{"id":5166,"date":"2021-02-02T05:43:38","date_gmt":"2021-02-02T09:43:38","guid":{"rendered":"https:\/\/gulf.adept.sr\/forms\/?page_id=5166"},"modified":"2021-02-02T05:43:40","modified_gmt":"2021-02-02T09:43:40","slug":"request-statement","status":"publish","type":"page","link":"https:\/\/gulf.adept.sr\/forms\/request-statement\/","title":{"rendered":"Request Statement"},"content":{"rendered":"<p style=\"text-align: center;\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-5148\" src=\"https:\/\/gulf.adept.sr\/forms\/wp-content\/uploads\/2021\/01\/Assuria_TT-logo-with-slogan-01-1-300x117.png\" alt=\"\" width=\"300\" height=\"117\" srcset=\"https:\/\/gulf.adept.sr\/forms\/wp-content\/uploads\/2021\/01\/Assuria_TT-logo-with-slogan-01-1-300x117.png 300w, https:\/\/gulf.adept.sr\/forms\/wp-content\/uploads\/2021\/01\/Assuria_TT-logo-with-slogan-01-1-1024x400.png 1024w, https:\/\/gulf.adept.sr\/forms\/wp-content\/uploads\/2021\/01\/Assuria_TT-logo-with-slogan-01-1.png 1212w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/p>\n<h2 style=\"text-align: center;\">Request Statement<\/h2>\n<p style=\"text-align: center;\"><script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper transaction-form_wrapper gform_legacy_markup_wrapper' id='gform_wrapper_77' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_77' class='transaction-form gform_legacy_markup' action='\/forms\/wp-json\/wp\/v2\/pages\/5166' novalidate autocomplete=\"off\">\n                        <div class='gform_body gform-body'><ul id='gform_fields_77' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_77_7\"  class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_77_7\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_77_7' >Policy No. (If unknown please tick box on the side)<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_7' id='input_77_7' type='text' value='' class='medium'   tabindex='49' placeholder='Policy No.'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_77_97\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_97\"><label class='gfield_label' for='input_77_97' >Please Select Policy Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_97' id='input_77_97' class='medium gfield_select' tabindex='50'   aria-required=\"true\" aria-invalid=\"false\" ><option value='GEM' >GEM<\/option><option value='ERA' >ERA<\/option><option value='URA' >URA<\/option><option value='D' >D<\/option><option value='T0' >T0<\/option><option value='TD' >TD<\/option><option value='EDM' >EDM<\/option><option value='TARP' >TARP<\/option><option value='TT' >TT<\/option><option value='RAP' >RAP<\/option><\/select><\/div><\/li><li id=\"field_77_94\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_77_94\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_77_94' >Policy No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_94' id='input_77_94' type='text' value='' class='medium'   tabindex='51' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_77_106\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_106\"><label class='gfield_label' for='input_77_106' >Policy No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_106' id='input_77_106' type='text' value='' class='medium'  aria-describedby=\"gfield_description_77_106\" tabindex='52' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_77_106'>GEM Policy Number Only<\/div><\/li><li id=\"field_77_105\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_105\"><label class='gfield_label' for='input_77_105' >Policy No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_105' id='input_77_105' type='text' value='' class='medium'  aria-describedby=\"gfield_description_77_105\" tabindex='53' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_77_105'>ERA Policy Number Only<\/div><\/li><li id=\"field_77_104\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_104\"><label class='gfield_label' for='input_77_104' >Policy No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_104' id='input_77_104' type='text' value='' class='medium'  aria-describedby=\"gfield_description_77_104\" tabindex='54' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_77_104'>URA Policy Number Only<\/div><\/li><li id=\"field_77_103\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_103\"><label class='gfield_label' for='input_77_103' >Policy No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_103' id='input_77_103' type='text' value='' class='medium'  aria-describedby=\"gfield_description_77_103\" tabindex='55' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_77_103'>D Policy Number Only<\/div><\/li><li id=\"field_77_102\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_102\"><label class='gfield_label' for='input_77_102' >Policy No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_102' id='input_77_102' type='text' value='' class='medium'  aria-describedby=\"gfield_description_77_102\" tabindex='56' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_77_102'>T0 Policy Number Only<\/div><\/li><li id=\"field_77_101\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_101\"><label class='gfield_label' for='input_77_101' >Policy No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_101' id='input_77_101' type='text' value='' class='medium'  aria-describedby=\"gfield_description_77_101\" tabindex='57' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_77_101'>TD Policy Number Only<\/div><\/li><li id=\"field_77_100\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_100\"><label class='gfield_label' for='input_77_100' >Policy No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_100' id='input_77_100' type='text' value='' class='medium'  aria-describedby=\"gfield_description_77_100\" tabindex='58' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_77_100'>EDM Policy Number Only<\/div><\/li><li id=\"field_77_99\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_99\"><label class='gfield_label' for='input_77_99' >Policy No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_99' id='input_77_99' type='text' value='' class='medium'  aria-describedby=\"gfield_description_77_99\" tabindex='59' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_77_99'>TARP Policy Number Only<\/div><\/li><li id=\"field_77_98\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_98\"><label class='gfield_label' for='input_77_98' >Policy No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_98' id='input_77_98' type='text' value='' class='medium'  