{"id":98,"date":"2013-08-21T19:13:12","date_gmt":"2013-08-21T23:13:12","guid":{"rendered":"http:\/\/wp.tristanhall.com\/?page_id=98"},"modified":"2013-08-21T19:13:12","modified_gmt":"2013-08-21T23:13:12","slug":"complete-auto-insurance-proposal","status":"publish","type":"page","link":"https:\/\/sumnar.com\/?page_id=98","title":{"rendered":"Complete Auto Insurance Proposal"},"content":{"rendered":"<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f116-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F98#wpcf7-f116-o1\" method=\"post\" class=\"wpcf7-form init\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"116\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.5.3\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f116-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<div class=\"controls\">\n<h3>Policyholder Name &amp; Address<\/h3>\n<p><label for=\"name\">Name <span class=\"required\">*<\/span><\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap name\"><input type=\"text\" name=\"name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"name\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><label for=\"phone\">Phone<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap phone\"><input type=\"tel\" name=\"phone\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" id=\"phone\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><label for=\"email\">Email<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap email\"><input type=\"email\" name=\"email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" id=\"email\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><label for=\"city\">City <span class=\"required\">*<\/span><\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap city\"><input type=\"text\" name=\"city\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"city\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><label for=\"state\">State <span class=\"required\">*<\/span><\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap state\"><input type=\"text\" name=\"state\" value=\"\" size=\"40\" maxlength=\"2\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"state\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><label for=\"zip\">ZIP Code <span class=\"required\">*<\/span><\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap zip\"><input type=\"number\" name=\"zip\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" id=\"zip\" min=\"0\" max=\"99999\" step=\"1\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><label for=\"dob\">Date of Birth <span class=\"required\">*<\/span><\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap dob\"><input type=\"text\" name=\"dob\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"dob\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/p>\n<h3>Vehicle Information<\/h3>\n<p><label for=\"vehicletype\">Type<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap vehicletype\"><select name=\"vehicletype\" class=\"wpcf7-form-control wpcf7-select\" id=\"vehicletype\" aria-invalid=\"false\"><option value=\"Auto\/Van\/Truck\/SUV\">Auto\/Van\/Truck\/SUV<\/option><option value=\"Conversion Van or Truck\">Conversion Van or Truck<\/option><option value=\"Customized Vehicle\">Customized Vehicle<\/option><\/select><\/span><\/p>\n<p><label for=\"vehicleyear\">Year<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap vehicleyear\"><input type=\"number\" name=\"vehicleyear\" value=\"2012\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" id=\"vehicleyear\" min=\"1900\" max=\"3000\" step=\"1\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><label for=\"vehiclemake\">Make<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap vehiclemake\"><select name=\"vehiclemake\" class=\"wpcf7-form-control wpcf7-select\" id=\"vehiclemake\" aria-invalid=\"false\"><option value=\"Acura\">Acura<\/option><option value=\"Audi\">Audi<\/option><option value=\"BMW\">BMW<\/option><option value=\"Buick\">Buick<\/option><option value=\"Cadillac\">Cadillac<\/option><option value=\"Chevrolet\">Chevrolet<\/option><option value=\"Chrysler\">Chrysler<\/option><option value=\"Dodge\">Dodge<\/option><option value=\"Fiat\">Fiat<\/option><option value=\"Fisker\">Fisker<\/option><option value=\"Ford\">Ford<\/option><option value=\"GMC\">GMC<\/option><option value=\"Honda\">Honda<\/option><option value=\"Hyundai\">Hyundai<\/option><option value=\"Infiniti\">Infiniti<\/option><option value=\"Jaguar\">Jaguar<\/option><option value=\"Jeep\">Jeep<\/option><option value=\"Kia\">Kia<\/option><option value=\"Land Rover\">Land Rover<\/option><option value=\"Lexus\">Lexus<\/option><option value=\"Lincoln\">Lincoln<\/option><option value=\"Mazda\">Mazda<\/option><option value=\"Mercedes-Benz\">Mercedes-Benz<\/option><option value=\"Mini\">Mini<\/option><option value=\"Mitsubishi\">Mitsubishi<\/option><option value=\"Nissan\">Nissan<\/option><option value=\"Porshe\">Porshe<\/option><option value=\"Saab\">Saab<\/option><option value=\"Scion\">Scion<\/option><option value=\"Smart\">Smart<\/option><option value=\"Subaru\">Subaru<\/option><option value=\"Suzuki\">Suzuki<\/option><option value=\"Tesla\">Tesla<\/option><option value=\"Toyota\">Toyota<\/option><option value=\"Volkswagen\">Volkswagen<\/option><option value=\"Volvo\">Volvo<\/option><option