{"id":1420,"date":"2026-04-06T09:35:46","date_gmt":"2026-04-06T09:35:46","guid":{"rendered":"https:\/\/dev.intrigueit.co\/norcrosslaw\/?page_id=1420"},"modified":"2026-04-09T09:26:14","modified_gmt":"2026-04-09T09:26:14","slug":"civil-intake-form","status":"publish","type":"page","link":"https:\/\/dev.intrigueit.co\/norcrosslaw\/civil-intake-form\/","title":{"rendered":"Civil Intake Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1420\" class=\"elementor elementor-1420\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d6ddaaf e-flex e-con-boxed e-con e-parent\" data-id=\"d6ddaaf\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-37e06f1 elementor-widget elementor-widget-heading\" data-id=\"37e06f1\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Civil Intake Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-41b7f60 e-flex e-con-boxed e-con e-parent\" data-id=\"41b7f60\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-e5f382d e-con-full e-flex e-con e-child\" data-id=\"e5f382d\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t<div class=\"elementor-element elementor-element-6492bbd elementor-widget elementor-widget-shortcode\" data-id=\"6492bbd\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><script>\nvar 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 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#112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_2' 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' target='gform_ajax_frame_2' id='gform_2'  action='\/norcrosslaw\/wp-json\/wp\/v2\/pages\/1420#gf_2' data-formid='2' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_2_1\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">CLIENT INFORMATION<\/h3><\/div><div id=\"field_2_3\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_3'>Client Name:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_2_3' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_4\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_4'>Home Address:<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_2_4' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_5\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_5'>Home Phone Number:<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_2_5' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_6\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_6'>Cell Phone Number:<\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_2_6' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_7\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_7'>Email Address:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_7' id='input_2_7' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_8\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_8'>Date of Birth:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_8' id='input_2_8' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_8_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_8_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_8' class='gform_hidden' value='https:\/\/dev.intrigueit.co\/norcrosslaw\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_9\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_9'>Place of Birth:<\/label><div class='ginput_container ginput_container_text'><input name='input_9' id='input_2_9' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_10\" class=\"gfield gfield--type-number gfield--input-type-number field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_10'>Social Security Number:<\/label><div class='ginput_container ginput_container_number'><input name='input_10' id='input_2_10' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_11\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_11'>Driver\u2019s License Number:<\/label><div class='ginput_container ginput_container_number'><input name='input_11' id='input_2_11' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_12'>State of Issuance:<\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_2_12' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_13\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SPOUSE INFORMATION<\/h3><\/div><div id=\"field_2_14\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_14'>Spouse\u2019s Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_2_14' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_15\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_15'>Spouse\u2019s Cell Phone Number:<\/label><div class='ginput_container ginput_container_phone'><input name='input_15' id='input_2_15' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_16\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_16'>Spouse\u2019s Email Address:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_16' id='input_2_16' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_2_17\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">SECONDARY\/EMERGENCY CONTACT INFORMATION<\/h3><\/div><div id=\"field_2_18\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_18'>Secondary\/Emergency Contact Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_2_18' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_19\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_19'>Secondary\/Emergency Contact Address:<\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_2_19' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_20\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_20'>Secondary\/ Emergency Contact Phone Number:<\/label><div class='ginput_container ginput_container_phone'><input name='input_20' id='input_2_20' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_21\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">CLIENTS EMPLOYER INFORMATION<\/h3><\/div><div id=\"field_2_22\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_22'>Employer\/Company Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_2_22' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_23\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_23'>Employer Phone Number:<\/label><div class='ginput_container ginput_container_phone'><input name='input_23' id='input_2_23' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_24\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_24'>Length of time employed:<\/label><div class='ginput_container ginput_container_text'><input name='input_24' id='input_2_24' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_25\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">DESCRIBE YOUR COMPLAINT<\/h3><\/div><div id=\"field_2_26\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_26'>Date of Injury:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_26' id='input_2_26' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_26_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_26_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_26' class='gform_hidden' value='https:\/\/dev.intrigueit.co\/norcrosslaw\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_27\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_27'>Location injury\/accident occurred:<\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_2_27' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_28\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_28'>Facts of your case:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_28' id='input_2_28' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_30\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">CLIENTS AUTO\/HOME INSURANCE INFORMATION, IF NECESSARY<\/h3><\/div><div id=\"field_2_31\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_31'>Name of auto insurance company:<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_2_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_32\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_32'>Policy Number:<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_2_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_33'>Name