{"id":6228,"date":"2024-09-16T10:13:49","date_gmt":"2024-09-16T16:13:49","guid":{"rendered":"https:\/\/bestpolicy.co\/?page_id=6228"},"modified":"2025-03-07T05:40:21","modified_gmt":"2025-03-07T12:40:21","slug":"aca-form-new-design-test","status":"publish","type":"page","link":"https:\/\/developer.bestpolicy.co\/es\/aca-form-new-design-test\/","title":{"rendered":"aca-form-new-design-test"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"6228\" class=\"elementor elementor-6228\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-764950b6 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"764950b6\" data-element_type=\"section\">\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-33 elementor-top-column elementor-element elementor-element-2f463af6\" data-id=\"2f463af6\" data-element_type=\"column\" id=\"pop-up-exit\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\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-10eec712 elementor-widget elementor-widget-heading\" data-id=\"10eec712\" 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<h6 class=\"elementor-heading-title elementor-size-default\">Don't skip on claiming the Best Policy! <\/h6>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2b66fc49 elementor-widget elementor-widget-heading\" data-id=\"2b66fc49\" 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<span class=\"elementor-heading-title elementor-size-default\">You're moments away from getting the best healthcare cover for you and your family. Is there any assistance we can provide?<\/span>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-58a1cddf elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"58a1cddf\" data-element_type=\"section\">\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-inner-column elementor-element elementor-element-2c62f482\" data-id=\"2c62f482\" 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-4d2df1ce elementor-align-justify elementor-widget__width-initial elementor-widget elementor-widget-button\" data-id=\"4d2df1ce\" data-element_type=\"widget\" id=\"continue-form\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"#\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Continue with the Form<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\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<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-7d2a1d42 elementor-section-boxed elementor-section-height-default elementor-section-height-default\" data-id=\"7d2a1d42\" data-element_type=\"section\">\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-inner-column elementor-element elementor-element-31f55f56\" data-id=\"31f55f56\" 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-66b8c514 elementor-align-justify elementor-widget elementor-widget-button\" data-id=\"66b8c514\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"#\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Speak to a Trusted Agent<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-2c82c3ff elementor-align-justify elementor-widget elementor-widget-button\" data-id=\"2c82c3ff\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"https:\/\/bestpolicy.co\/\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t<span class=\"elementor-button-icon\">\n\t\t\t\t<svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" xmlns:xlink=\"http:\/\/www.w3.org\/1999\/xlink\" height=\"800px\" width=\"800px\" id=\"Capa_1\" viewbox=\"-22.71 -22.71 272.52 272.52\" xml:space=\"preserve\" fill=\"#0F2B69\"> <g id=\"SVGRepo_bgCarrier\" stroke-width=\"0\"><\/g> <g id=\"SVGRepo_tracerCarrier\" stroke-linecap=\"round\" stroke-linejoin=\"round\"><\/g> <g id=\"SVGRepo_iconCarrier\"> <g> <g> <polygon style=\"fill:#0F2B69;\" points=\"152.835,39.285 146.933,45.183 211.113,109.373 0,109.373 0,117.723 211.124,117.723 146.933,181.902 152.835,187.811 227.096,113.55 \"><\/polygon> <\/g> <\/g> <\/g> <\/svg>\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Continue to homepage<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\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\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-51594841\" data-id=\"51594841\" 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<div class=\"elementor-column elementor-col-33 elementor-top-column elementor-element elementor-element-5fec6865\" data-id=\"5fec6865\" 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-570b4120 elementor-section-full_width elementor-section-height-default elementor-section-height-default\" data-id=\"570b4120\" 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-1daefbb\" data-id=\"1daefbb\" 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-4aaa496d elementor-widget__width-initial elementor-widget elementor-widget-shortcode\" data-id=\"4aaa496d\" 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_51' style='display:none'><div id='gf_51' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indicates required fields<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_51'  action='\/es\/wp-json\/wp\/v2\/pages\/6228#gf_51' data-formid='51' novalidate data-trp-original-action=\"\/es\/wp-json\/wp\/v2\/pages\/6228#gf_51\"><input id=\"partial_entry_id_51\" class=\"partial_entry_id\" type=\"hidden\" name=\"partial_entry_id\" value=\"pending\" data-form_id=\"51\"\/>\n                        <div class='gform-body gform_body'><div id='gform_page_51_1' class='gform_page stepper' data-js='page-field-id-0' >\n                                    <div class='gform_page_fields'><div id='gform_fields_51' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_51_234\" 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_51_234\" ><\/div>\n\n\n<div class=\"gf_container\">\n<div class=\"gf_right_half_fields\">\n\n<div><\/div><div id=\"field_51_232\" 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_51_232\" ><\/div>\n<img id=\"bestpolicy-logo-form\" decoding=\"async\" width=\"429\" height=\"79\" src=\"https:\/\/bestpolicy.co\/wp-content\/uploads\/2022\/07\/bestpolicy-1.png\" class=\"attachment-large size-large wp-image-4727\" alt=\"\" srcset=\"https:\/\/bestpolicy.co\/wp-content\/uploads\/2022\/07\/bestpolicy-1.png 429w, https:\/\/bestpolicy.co\/wp-content\/uploads\/2022\/07\/bestpolicy-1-300x55.png\" style=\"    width: 33.725%;\">\t\n<div id=\"steps-container\">\n    <div id=\"step active\">\n<div id=\"step-bar\"><\/div>\nSTEP 1<\/div>\n    <div id=\"step\">\n<div id=\"step-bar\"><\/div>\nSTEP 2<\/div>\n  <\/div> \n<div><\/div><div id=\"field_51_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_51_216\" ><div class='ginput_container ginput_container_text'><input name='input_216' id='input_51_216' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_51_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_51_274\" ><div class='ginput_container ginput_container_text'><input name='input_274' id='input_51_274' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_51_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_51_230\" ><div class='ginput_container ginput_container_text'><input name='input_230' id='input_51_230' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_51_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_51_275\" ><div class='ginput_container ginput_container_text'><input name='input_275' id='input_51_275' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_51_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_51_272\" ><div class='ginput_container ginput_container_text'><input name='input_272' id='input_51_272' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_51_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_51_276\" ><div class='ginput_container ginput_container_text'><input name='input_276' id='input_51_276' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_51_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_51_266\" ><div class='ginput_container ginput_container_text'><input name='input_266' id='input_51_266' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='partial' \/><\/div><\/div><div id=\"field_51_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_51_215\" ><div class='ginput_container ginput_container_text'><input name='input_215' id='input_51_215' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='none' \/><\/div><\/div><div id=\"field_51_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_51_227\" ><div class='ginput_container ginput_container_text'><input name='input_227' id='input_51_227' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='internal' \/><\/div><\/div><div id=\"field_51_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_51_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_51_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_51_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_51_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) based on the information I previously provided. I also give them consent to contact me through: Email, SMS or by Phone.