value=\"Other\">Other<\/option><\/select><\/span><\/p>\n<p><label for=\"vehiclemodel\">Model<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap vehiclemodel\"><input type=\"text\" name=\"vehiclemodel\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"vehiclemodel\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><label for=\"vehiclevin\">VIN <span class=\"required\">*<\/span><\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap vehiclevin\"><input type=\"text\" name=\"vehiclevin\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" id=\"vehiclevin\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><label for=\"vehicleuse\">Primary Use<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap vehicleuse\"><select name=\"vehicleuse\" class=\"wpcf7-form-control wpcf7-select\" id=\"vehicleuse\" aria-invalid=\"false\"><option value=\"Personal (To\/From Work, School, etc.)\">Personal (To\/From Work, School, etc.)<\/option><option value=\"Business (Business Errands, Sales Calls, etc.)\">Business (Business Errands, Sales Calls, etc.)<\/option><option value=\"Pleasure (Recreational Driving Only)\">Pleasure (Recreational Driving Only)<\/option><option value=\"Farming (Agriculture, etc.)\">Farming (Agriculture, etc.)<\/option><\/select><\/span><\/p>\n<p><label for=\"milestowork\">Miles to Work<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap milestowork\"><input type=\"number\" name=\"milestowork\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" id=\"milestowork\" min=\"0\" max=\"1000000\" step=\"1\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><label for=\"vehicleown\">Own or Lease Vehicle<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap vehicleown\"><select name=\"vehicleown\" class=\"wpcf7-form-control wpcf7-select\" id=\"vehicleown\" aria-invalid=\"false\"><option value=\"Own and Make Payments\">Own and Make Payments<\/option><option value=\"Own and Do Not Make Payments\">Own and Do Not Make Payments<\/option><option value=\"Lease\">Lease<\/option><\/select><\/span><\/p>\n<p><label for=\"hascurrentautoinsurance\">Do You Currently Have Auto Insurance?<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap hascurrentautoinsurance\"><span class=\"wpcf7-form-control wpcf7-radio\" id=\"hascurrentautoinsurance\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"radio\" name=\"hascurrentautoinsurance\" value=\"Yes\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"radio\" name=\"hascurrentautoinsurance\" value=\"No\" \/><\/label><\/span><\/span><\/span><\/p>\n<p><label for=\"bilimit\">Bodily Injury Limits Requested<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap bilimit\"><select name=\"bilimit\" class=\"wpcf7-form-control wpcf7-select\" id=\"bilimit\" aria-invalid=\"false\"><option value=\"$100,000\/$300,000\">$100,000\/$300,000<\/option><option value=\"$250,000\/$500,000\">$250,000\/$500,000<\/option><option value=\"$500,000\/$500,000\">$500,000\/$500,000<\/option><option value=\"$500,000\/$1,000,000\">$500,000\/$1,000,000<\/option><option value=\"$1,000,000\/$1,000,000\">$1,000,000\/$1,000,000<\/option><\/select><\/span><\/p>\n<p><label for=\"liabilitylimit\">Uninsured or Underinsured Motorist Liability Limit<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap liabilitylimit\"><input type=\"text\" name=\"liabilitylimit\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"liabilitylimit\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><label for=\"checkallapply\">Check All That Apply<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap checkallapply\"><span class=\"wpcf7-form-control wpcf7-checkbox\" id=\"checkallapply\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkallapply[]\" value=\"Comprehensive\" \/><span class=\"wpcf7-list-item-label\">Comprehensive<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkallapply[]\" value=\"Collision\" \/><span class=\"wpcf7-list-item-label\">Collision<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkallapply[]\" value=\"Rental Car Reimbursement\" \/><span class=\"wpcf7-list-item-label\">Rental Car Reimbursement<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkallapply[]\" value=\"Anti Theft Device\" \/><span class=\"wpcf7-list-item-label\">Anti Theft Device<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkallapply[]\" value=\"Loan\/Lease Payoff\" \/><span class=\"wpcf7-list-item-label\">Loan\/Lease Payoff<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkallapply[]\" value=\"Roadside Assistance\" \/><span class=\"wpcf7-list-item-label\">Roadside Assistance<\/span><\/span><\/span><\/span><\/p>\n<h3>Driver Information<\/h3>\n<p><label for=\"drivername\">Name<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap drivername\"><input type=\"text\" name=\"drivername\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"drivername\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><label for=\"driverdob\">Date of Birth<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap driverdob\"><input type=\"text\" name=\"driverdob\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"driverdob\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><label for=\"maritalstatus\">Marital Status<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap maritalstatus\"><span class=\"wpcf7-form-control