of home insurance company:<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_2_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_34\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_34'>Policy Number:<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_2_34' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_35\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">CLIENTS HEALTH INSURANCE INFORMATION, IF APPLICABLE<\/h3><\/div><div id=\"field_2_36\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_36'>Name of Insurance Company:<\/label><div class='ginput_container ginput_container_text'><input name='input_36' id='input_2_36' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_38\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_38'>Policy Number:<\/label><div class='ginput_container ginput_container_text'><input name='input_38' id='input_2_38' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_39\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">OTHER PARTY\u2019S GENERAL INFORMATION<\/h3><\/div><div id=\"field_2_40\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_40'>Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_2_40' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_41\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_41'>Address:<\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_2_41' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_42\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_42'>Phone Number:<\/label><div class='ginput_container ginput_container_phone'><input name='input_42' id='input_2_42' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_43\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">MOTOR VEHICLE ACCIDENT, IF APPLICABLE<\/h3><\/div><div id=\"field_2_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_45'>Defendant Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_2_45' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_46\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_46'>Defendant\u2019s Address:<\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_2_46' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_47\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_47'>Defendant\u2019s Phone Number:<\/label><div class='ginput_container ginput_container_phone'><input name='input_47' id='input_2_47' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_48\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_48'>Defendant\u2019s Driver\u2019s License Number:<\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_2_48' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_50\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_50'>Defendant\u2019s Insurance Company:<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_2_50' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_51\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_51'>Defendant\u2019s Policy Number:<\/label><div class='ginput_container ginput_container_text'><input name='input_51' id='input_2_51' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_52\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_52'>Defendant\u2019s License Plate Number:<\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_2_52' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_53\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_53'>Insurance Claim Number:<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_2_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_54\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_54'>Date claim was made:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_54' id='input_2_54' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_54_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_54_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_54' class='gform_hidden' value='https:\/\/dev.intrigueit.co\/norcrosslaw\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_2_55\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">OTHER PARTY\u2019S INFORMATION CONTINUED (if needed)<\/h3><\/div><div id=\"field_2_56\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_56'>Other Party\u2019s Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_2_56' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_57\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_57'>Other Party\u2019s Address:<\/label><div class='ginput_container ginput_container_text'><input name='input_57' id='input_2_57' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_58\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_58'>Other Party\u2019s Driver\u2019s License Number:<\/label><div class='ginput_container ginput_container_text'><input name='input_58' id='input_2_58' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_59\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_59'>Other Party\u2019s Insurance Company:<\/label><div class='ginput_container ginput_container_text'><input name='input_59' id='input_2_59' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_60\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_60'>Other Party\u2019s Policy Number:<\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_2_60' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_61\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">ACCIDENT, INJURY, OR COMPLAINT EVENT DETAILS<\/h3><\/div><div id=\"field_2_62\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_62'>CLIENT NAME:<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_2_62' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_63\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_63'>DATE OF THE EVENT:<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_63' id='input_2_63' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_2_63_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_2_63_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_2_63' class='gform_hidden' value='https:\/\/dev.intrigueit.co\/norcrosslaw\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_2_64\" class=\"gfield gfield--type-time gfield--input-type-time field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >TIME:<\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_2_64'>\n                            <input type='number' name='input_64[]' id='input_2_64_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> \n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_2_64_1'>Hours<\/label>\n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' name='input_64[]' id='input_2_64_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_2_64_2'>Minutes<\/label>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_64[]' id='input_2_64_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_2_64_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><div id=\"field_2_65\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_65'>DAY OF WEEK:<\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_2_65' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_67\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_67'>LOCATION:<\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_2_67' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_68\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_68'>CITY:<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_2_68' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_69\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_69'>COUNTY:<\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_2_69' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_70\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_70'>STATE:<\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_2_70' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_71\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_71'>PLEASE DESCRIBE THE EVENT THAT HAS