*<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_51_254'><div class='gchoice gchoice_51_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_51_254_1'   aria-describedby=\"gfield_description_51_254\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_51_254_1' id='label_51_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_51_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_51_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_51_13'>\n                            \n                            <span id='input_51_13_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.3' id='input_51_13_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                    <label for='input_51_13_3' class='gform-field-label gform-field-label--type-sub'>First Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_51_13_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_13.6' id='input_51_13_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                    <label for='input_51_13_6' class='gform-field-label gform-field-label--type-sub'>Last Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_51_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_51_15\" ><label class='gfield_label gform-field-label' for='input_51_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_51_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_51_15' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_51_15\" autocomplete=\"email\"\/>\n                        <\/div><\/div><div id=\"field_51_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_51_222\" ><label class='gfield_label gform-field-label' for='input_51_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_51_222' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_258\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full flex row justify-start mt-0 gap-5 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_51_258\" ><div class=\"hidden\"><\/div><fieldset id=\"field_51_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_51_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_51_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_51_32_1_container'><label for='input_51_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_51_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_51_32_2_container'><label for='input_51_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_51_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_51_32_3_container'><label for='input_51_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_51_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_51_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_51_225\" ><label class='gfield_label gform-field-label' for='input_51_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_51_225' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_259\" 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_hidden\"  data-js-reload=\"field_51_259\" ><\/div><\/div><fieldset id=\"field_51_16\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_16\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street ginput_container_address gform-grid-row' id='input_51_16' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_51_16_1_container' >\n                                        <input type='text' name='input_16.1' id='input_51_16_1' value=''    aria-required='true'   autocomplete=\"address-line1\" \/>\n                                        <label for='input_51_16_1' id='input_51_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_51_16_4' value=''\/><input type='hidden' class='gform_hidden' name='input_16.6' id='input_51_16_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_51_262\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full row justify-between mv-col mt-0 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_51_262\" ><div class=\"hidden\"><\/div><div id=\"field_51_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_51_76\" ><label class='gfield_label gform-field-label' for='input_51_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_51_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_51_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_51_255\" ><label class='gfield_label gform-field-label' for='input_51_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_51_255' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_263\" 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_hidden\"  data-js-reload=\"field_51_263\" ><\/div><\/div><fieldset id=\"field_51_55\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full tooltip w-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_55\" ><legend class='gfield_label gform-field-label' >Do you currently have any of the following health insurance options?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_51_55'> <div class=\"tooltip-container\">\n     <span class=\"info-icon\"><img decoding=\"async\" src=\"https:\/\/bestpolicy.co\/wp-content\/uploads\/2024\/09\/info.svg\"\/> &nbspWhy do you need to know this information?<\/span>\n    <span class=\"tooltip-text\">Currently our healthcare insurance plans are only available to those that aren't currently enrolled in Medicare, Medicaid, veterans, or employee coverage.<\/span>\n  <\/div>\n<\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_55'>\n\t\t\t<div class='gchoice gchoice_51_55_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='None of the below. I want Best Policy to enroll me.'  id='choice_51_55_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_51_55\"   \/>\n\t\t\t\t\t<label for='choice_51_55_0' id='label_51_55_0' class='gform-field-label gform-field-label--type-inline'>None of the below. I want Best Policy to enroll me.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_55_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Medicare'  id='choice_51_55_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_55_1' id='label_51_55_1' class='gform-field-label gform-field-label--type-inline'>Medicare<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_55_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Medicaid or Chip Coverage'  id='choice_51_55_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_55_2' id='label_51_55_2' class='gform-field-label gform-field-label--type-inline'>Cobertura de Medicaid o Chip<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_55_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Veterans Coverage'  id='choice_51_55_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_55_3' id='label_51_55_3' class='gform-field-label gform-field-label--type-inline'>Cobertura para veteranos<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_55_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Employer Coverage'  id='choice_51_55_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_55_4' id='label_51_55_4' class='gform-field-label gform-field-label--type-inline'>Cobertura patronal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_55_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='Current ACA Marketplace Plan'  id='choice_51_55_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_55_5' id='label_51_55_5' class='gform-field-label gform-field-label--type-inline'>Plan actual del mercado ACA<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_55_6'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_55' type='radio' value='I&#039;m not certain'  id='choice_51_55_6' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_55_6' id='label_51_55_6' class='gform-field-label gform-field-label--type-inline'>No estoy seguro<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_51_273\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_273\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Al proporcionar su n\u00famero de tel\u00e9fono y enviar este formulario, da su consentimiento para recibir mensajes de texto automatizados y de agente sobre actualizaciones del seguro ACA (Ley de Asistencia Asequible), informaci\u00f3n de inscripci\u00f3n y ofertas relacionadas.<\/legend><div class='ginput_container ginput_container_consent'><input name='input_273.1' id='input_51_273_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_51_273\"  aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_51_273_1' >S\u00ed, doy permiso.