field-label gform-field-label--type-inline'>HIV\/AIDS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_65_323_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_323.2' type='checkbox'  value='Lupus'  id='choice_65_323_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_323_2' id='label_65_323_2' class='gform-field-label gform-field-label--type-inline'>Lupus<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_65_323_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_323.3' type='checkbox'  value='Multiple sclerosis'  id='choice_65_323_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_323_3' id='label_65_323_3' class='gform-field-label gform-field-label--type-inline'>Multiple sclerosis<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_65_323_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_323.4' type='checkbox'  value='Rheumatoid arthritis (moderate to severe)'  id='choice_65_323_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_323_4' id='label_65_323_4' class='gform-field-label gform-field-label--type-inline'>Rheumatoid arthritis (moderate to severe)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_65_323_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_323.5' type='checkbox'  value='Other serious autoimmune conditions'  id='choice_65_323_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_323_5' id='label_65_323_5' class='gform-field-label gform-field-label--type-inline'>Other serious autoimmune conditions<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_65_324\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_65_324\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Select all Neurological and Mental Health Condition that apply:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_65_324'><div class='gchoice gchoice_65_324_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_324.1' type='checkbox'  value='Epilepsy or seizure disorders (uncontrolled)'  id='choice_65_324_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_324_1' id='label_65_324_1' class='gform-field-label gform-field-label--type-inline'>Epilepsy or seizure disorders (uncontrolled)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_65_324_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_324.2' type='checkbox'  value='Alzheimer\u2019s, Parkinson\u2019s, or other degenerative neurological conditions'  id='choice_65_324_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_324_2' id='label_65_324_2' class='gform-field-label gform-field-label--type-inline'>Alzheimer\u2019s, Parkinson\u2019s, or other degenerative neurological conditions<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_65_324_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_324.3' type='checkbox'  value='Schizophrenia or severe mental illness requiring hospitalization'  id='choice_65_324_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_65_324_3' id='label_65_324_3' class='gform-field-label gform-field-label--type-inline'>Schizophrenia or severe mental illness requiring hospitalization<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_65_325\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below 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De este modo se le dar\u00e1 de baja de futuras comunicaciones.<br \/>\nAYUDA: Para obtener ayuda, responda AYUDA a cualquier mensaje o p\u00f3ngase en contacto con nuestro equipo de asistencia en info@bestpolicy.co.<br \/>\nSu consentimiento para recibir mensajes de texto no es una condici\u00f3n para adquirir bienes o servicios.<\/div><\/fieldset><div id=\"field_65_143\" class=\"gfield gfield--type-post_custom_field gfield--input-type-text gfield--width-full xxTrustedFormCertUrl field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_65_143\" ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"This field is hidden when viewing the form\"><\/i><span>This field is hidden when viewing the form<\/span><\/div><label class='gfield_label gform-field-label' for='input_65_143'>xxTrustedFormCertUrl<\/label><div class='ginput_container 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