LEAD TO YOUR COMPLAINT:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_71' id='input_2_71' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_73\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">WITNESS TO ACCIDENT, INJURY OR COMPLAINT INFORMATION<\/h3><\/div><div id=\"field_2_75\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_75'>NAME:<\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_2_75' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_76\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_76'>ADDRESS:<\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_2_76' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_78\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_78'>PHONE NUMBER:<\/label><div class='ginput_container ginput_container_phone'><input name='input_78' id='input_2_78' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_79\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_79'>PERSONAL INFORMATION THEY CAN TESTIFY TOO:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_79' id='input_2_79' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_80\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">WITNESS TO ACCIDENT, INJURY OR COMPLAINT INFORMATION<\/h3><\/div><div id=\"field_2_81\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_81'>NAME:<\/label><div class='ginput_container ginput_container_text'><input name='input_81' id='input_2_81' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_82\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_82'>ADDRESS:<\/label><div class='ginput_container ginput_container_text'><input name='input_82' id='input_2_82' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_83\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_83'>PHONE NUMBER:<\/label><div class='ginput_container ginput_container_phone'><input name='input_83' id='input_2_83' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_84\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_84'>PERSONAL INFORMATION THEY CAN TESTIFY TOO:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_84' id='input_2_84' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_85\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">WITNESS TO ACCIDENT, INJURY OR COMPLAINT INFORMATION<\/h3><\/div><div id=\"field_2_87\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_87'>NAME:<\/label><div class='ginput_container ginput_container_text'><input name='input_87' id='input_2_87' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_88\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_88'>ADDRESS:<\/label><div class='ginput_container ginput_container_text'><input name='input_88' id='input_2_88' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_89\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_89'>PHONE NUMBER:<\/label><div class='ginput_container ginput_container_phone'><input name='input_89' id='input_2_89' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_90\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_90'>PERSONAL INFORMATION THEY CAN TESTIFY TOO:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_90' id='input_2_90' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_91\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">WITNESS TO ACCIDENT, INJURY OR COMPLAINT INFORMATION<\/h3><\/div><div id=\"field_2_92\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_92'>NAME:<\/label><div class='ginput_container ginput_container_text'><input name='input_92' id='input_2_92' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_93\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_93'>ADDRESS:<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_2_93' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_94\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_94'>PHONE NUMBER:<\/label><div class='ginput_container ginput_container_phone'><input name='input_94' id='input_2_94' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_95\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_95'>PERSONAL INFORMATION THEY CAN TESTIFY TOO:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_95' id='input_2_95' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_96\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">WITNESS TO ACCIDENT, INJURY OR COMPLAINT INFORMATION<\/h3><\/div><div id=\"field_2_97\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_97'>NAME:<\/label><div class='ginput_container ginput_container_text'><input name='input_97' id='input_2_97' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_98\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_98'>ADDRESS:<\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_2_98' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_99\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_99'>PHONE NUMBER:<\/label><div class='ginput_container ginput_container_phone'><input name='input_99' id='input_2_99' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_100\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_100'>PERSONAL INFORMATION THEY CAN TESTIFY TOO:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_100' id='input_2_100' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_102\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">WITNESS TO ACCIDENT, INJURY OR COMPLAINT INFORMATION<\/h3><\/div><div id=\"field_2_103\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_103'>NAME:<\/label><div class='ginput_container ginput_container_text'><input name='input_103' id='input_2_103' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_104\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_104'>ADDRESS:<\/label><div class='ginput_container ginput_container_text'><input name='input_104' id='input_2_104' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_105\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_105'>PHONE NUMBER:<\/label><div class='ginput_container ginput_container_phone'><input name='input_105' id='input_2_105' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_106\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_106'>PERSONAL INFORMATION THEY CAN TESTIFY TOO:<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_106' id='input_2_106' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_2_107\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_107'>Client Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_107' id='input_2_107' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_108\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">BEFORE AND AFTER WITNESSES FOR INJURY CASES<\/h3><\/div><div id=\"field_2_109\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Please provide the following information for friends, family, or coworkers who knew you\nbefore and after the accident or injury and will be able to attend trial to testify on your behalf\nif necessary. All witnesses must be 18 years of age or older.