<\/label><input type='hidden' name='input_273.2' value='Yes, I give Permission.' class='gform_hidden' \/><input type='hidden' name='input_273.3' value='58' class='gform_hidden' \/><\/div><div class='gfield_description gfield_consent_description' id='gfield_consent_description_51_273'>Message Frequency: You may receive recurring messages based on your interactions and ACA enrollment cycle.<br \/>\nTarifas de mensajes y datos: Pueden aplicarse tarifas est\u00e1ndar de mensajes y datos. Consulta los detalles con tu operador de telefon\u00eda m\u00f3vil.<br \/>\nExclusi\u00f3n voluntaria: Puede darse de baja en cualquier momento respondiendo STOP a cualquier mensaje de texto. 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_51_217\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_217\" ><p style=\"color:red; font-weight: bold; font-size: 20px\">\u00bfEst\u00e1 seguro de que tiene Medicare?<\/p>\n\nSi tiene MEDICARE no podremos ayudarle, por favor elija otra opci\u00f3n si desea continuar. <\/div><div id=\"field_51_219\" 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_51_219\" ><p style=\"color:red; font-weight: bold; font-size: 20px\">Are you sure you have Medicaid?<\/p>\n\nsi tiene Medicaid, podr\u00eda correr el riesgo de perderlo si le aprueban esta subvenci\u00f3n<\/div><div id=\"field_51_220\" 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_51_220\" ><p style=\"color:red; font-weight: bold; font-size: 20px\">Are you sure you have Veterans Coverage?<\/p>\n\nSi tiene cobertura para veteranos no podremos ayudarle, si desea continuar elija otra opci\u00f3n. <\/div><div id=\"field_51_221\" 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_51_221\" ><p style=\"color:red; font-weight: bold; font-size: 20px\">\u00bfEst\u00e1 seguro de que tiene Medicare?<\/p>\n\nSi usted tiene Cobertura del Empleador no podremos ayudarle, si por favor elija otra opci\u00f3n si desea continuar. <\/div><div id=\"field_51_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_51_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_51_229\" 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_51_229\" ><br><\/br>\n<p style=\"color:red; font-weight: bold; font-size: 20px\">Looks like your State is not currently supported!<\/p>\n<\/div><div id=\"field_51_235\" 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_51_235\" >\n\n\n\n<\/div><\/div><div id=\"field_51_239\" 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_51_239\" ><\/div>  \n<div id=\"img-container\" style=\"width:100%;height:calc(100% + 84px); \">\n<div class=\"gf_right_half_image\"> \n<img decoding=\"async\" src=\"https:\/\/bestpolicy.co\/wp-content\/uploads\/2024\/09\/family-1.png\"\/>\n<div class=\"right-label\"> \n<h1>Welcome to Best Policy!<\/h1>\n<span>\nGet $0 health insurance in minutes. Let\u2019s get started on finding you the best health insurance for you and your family.\n<\/span>\n\n<div\n      id=\"state-popup-container\"\n      class=\"notification-popup state-popup\"\n      style=\"        display: none;        position: absolute;        bottom: 0;        left: 20%;        transform: translateX(-40%);        background: white;        border-radius: 16px;        box-shadow: 0 16px 32px rgba(0, 0, 0, 0.12);        margin-bottom: 20px;        padding: 12px 16px;        width: 18vw;        overflow: hidden;        animation: slideInUp 0.6s cubic-bezier(0.68, -0.55, 0.265, 1.55);        border: 1px solid rgba(255, 255, 255, 0.2);      \"\n    >\n      <div\n        style=\"          content: '';          display: block;          height: 3px;          background: linear-gradient(90deg, #00d4aa, #00a8ff);          margin-bottom: 8px;          border-radius: 3px;        \"\n      ><\/div>\n\n      <div\n        class=\"popup-header\"\n        style=\"display: flex; align-items: center; gap: 8px; margin-bottom: 6px\"\n      >\n        <div\n          class=\"pulse-dot\"\n          style=\"            width: 10px;            height: 10px;            background: #00d4aa;            border-radius: 50%;            position: relative;            animation: pulse 2s infinite;          \"\n        >\n          <div\n            style=\"              position: absolute;              top: -4px;              left: -4px;              width: 16px;              height: 16px;              border: 2px solid #00d4aa;              border-radius: 50%;              opacity: 0;              animation: ripple 2s infinite;            \"\n          ><\/div>\n        <\/div>\n        <span\n          class=\"live-text\"\n          style=\"            font-size: 12px;            font-weight: 600;            color: #00d4aa;            text-transform: uppercase;            letter-spacing: 0.3px;          \"\n          >Live Activity<\/span\n>\n      <\/div>\n\n      <div\n        class=\"purchase-content\"\n        style=\"display: flex; gap: 12px; align-items: flex-start\"\n      >\n        <div\n          class=\"user-avatar\"\n          style=\"            width: 36px;            height: 36px;            border-radius: 8px;            background: linear-gradient(135deg, #667eea, #764ba2);            display: flex;            align-items: center;            justify-content: center;            color: white;            font-weight: 600;            font-size: 14px;            flex-shrink: 0;          \"\n        >\n          JD\n        <\/div>\n        <div class=\"purchase-details\" style=\"flex: 1\">\n          <div\n            class=\"user-location\"\n            style=\"font-size: 12px; color: #666; margin-bottom: 0px\"\n          >\n            Someone from <span id=\"popup-state-name\" style=\"font-size: 12px; \">Texas<\/span>\n          <\/div>\n          <div\n            class=\"purchase-message\"\n            style=\"              font-size: 14px;              color: #333;              line-height: 1;              margin-bottom: 2px;            \"\n            id=\"popup-main-message\"\n          >\n            <!-- Filled by script -->\n          <\/div>\n          <div\n            class=\"time-ago\"\n            style=\"font-size: 12px; color: #999\"\n            id=\"popup-footer-message\"\n          >\n            <!-- Filled by script -->\n          <\/div>\n        <\/div>\n      <\/div>\n\n      <div\n        class=\"social-proof\"\n        style=\"          margin-top: 8px;          padding-top: 6px;          border-top: 1px solid #f0f0f0;          display: flex;          align-items: center;          gap: 6px;        \"\n      >\n        \n      <\/div>\n \n\n\n\n\n\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<\/div><div id=\"field_51_309\" 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_51_309\" ><script>\ndocument.addEventListener('DOMContentLoaded', function () {\n  const dropdown = document.querySelector('[name=\"input_76\"]');\n  const popupContainer = document.getElementById('state-popup-container');\n  const stateNameEl = document.getElementById('popup-state-name');\n  const mainMessageEl = document.getElementById('popup-main-message');\n  const footerMessageEl = document.getElementById('popup-footer-message');\n\n const popupMessages = {\n    message1: {\n      main: 'Over 8,000 in <span style=\"font-weight: 600; font-size: 14px;\">[selectedState]<\/span> <span style=\"font-size: 14px; font-weight: 600; color: #00a8ff\">have locked in $0 plans.<\/span> <br> Families across the state are securing free health insurance.',\n      footer: \"Act now \u2013 don't miss your chance!\",\n    },\n    message2: {\n      main: 'Thousands in <span style=\"font-weight: 600; font-size: 14px;\">[selectedState]<\/span> <span style=\"font-size: 14px; font-weight: 600; color: #00a8ff\">now have $0 health plans.<\/span> <br> More are enrolling every day.',\n      footer: \"See if you qualify!\",\n    },\n    message3: {\n      main: 'In <span style=\"font-weight: 600; font-size: 14px;\">[selectedState]<\/span>, <span style=\"font-size: 14px; font-weight: 600; color: #00a8ff\">8,000+ residents are paying $0 for coverage.<\/span> <br> Affordable health insurance is within reach.',\n      footer: \"Join them today!\",\n    },\n    message4: {\n      main: '<span style=\"font-weight: 600; font-size: 14px;\">[selectedState]<\/span> <span style=\"font-size: 14px; font-weight: 600; color: #00a8ff\">families are claiming $0 health plans fast.<\/span> <br> Spots are filling up quickly.',\n      footer: \"Don't wait \u2013 check eligibility now!