wpcf7-radio\" id=\"maritalstatus\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Single<\/span><input type=\"radio\" name=\"maritalstatus\" value=\"Single\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">Married<\/span><input type=\"radio\" name=\"maritalstatus\" value=\"Married\" \/><\/label><\/span><\/span><\/span><\/p>\n<p><label for=\"gender\">Gender<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap gender\"><span class=\"wpcf7-form-control wpcf7-radio\" id=\"gender\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Male<\/span><input type=\"radio\" name=\"gender\" value=\"Male\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">Female<\/span><input type=\"radio\" name=\"gender\" value=\"Female\" \/><\/label><\/span><\/span><\/span><\/p>\n<p><label for=\"licensenumber\">Driver's License Number<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap licensenumber\"><input type=\"text\" name=\"licensenumber\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"licensenumber\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><label for=\"claimstickets\">Please describe any claims, tickets, etc. that you might have. Be sure to include the date and amount of each.<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap claimstickets\"><textarea name=\"claimstickets\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" id=\"claimstickets\" aria-invalid=\"false\"><\/textarea><\/span><\/p>\n<h3>Other Information<\/h3>\n<p><label for=\"priorcarrier\">Prior\/Current Insurance Provider<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap priorcarrier\"><input type=\"text\" name=\"priorcarrier\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"priorcarrier\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><label for=\"yearsinsured\">Years Insured with Provider<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap yearsinsured\"><input type=\"number\" name=\"yearsinsured\" value=\"\" class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" id=\"yearsinsured\" min=\"1\" max=\"100\" step=\"1\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><label for=\"rentownhome\">Do You Rent or Own a Home?<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap rentownhome\"><span class=\"wpcf7-form-control wpcf7-radio\" id=\"rentownhome\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Own<\/span><input type=\"radio\" name=\"rentownhome\" value=\"Own\" \/><\/label><\/span><span class=\"wpcf7-list-item\"><label><span class=\"wpcf7-list-item-label\">Rent<\/span><input type=\"radio\" name=\"rentownhome\" value=\"Rent\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">N\/A<\/span><input type=\"radio\" name=\"rentownhome\" value=\"N\/A\" \/><\/label><\/span><\/span><\/span><\/p>\n<p><label for=\"employer\">Where Are You Employed?<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap employer\"><input type=\"text\" name=\"employer\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"employer\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><label for=\"medicalinsurance\">Do You Have Medical Insurance?<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap medicalinsurance\"><span class=\"wpcf7-form-control wpcf7-radio\" id=\"medicalinsurance\"><span class=\"wpcf7-list-item first\"><label><span class=\"wpcf7-list-item-label\">Yes<\/span><input type=\"radio\" name=\"medicalinsurance\" value=\"Yes\" \/><\/label><\/span><span class=\"wpcf7-list-item last\"><label><span class=\"wpcf7-list-item-label\">No<\/span><input type=\"radio\" name=\"medicalinsurance\" value=\"No\" \/><\/label><\/span><\/span><\/span><\/p>\n<p><label for=\"ifmedical\">If Yes, Who is Your Current Health Insurance Provider?<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap ifmedical\"><input type=\"text\" name=\"ifmedical\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"ifmedical\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><label for=\"referral\">How Did You Hear About Us?<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap referral\"><input type=\"text\" name=\"referral\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" id=\"referral\" aria-invalid=\"false\" \/><\/span><\/p>\n<p><label for=\"comments\">Comments<\/label><\/p>\n<p><span class=\"wpcf7-form-control-wrap comments\"><textarea name=\"comments\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea\" id=\"comments\" aria-invalid=\"false\"><\/textarea><\/span><\/p>\n<p><input type=\"submit\" value=\"Send\" class=\"wpcf7-form-control has-spinner wpcf7-submit\" \/><\/p>\n<\/div>\n<div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"open","template":"onecolumn-page.php","meta":[],"_links":{"self":[{"href":"https:\/\/sumnar.com\/index.php?rest_route=\/wp\/v2\/pages\/98"}],"collection":[{"href":"https:\/\/sumnar.com\/index.php?rest_route=\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/sumnar.com\/index.php?rest_route=\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/sumnar.com\/index.php?rest_route=\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/sumnar.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=98"}],"version-history":[{"count":0,"href":"https:\/\/sumnar.com\/index.php?rest_route=\/wp\/v2\/pages\/98\/revisions"}],"wp:attachment":[{"href":"https:\/\/sumnar.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=98"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}