<\/p><\/div><div id=\"field_2_111\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Before and After Witness 1<\/h3><\/div><div id=\"field_2_110\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_110'>Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_110' id='input_2_110' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_112\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_112'>Address:<\/label><div class='ginput_container ginput_container_text'><input name='input_112' id='input_2_112' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_113\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_113'>City:<\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_2_113' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_114\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_114'>State:<\/label><div class='ginput_container ginput_container_text'><input name='input_114' id='input_2_114' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_115\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_115'>Zip Code:<\/label><div class='ginput_container ginput_container_number'><input name='input_115' id='input_2_115' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_116\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_116'>Phone Number:<\/label><div class='ginput_container ginput_container_phone'><input name='input_116' id='input_2_116' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_117\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Before and After Witness 2<\/h3><\/div><div id=\"field_2_118\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_118'>Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_2_118' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_119\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_119'>Address:<\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_2_119' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_120\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_120'>City:<\/label><div class='ginput_container ginput_container_text'><input name='input_120' id='input_2_120' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_121\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_121'>State:<\/label><div class='ginput_container ginput_container_text'><input name='input_121' id='input_2_121' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_122\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_122'>Zip Code:<\/label><div class='ginput_container ginput_container_number'><input name='input_122' id='input_2_122' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_123\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_123'>Phone Number:<\/label><div class='ginput_container ginput_container_phone'><input name='input_123' id='input_2_123' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_124\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Before and After Witness 3<\/h3><\/div><div id=\"field_2_125\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_125'>Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_2_125' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_126\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_126'>Address:<\/label><div class='ginput_container ginput_container_text'><input name='input_126' id='input_2_126' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_127\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_127'>City:<\/label><div class='ginput_container ginput_container_text'><input name='input_127' id='input_2_127' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_128\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_128'>State:<\/label><div class='ginput_container ginput_container_text'><input name='input_128' id='input_2_128' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_129\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_129'>Zip Code:<\/label><div class='ginput_container ginput_container_number'><input name='input_129' id='input_2_129' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_130\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_130'>Phone Number:<\/label><div class='ginput_container ginput_container_phone'><input name='input_130' id='input_2_130' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_131\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Before and After Witness 4<\/h3><\/div><div id=\"field_2_132\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_132'>Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_132' id='input_2_132' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_133\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_133'>Address:<\/label><div class='ginput_container ginput_container_text'><input name='input_133' id='input_2_133' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_134\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_134'>City:<\/label><div class='ginput_container ginput_container_text'><input name='input_134' id='input_2_134' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_135\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_135'>State:<\/label><div class='ginput_container ginput_container_text'><input name='input_135' id='input_2_135' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_136\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_136'>Zip Code:<\/label><div class='ginput_container ginput_container_text'><input name='input_136' id='input_2_136' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_137\" class=\"gfield gfield--type-phone gfield--input-type-phone field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_137'>Phone Number:<\/label><div class='ginput_container ginput_container_phone'><input name='input_137' id='input_2_137' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_138\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Before and After Witness 5<\/h3><\/div><div id=\"field_2_139\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_139'>Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_139' id='input_2_139' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_140\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_140'>Address:<\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_2_140' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_141\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_141'>City:<\/label><div class='ginput_container ginput_container_text'><input name='input_141' id='input_2_141' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_142\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_142'>State:<\/label><div class='ginput_container ginput_container_text'><input name='input_142' id='input_2_142' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_144\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_144'>Zip Code:<\/label><div class='ginput_container ginput_container_number'><input name='input_144' id='input_2_144' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_2_145\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Before and After Witness 6<\/h3><\/div><div id=\"field_2_146\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_146'>Name:<\/label><div class='ginput_container ginput_container_text'><input name='input_146' id='input_2_146' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_147\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_147'>Address:<\/label><div class='ginput_container ginput_container_text'><input name='input_147' id='input_2_147' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_148\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_148'>City:<\/label><div class='ginput_container ginput_container_text'><input name='input_148' id='input_2_148' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_149\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_149'>State:<\/label><div class='ginput_container ginput_container_text'><input name='input_149' id='input_2_149' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_2_151\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_2_151'>Zip Code:<\/label><div class='ginput_container ginput_container_number'><input name='input_151' id='input_2_151' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_2' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> <input type='hidden' name='gform_ajax' value='form_id=2&amp;title=&amp;description=&amp;tabindex=0&amp;theme=orbital&amp;styles=[]&amp;hash=ae675b106de152eef5ba2b8517f177e4' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_2' value='iframe' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_2' id='gform_theme_2' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_2' id='gform_style_settings_2' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_2' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='2' \/>\n            \n    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