\",\n    },\n    message5: {\n      main: 'Over 8,000 in <span style=\"font-weight: 600; font-size: 14px;\">[selectedState]<\/span> <span style=\"font-size: 14px; font-weight: 600; color: #00a8ff\">got their $0 health coverage.<\/span> <br> You could be next.',\n      footer: \"Don't miss out \u2013 enroll now!\",\n    },\n    message6: {\n      main: `8,000+ <span style=\"font-weight: 600; font-size: 14px;\">[selectedState]<\/span> residents <span style=\"font-size: 14px; font-weight: 600; color: #00a8ff\">secured $0 plans this year.<\/span> <br> Health insurance doesn't have to cost a thing.`,\n      footer: \"Find your plan today!\",\n    },\n    message7: {\n      main: 'More families in <span style=\"font-weight: 600; font-size: 14px;\">[selectedState]<\/span>, <span style=\"font-size: 14px; font-weight: 600; color: #00a8ff\">are getting $0 insurance.<\/span> <br> Join thousands already covered.',\n      footer: \"Act fast before time runs out!\",\n    },\n    message8: {\n      main: 'In <span style=\"font-weight: 600; font-size: 14px;\">[selectedState]<\/span>, <span style=\"font-size: 14px; font-weight: 600; color: #00a8ff\">8,000 people have enrolled in $0 plans.<\/span> <br> Affordable health care is closer than you think.',\n      footer: \"Tap to see if you qualify.\",\n    },\n    message9: {\n      main: `<span style=\"font-size: 14px; font-weight: 600; color: #00a8ff\">$0 health plans claimed by thousands in <\/span> <span style=\"font-weight: 600; font-size: 14px;\">[selectedState]<\/span><br> It's your turn to get covered.`,\n      footer: \"Don't delay!\",\n    },\n    message10: {\n      main: 'Families in <span style=\"font-weight: 600; font-size: 14px;\">[selectedState]<\/span> are rushing to get <span style=\"font-size: 14px; font-weight: 600; color: #00a8ff\">$0 coverage.<\/span> <br> Over 8,000 already enrolled.',\n      footer: \"Make sure you don't miss this!\",\n    }\n  };\n\n  let lastSelectedState = null; \/\/ to track last state shown\n\n  popupContainer.style.display = 'none';\n\n  if (!dropdown) return;\n\n  dropdown.addEventListener('change', function () {\n    const selectedState = dropdown.value;\n\n \n    if (selectedState === lastSelectedState) return;\n\n    const keys = Object.keys(popupMessages);\n    const randomKey = keys[Math.floor(Math.random() * keys.length)];\n    const selectedMessage = popupMessages[randomKey];\n\n    if (selectedMessage) {\n      const main = selectedMessage.main.replace(\/\\[selectedState\\]\/g, selectedState);\n      const footer = selectedMessage.footer;\n\n      stateNameEl.textContent = selectedState;\n      mainMessageEl.innerHTML = main;\n      footerMessageEl.textContent = footer;\n      popupContainer.style.display = 'block';\n\n      lastSelectedState = selectedState; \/\/ update last selected\n    } else {\n      popupContainer.style.display = 'none';\n      lastSelectedState = null;\n    }\n  });\n});\n<\/script><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_51_213' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' value='Continue'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_51_2' class='gform_page page-between' data-js='page-field-id-213' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_51_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_51_237\" 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_51_237\" ><\/div>\n\n\n<div class=\"gf_container\">\n<div class=\"gf_right_half_fields\">\n\n<div><\/div><div id=\"field_51_236\" 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_51_236\" ><\/div>\n<img decoding=\"async\" width=\"429\" height=\"79\" src=\"https:\/\/bestpolicy.co\/wp-content\/uploads\/2022\/07\/bestpolicy-1.png\" class=\"attachment-large size-large wp-image-4727\" alt=\"\" srcset=\"https:\/\/bestpolicy.co\/wp-content\/uploads\/2022\/07\/bestpolicy-1.png 429w, https:\/\/bestpolicy.co\/wp-content\/uploads\/2022\/07\/bestpolicy-1-300x55.png\" style=\"    width: 33.725%;\">\t\n<div id=\"steps-container\">\n    <div id=\"step done\">\n<div id=\"step-bar\"><\/div>\nSTEP 1<\/div>\n    <div id=\"step active\">\n<div id=\"step-bar\"><\/div>\nSTEP 2<\/div>\n  <\/div>\n<div><\/div><div id=\"field_51_260\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full row justify-between mv-col 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_51_260\" ><div class=\"hidden\"><\/div><div id=\"field_51_261\" 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_hidden\"  data-js-reload=\"field_51_261\" ><\/div><\/div><fieldset id=\"field_51_123\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full carrier field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_123\" ><legend class='gfield_label gform-field-label' >\u00bfQu\u00e9 compa\u00f1\u00eda a\u00e9rea le interesa?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_123'>\n\t\t\t<div class='gchoice gchoice_51_123_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_123' type='radio' value=''  id='choice_51_123_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_123_0' id='label_51_123_0' class='gform-field-label gform-field-label--type-inline'><\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_51_208\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio 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_51_208\" ><legend class='gfield_label gform-field-label' >Selecci\u00f3n de planes<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_208'>\n\t\t\t<div class='gchoice gchoice_51_208_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_208' type='radio' value=''  id='choice_51_208_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_208_0' id='label_51_208_0' class='gform-field-label gform-field-label--type-inline'><\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_51_277\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_277\" ><legend class='gfield_label gform-field-label' >Situaci\u00f3n de inmigraci\u00f3n<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_277'>\n\t\t\t<div class='gchoice gchoice_51_277_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_277' type='radio' value='U.S. Citizen' checked='checked' id='choice_51_277_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_51_277\"   \/>\n\t\t\t\t\t<label for='choice_51_277_0' id='label_51_277_0' class='gform-field-label gform-field-label--type-inline'>Ciudadano estadounidense<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_277_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_277' type='radio' value='Permanent Resident (Green Card holder)'  id='choice_51_277_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_277_1' id='label_51_277_1' class='gform-field-label gform-field-label--type-inline'>Residente permanente (titular de la tarjeta verde)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_277_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_277' type='radio' value='Temporary Resident'  id='choice_51_277_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_277_2' id='label_51_277_2' class='gform-field-label gform-field-label--type-inline'>Residente temporal<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_277_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_277' type='radio' value='Asylum Seeker'  id='choice_51_277_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_277_3' id='label_51_277_3' class='gform-field-label gform-field-label--type-inline'>Solicitante de asilo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_277_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_277' type='radio' value='Refugee'  id='choice_51_277_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_277_4' id='label_51_277_4' class='gform-field-label gform-field-label--type-inline'>Refugiados<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_277_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_277' type='radio' value='gf_other_choice'  id='choice_51_277_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_277_5' id='label_51_277_5' class='gform-field-label gform-field-label--type-inline'>Otros<\/label><br \/><input id='input_51_277_other' class='gchoice_other_control' name='input_277_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_51_277'>Indique su situaci\u00f3n legal de inmigraci\u00f3n y el n\u00famero de identificaci\u00f3n correspondiente.<\/div><\/fieldset><div id=\"field_51_21\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half tooltip w-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_21\" ><label class='gfield_label gform-field-label' for='input_51_21'>Social security number:*<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_51_21' type='text' value='' class='large'  aria-describedby=\"gfield_description_51_21\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_51_21'> <div class=\"tooltip-container\">\n     <span class=\"info-icon\"><img decoding=\"async\" src=\"https:\/\/bestpolicy.co\/wp-content\/uploads\/2024\/09\/info.svg\"\/> &nbspWhy do you need my SSN?<\/span>\n    <span class=\"tooltip-text\">We need your SSN to verify your identity, coordinate benefits, report coverage to the IRS, prevent fraud, and process claims accurately.<\/span>\n  <\/div>\n\n<\/div><\/div><div id=\"field_51_304\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full file-upload gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_304\" ><label class='gfield_label gform-field-label' for='input_51_304'>Immigration Status ID<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='2097152' \/><input name='input_304' id='input_51_304' type='file' class='large' aria-describedby=\"gfield_upload_rules_51_304\" onchange='javascript:gformValidateFileSize( this, 2097152 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_51_304'>Accepted file types: jpg, png, svg, gif, jpeg, xlsx, xls, pdf, Max. file size: 2 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_51_304'><\/div><\/div><\/div><div id=\"field_51_305\" 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_51_305\" ><script src=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/xlsx\/0.18.5\/xlsx.full.min.js\"><\/script>\n<script src=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/pdf.js\/2.12.313\/pdf.min.js\"><\/script>  \n \n  <div class=\"gfield_description file-preview-container\">  <\/div>\n<!-- Image Modal -->\n<div id=\"imageModal\" style=\"display:none; position:fixed; z-index:9999; left:0; top:0; width:100%; height:100%; background-color:rgba(0,0,0,0.8); justify-content:center; align-items:center;\">\n  <span id=\"closeModal\" style=\"position:absolute; top:20px; right:35px; color:white; font-size:40px; cursor:pointer;\">&times;<\/span>\n  <img id=\"modalImg\" style=\"max-width:90%; max-height:90%;\" \/>\n<\/div><\/div><div id=\"field_51_278\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_278\" ><label class='gfield_label gform-field-label' for='input_51_278'>N\u00famero de la tarjeta de autorizaci\u00f3n de empleo (EAD)<\/label><div class='ginput_container ginput_container_text'><input name='input_278' id='input_51_278' type='text' value='' class='medium'  aria-describedby=\"gfield_description_51_278\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_51_278'>(Si tiene una Tarjeta de Autorizaci\u00f3n de Empleo, introduzca el n\u00famero aqu\u00ed).<\/div><\/div><div id=\"field_51_279\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_279\" ><label class='gfield_label gform-field-label' for='input_51_279'>N\u00famero de extranjero (N\u00famero A)<\/label><div class='ginput_container ginput_container_text'><input name='input_279' id='input_51_279' type='text' value='' class='medium'  aria-describedby=\"gfield_description_51_279\"    aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_51_279'>(Si es residente permanente o tiene otro estatus de inmigraci\u00f3n que le proporcione un n\u00famero de extranjero, introd\u00fazcalo aqu\u00ed).<\/div><\/div><div id=\"field_51_26\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full w-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_26\" ><label class='gfield_label gform-field-label' for='input_51_26'>G\u00e9nero<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_51_26' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Male' >Hombre<\/option><option value='Female' >Mujer<\/option><\/select><\/div><\/div><fieldset id=\"field_51_67\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full radio-same-line gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_67\" ><legend class='gfield_label gform-field-label' >Situaci\u00f3n fiscal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_67'>\n\t\t\t<div class='gchoice gchoice_51_67_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Single'  id='choice_51_67_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_67_0' id='label_51_67_0' class='gform-field-label gform-field-label--type-inline'>\u00danico<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_67_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_67' type='radio' value='Yes'  id='choice_51_67_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_67_1' id='label_51_67_1' class='gform-field-label gform-field-label--type-inline'>Casado que presenta una declaraci\u00f3n conjunta (las parejas casadas deben presentar una declaraci\u00f3n conjunta para tener derecho a la ayuda)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_287\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_51_287\" ><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><h3 class=\"gsection_title\">Spouse General Info<\/h3><\/div><div id=\"field_51_288\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_288\" ><label class='gfield_label gform-field-label' for='input_51_288'>Nombre del c\u00f3nyuge<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_288' id='input_51_288' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_289\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_289\" ><label class='gfield_label gform-field-label' for='input_51_289'>C\u00f3nyuge Apellido<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_289' id='input_51_289' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_290\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_290\" ><label class='gfield_label gform-field-label' for='input_51_290'>Fecha de nacimiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_290' id='input_51_290' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_51_290_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_51_290_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_290' class='gform_hidden' value='https:\/\/developer.bestpolicy.co\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_51_291\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_291\" ><label class='gfield_label gform-field-label' for='input_51_291'>Sexo del c\u00f3nyuge<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_291' id='input_51_291' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Male' >Hombre<\/option><option value='Female' >Mujer<\/option><\/select><\/div><\/div><div id=\"field_51_292\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_292\" ><label class='gfield_label gform-field-label' for='input_51_292'>N\u00famero de la Seguridad Social del c\u00f3nyuge<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_292' id='input_51_292' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_307\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_307\" ><label class='gfield_label gform-field-label' for='input_51_307'>Ingresos del c\u00f3nyuge<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_307' id='input_51_307' type='text' value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_293\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_293\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consentimiento del c\u00f3nyuge<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_51_293'><div class='gchoice gchoice_51_293_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_293.1' type='checkbox'  value='Please add this Dependant to my health insurance policy'  id='choice_51_293_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_51_293_1' id='label_51_293_1' class='gform-field-label gform-field-label--type-inline'>Por favor, a\u00f1ada a esta persona a mi p\u00f3liza de seguro de enfermedad<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_294\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_51_294\" ><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><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_51_71\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full radio-same-line gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_71\" ><legend class='gfield_label gform-field-label' >Will you be claiming any dependents on your taxes in 2024?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_71'>\n\t\t\t<div class='gchoice gchoice_51_71_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='Yes'  id='choice_51_71_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_71_0' id='label_51_71_0' class='gform-field-label gform-field-label--type-inline'>S\u00ed<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_71_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_71' type='radio' value='No'  id='choice_51_71_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_71_1' id='label_51_71_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_51_253\" class=\"gfield gfield--type-name gfield--input-type-name 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_51_253\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Dependent&#039;s Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_51_253'>\n                            \n                            <span id='input_51_253_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_253.3' id='input_51_253_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_51_253_3' class='gform-field-label gform-field-label--type-sub'>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_51_253_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_253.6' id='input_51_253_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_51_253_6' class='gform-field-label gform-field-label--type-sub'>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_51_109\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_109\" ><label class='gfield_label gform-field-label' for='input_51_109'>Dependent&#039;s Gender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_109' id='input_51_109' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Male' >Hombre<\/option><option value='Female' >Mujer<\/option><\/select><\/div><\/div><fieldset id=\"field_51_308\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_308\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Dependent 1  Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_51_308'><div class='gchoice gchoice_51_308_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_308.1' type='checkbox'  value='Please add this Dependent to my health insurance policy'  id='choice_51_308_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_51_308_1' id='label_51_308_1' class='gform-field-label gform-field-label--type-inline'>Please add this Dependent to my health insurance policy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_107\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon 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_51_107\" ><label class='gfield_label gform-field-label' for='input_51_107'>Dependent\u2019s Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_107' id='input_51_107' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_51_107_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_51_107_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_107' class='gform_hidden' value='https:\/\/developer.bestpolicy.co\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_51_110\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full ssn-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_110\" ><label class='gfield_label gform-field-label' for='input_51_110'>Dependent\u2019s social security number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_51_110' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_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_51_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_51_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_51_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_51_296\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_296\" ><label class='gfield_label gform-field-label' for='input_51_296'>Please select the value closest to your estimated 2024 income<\/label><div class='ginput_container ginput_container_number'><input name='input_296' id='input_51_296' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_51_264\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full w-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_264\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Have you had any changes in the last 60 days or upcoming loss of coverage?*<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_51_264'><div class='gchoice gchoice_51_264_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_264.1' type='checkbox'  value='None' checked='checked' id='choice_51_264_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_51_264_1' id='label_51_264_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_51_264_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_264.2' type='checkbox'  value='Loss Coverage'  id='choice_51_264_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_51_264_2' id='label_51_264_2' class='gform-field-label gform-field-label--type-inline'>Cobertura de p\u00e9rdidas<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_51_264_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_264.3' type='checkbox'  value='Release from incarceration'  id='choice_51_264_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_51_264_3' id='label_51_264_3' class='gform-field-label gform-field-label--type-inline'>Release from incarceration<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_51_264_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_264.4' type='checkbox'  value='Moved'  id='choice_51_264_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_51_264_4' id='label_51_264_4' class='gform-field-label gform-field-label--type-inline'>Moved<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_51_264_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_264.5' type='checkbox'  value='Change in marital status'  id='choice_51_264_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_51_264_5' id='label_51_264_5' class='gform-field-label gform-field-label--type-inline'>Change in marital status<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_51_282\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_282\" ><legend class='gfield_label gform-field-label' >Loss coverage<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_51_282'>\n\t\t\t<div class='gchoice gchoice_51_282_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_282' type='radio' value='Medicare'  id='choice_51_282_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_51_282\"   \/>\n\t\t\t\t\t<label for='choice_51_282_0' id='label_51_282_0' class='gform-field-label gform-field-label--type-inline'>Medicare<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_282_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_282' type='radio' value='Medicaid\/CHIP'  id='choice_51_282_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_282_1' id='label_51_282_1' class='gform-field-label gform-field-label--type-inline'>Medicaid\/CHIP<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_282_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_282' type='radio' value='Employer Plan'  id='choice_51_282_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_282_2' id='label_51_282_2' class='gform-field-label gform-field-label--type-inline'>Plan de empresa<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_51_282_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_282' type='radio' value='gf_other_choice'  id='choice_51_282_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_51_282_3' id='label_51_282_3' class='gform-field-label gform-field-label--type-inline'>Otros<\/label><br \/><input id='input_51_282_other' class='gchoice_other_control' name='input_282_other' type='text' value='Other' aria-label='Other Choice, please specify'  disabled='disabled' \/>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_51_282'>What type of loss coverage?<\/div><\/fieldset><div id=\"field_51_284\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_284\" ><label class='gfield_label gform-field-label' for='input_51_284'>Cobertura de p\u00e9rdidas<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_284' id='input_51_284' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_51_284_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_51_284_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_284' class='gform_hidden' value='https:\/\/developer.bestpolicy.co\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_51_283\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon 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_51_283\" ><label class='gfield_label gform-field-label' for='input_51_283'>Release from incarceration<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_283' id='input_51_283' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_51_283_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_51_283_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_283' class='gform_hidden' value='https:\/\/developer.bestpolicy.co\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_51_285\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_285\" ><label class='gfield_label gform-field-label' for='input_51_285'>Moved<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_285' id='input_51_285' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_51_285_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_51_285_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_51_285' class='gform_hidden' value='https:\/\/developer.bestpolicy.co\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_51_286\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_286\" ><label class='gfield_label gform-field-label' for='input_51_286'>Former Zipcode<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_286' id='input_51_286' type='text' value='' class='large'  aria-describedby=\"gfield_description_51_286\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_51_286'>Zip code of your last Address <\/div><\/div><div id=\"field_51_169\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_169\" > <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 consent?  <\/span>\n    <span class=\"tooltip-text\">User consent ensures that you are informed and agree to how your health information is handled, protecting privacy, complying with HIPAA, and maintaining trust between yourself and Best Policy.<\/span>\n  <\/div>\n\n<\/div><fieldset id=\"field_51_105\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_105\" ><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 gfield_consent_description' id='gfield_consent_description_51_105'>By clicking \u201cI Agree\u201d, I am providing my electronic signature expressly authorizing My Health Insurance, LLC and Best Policy, LLC and\/or its affiliate to contact me by email, phone or text (including an automatic dialing system or artificial\/pre-recorded voice) at the home or cell phone number above. I understand I am not required to sign\/agree to this as a condition to purchase. I give my permission to My Health Insurance, LLC and Best Policy, LLC and\/or its affiliates to serve as the health insurance agency, agent, and\/or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned agency, agent, and\/or broker to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following: 1- Searching for an existing Marketplace application; 2- Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums; 3- Providing ongoing account maintenance and enrollment assistance, as necessary; or 4- Responding to inquiries from the Marketplace regarding my Marketplace application. I understand that the agency, agent, and\/or broker will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The agency, agent, and\/or broker will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above. I confirm that the information I provided for entry on my Marketplace eligibility and enrollment application is true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agency, agent, and\/or broker beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by emailing privacy@myhealthinsurance.ai<\/div><div class='ginput_container ginput_container_consent'><input name='input_105.1' id='input_51_105_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_51_105\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_51_105_1' >S\u00ed, estoy de acuerdo<\/label><input type='hidden' name='input_105.2' value='Yes, I Agree' class='gform_hidden' \/><input type='hidden' name='input_105.3' value='58' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_51_61\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_61\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Verificaci\u00f3n de ingresos<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_51_61'>Al hacer clic en la casilla de abajo, doy mi consentimiento y autorizaci\u00f3n a My Health Insurance, LLC y Best Policy, LLC y \/ o sus afiliados para presentar mis ingresos estimados como se indica. Soy consciente de que no puedo predecir el futuro, pero los ingresos proporcionados son mi mejor estimaci\u00f3n y se hacen de buena fe. Tambi\u00e9n doy mi consentimiento y autorizaci\u00f3n a My Health Insurance, LLC y Best Policy, LLC y\/o sus afiliados para presentar una carta de verificaci\u00f3n de ingresos en mi nombre si as\u00ed lo requiere el mercado.<\/div><div class='ginput_container ginput_container_consent'><input name='input_61.1' id='input_51_61_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_51_61\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_51_61_1' >S\u00ed, estoy de acuerdo<\/label><input type='hidden' name='input_61.2' value='Yes, I Agree' class='gform_hidden' \/><input type='hidden' name='input_61.3' value='58' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_51_64\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_64\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Consent to Enrollment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_51_64'>Disclaimer for Health Insurance Applications<br \/>\nPlease note that due to circumstances beyond our control, we cannot guarantee the processing time for your application. However, we strive to handle your application as promptly as possible. If we require further clarification or additional information, one of our knowledgeable agents will contact you using the method you specified in your application.<br \/>\nWe are committed to meeting your healthcare and ancillary insurance needs and aim to become the agency you are proud to recommend to your family and friends. If a prompt submission of your application is necessary or you have any questions before submitting your application, please contact us at 385-308-5251 (available from 9 AM to 9 PM Eastern) or via email at Info@BestPolicy.co.<\/div><div class='ginput_container ginput_container_consent'><input name='input_64.1' id='input_51_64_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_51_64\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_51_64_1' >S\u00ed, estoy de acuerdo<\/label><input type='hidden' name='input_64.2' value='Yes, I Agree' class='gform_hidden' \/><input type='hidden' name='input_64.3' value='58' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_51_310\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_310\" ><p><strong>First Name:<\/strong> <span id=\"display-first-name\"><\/span><\/p>\n<p><strong>Last Name:<\/strong> <span id=\"display-last-name\"><\/span><\/p>\n<p><strong>Email:<\/strong> <span id=\"display-email\"><\/span><\/p>\n<p><strong>Phone:<\/strong> <span id=\"display-phone\"><\/span><\/p>\n<p><strong>Address:<\/strong> <span id=\"display-address\"><\/span><\/p><\/div><div id=\"field_51_297\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full consent-signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_297\" ><label class='gfield_label gform-field-label' for='input_51_297'>Consent Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_297' id='input_51_297' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_298\" 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_51_298\" ><div id=\"consent-signature-preview-wrap\">\n  <img decoding=\"async\" id=\"consent-signature-preview\" src=\"\" alt=\"Signature Preview\" style=\"display:none; max-width: 100%; margin-bottom: 10px;\" \/>\n  <button type=\"button\" id=\"consent-save-signature-btn\" style=\"display:none;\">Use This Signature<\/button>\n  <div id=\"consent-signature-status\" style=\"margin-top:10px;color:green;\"><\/div>\n<\/div><\/div><div id=\"field_51_299\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full consent-signature-url gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_51_299\" ><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_51_299'>Consent Signature Url<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_299' id='input_51_299' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_51_65\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_65\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Authorization and Tax attestation<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_51_65'>If another agent goes into your application and changes the agent of record, we will no longer have access to your policy. Should that happen, do you give permission to our agency to go back in and be listed as agent of record?  | Renewal Authorization: Open Enrollment begins Nov 1st of every year. This is when we need to re-enroll your health policy with us. Do you authorize us to auto-renew your insurance policy and change your plan to a different company if needed to ensure your plan remains $0 even if there is a different network of doctors? This allows us to remain agent of record and ensure your coverage does not lapse. | Tax Attestation - Please confirm that you: (1) Agree to allow the Marketplace to use your income data, including information from tax returns, for the next 5 years; (2) understand that you are not eligible for a premium tax credit if found eligible for other qualifying health coverage, such as Medicaid, CHIP, or a job-based health plan; (3) understand that if you become eligible for other qualifying health coverage, you must contact the Marketplace to end your coverage and premium tax credit; (4) understand if the income on your tax return is higher than the amount of income on your application, you may owe additional federal income tax. I acknowledge that to participate in the Affordable Care Act program, I am required to file taxes for any year in which I have been enrolled. Failure to do so may result in loss of future eligibility<\/div><div class='ginput_container ginput_container_consent'><input name='input_65.1' id='input_51_65_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_51_65\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_51_65_1' >S\u00ed, estoy de acuerdo<\/label><input type='hidden' name='input_65.2' value='Yes, I Agree' class='gform_hidden' \/><input type='hidden' name='input_65.3' value='58' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_51_265\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_265\" > <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 consent?  <\/span>\n    <span class=\"tooltip-text\">User consent ensures that you are informed and agree to how your health information is handled, protecting privacy, complying with HIPAA, and maintaining trust between yourself and Best Policy.<\/span>\n  <\/div>\n\n<\/div><fieldset id=\"field_51_66\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_66\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Verification of Information &amp; Submit Application<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_51_66'>I have reviewed the above application information and attest to its accuracy,  You agree that you have provided true answers to all of the questions to the best of your knowledge, and you know you may be subject to penalties under federal law if you intentionally provide false information. You attest that your estimated income for 2024 will be at least the Federal Poverty Limit for your state and household requirements . You agree to notify us as soon as you become aware of any changes to expected income per month that you provided above. Failure to notify us of any changes may result in your eligibility being affected. A Best Policy or My Health Insurance licensed agent will call you as we process your enrollment. You authorize Best Policy or My Health Insurance to submit an application on your behalf even if we cannot reach you immediately.<\/div><div class='ginput_container ginput_container_consent'><input name='input_66.1' id='input_51_66_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_51_66\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_51_66_1' >S\u00ed, estoy de acuerdo<\/label><input type='hidden' name='input_66.2' value='Yes, I Agree' class='gform_hidden' \/><input type='hidden' name='input_66.3' value='58' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_51_301\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full signature gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_51_301\" ><label class='gfield_label gform-field-label' for='input_51_301'>Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_301' id='input_51_301' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_302\" 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_51_302\" ><div id=\"signature-preview-wrap\">\n  <img decoding=\"async\" id=\"signature-preview\" src=\"\" alt=\"Signature Preview\" style=\"display:none; max-width: 100%; margin-bottom: 10px;\" \/>\n  <button type=\"button\" id=\"save-signature-btn\" style=\"display:none;\">Use This Signature<\/button>\n  <div id=\"signature-status\" style=\"margin-top:10px;color:green;\"><\/div>\n<\/div><\/div><div id=\"field_51_303\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full signature-url gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_51_303\" ><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_51_303'>Signature Url<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_303' id='input_51_303' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_103\" 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_51_103\" >By signing, I grant permission to act on my behalf and that of my entire household in matters related to enrollment in a Qualified Health Plan via the Federally Facilitated Marketplace. This authorization also extends to any authorized representative or power of attorney acting on my behalf. The agents empowered by this agreement are My Health Insurance, LLC and Best Policy Co and\/or its affiliates. These agents are authorized to locate existing Marketplace applications, complete applications for eligibility in various plans and programs, provide necessary ongoing maintenance, and respond to inquiries about my application from the Marketplace. I understand and agree that my personally identifiable information will be accessed and used solely for the objectives specified in this document. I have reviewed and verified that the information included in this application is correct to the best of my knowledge. I am under no obligation to disclose additional personal or health-related information beyond what is required for these applications. My consent remains effective until I choose to revoke it. For any modifications or to revoke this consent, I can email privacy@myhealthinsurance.ai<\/div><fieldset id=\"field_51_138\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_hidden\"  data-js-reload=\"field_51_138\" ><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><legend class='gfield_label gform-field-label gfield_label_before_complex' >To proceed, please confirm your contact details by choosing how you&#039;d like to receive your confirmation code:<\/legend><div class='gfield_description' id='gfield_description_51_138'> <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 I need an SMS or email code?<\/span>\n    <span class=\"tooltip-text\">This is to ensure that we have got the correct contact details to contact you concerning your new healthcare plan.<\/span>\n  <\/div>\n\n<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_51_138'><div class='gchoice gchoice_51_138_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_138.1' type='checkbox'  value='By SMS'  id='choice_51_138_1'   aria-describedby=\"gfield_description_51_138\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_51_138_1' id='label_51_138_1' class='gform-field-label gform-field-label--type-inline'>By SMS<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_51_138_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_138.2' type='checkbox'  value='By Email'  id='choice_51_138_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_51_138_2' id='label_51_138_2' class='gform-field-label gform-field-label--type-inline'>By Email<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_51_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_51_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_51_143'>xxTrustedFormCertUrl<\/label><div class='ginput_container ginput_container_text'><input name='input_143' id='input_51_143' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_51_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_51_142\" ><\/div><div id=\"field_51_238\" 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_51_238\" >\n\n\n\n<\/div><\/div><div id=\"field_51_233\" 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_51_233\" >\n<\/div>  \n<div  id=\"img-container\" style=\"width:100%;height:calc(100% + 84px);\"><div class=\"gf_right_half_image\"> \n<img decoding=\"async\" src=\"https:\/\/bestpolicy.co\/wp-content\/uploads\/2024\/09\/family-2.png\"\/>\n<div class=\"right-label\"> \n<h1>Great work, you\u2019re almost there!<\/h1>\n \n<\/div>\n<\/div>\n<\/div>\n<\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_51' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' value='Back'  \/> <input type='submit' id='gform_submit_button_51' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_51' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_51' id='gform_theme_51' value='gravity-theme' \/>\n            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