aria-describedby=\"gfield_description_77_98\" tabindex='60' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_77_98'>TT Policy Number Only<\/div><\/li><li id=\"field_77_110\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_110\"><label class='gfield_label' for='input_77_110' >Policy No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_110' id='input_77_110' type='text' value='' class='medium'  aria-describedby=\"gfield_description_77_110\" tabindex='61' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_77_110'>RAP Policy Number Only<\/div><\/li><li id=\"field_77_71\"  class=\"gfield gf_right_half checkboxes field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_77_71\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label screen-reader-text gfield_label_before_complex'  ><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_77_71'><li class='gchoice gchoice_77_71_1'>\n\t\t\t\t\t\t\t\t<input autocomplete=\"off\"  class='gfield-choice-input' name='input_71.1' type='checkbox'  value='unknown'  id='choice_77_71_1' tabindex='62'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_77_71_1' id='label_77_71_1'><\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_77_109\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_109\">        <div style=\"background-color: #808080; padding: 10px; display: inline-block; font-size: 18px; color: #FFFFFF\n;\">\n            <p><strong>Please Make Sure Policy Type and Policy Numbers are accurate.<\/strong><\/p>\n        <\/div><\/li><li id=\"field_77_72\"  class=\"gfield clr gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_72\"><\/li><li id=\"field_77_1\"  class=\"gfield salutation field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_1\"><label class='gfield_label' for='input_77_1' >Salutation<\/label><div class='ginput_container ginput_container_select'><select name='input_1' id='input_77_1' class='large gfield_select' tabindex='63'    aria-invalid=\"false\" ><option value='Mr.' >Mr.<\/option><option value='Miss.' >Miss.<\/option><option value='Mrs.' >Mrs.<\/option><option value='Dr.' >Dr.<\/option><\/select><\/div><\/li><li id=\"field_77_2\"  class=\"gfield name gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_2\"><label class='gfield_label' for='input_77_2' >First Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_2' id='input_77_2' type='text' value='' class='large'   tabindex='64' placeholder='First Name' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_77_6\"  class=\"gfield name field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_6\"><label class='gfield_label' for='input_77_6' >Middle Name<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_6' id='input_77_6' type='text' value='' class='large'   tabindex='65' placeholder='Middle Name'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_77_4\"  class=\"gfield name gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_4\"><label class='gfield_label' for='input_77_4' >Last Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_4' id='input_77_4' type='text' value='' class='large'   tabindex='66' placeholder='Last Name' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_77_8\"  class=\"gfield gf_middle_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_8\"><label class='gfield_label' for='input_77_8' >Contact No.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input autocomplete=\"off\"  name='input_8' id='input_77_8' type='tel' value='' class='large' tabindex='67' placeholder='Contact No.' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_77_108\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_77_108\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label'  >Do you have an Email Address ?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_77_108'>\n\t\t\t<li class='gchoice gchoice_77_108_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_108' type='radio' value='Yes'  id='choice_77_108_0' tabindex='68'   \/>\n\t\t\t\t<label for='choice_77_108_0' id='label_77_108_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_77_108_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_108' type='radio' value='No'  id='choice_77_108_1' tabindex='69'   \/>\n\t\t\t\t<label for='choice_77_108_1' id='label_77_108_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_77_9\"  class=\"gfield gf_left_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_9\"><label class='gfield_label' for='input_77_9' >Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input autocomplete=\"off\"  name='input_9' id='input_77_9' type='email' value='' class='large' tabindex='70'  placeholder='Email' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_77_35\"  class=\"gfield clr gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_35\"><\/li><li id=\"field_77_92\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_92\"><label class='gfield_label' for='input_77_92' >Branch of Request<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_92' id='input_77_92' class='medium gfield_select' tabindex='71'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Branch of Request<\/option><option value='San Fernando' >San Fernando<\/option><option value='Chaguanas' >Chaguanas<\/option><option value='Arima' >Arima<\/option><option value='Tobago' >Tobago<\/option><option value='Port of Spain' >Port of Spain<\/option><\/select><\/div><\/li><li id=\"field_77_107\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_107\"><label class='gfield_label' for='input_77_107' >Preferred Branch<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_107' id='input_77_107' class='medium gfield_select' tabindex='72'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Preferred Branch<\/option><option value='San Fernando' >San Fernando<\/option><option value='Chaguanas' >Chaguanas<\/option><option value='Arima' >Arima<\/option><option value='Tobago' >Tobago<\/option><option value='Port of Spain' >Port of Spain<\/option><\/select><\/div><\/li><li id=\"field_77_93\"  class=\"gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_77_93\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_77_93' >Preferred Branch<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_93' id='input_77_93' type='text' value='' class='medium'   tabindex='73' placeholder='Preferred Branch' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_77_89\"  class=\"gfield clr gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_89\"><\/li><li id=\"field_77_83\"  class=\"gfield gf_left_third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_83\"><label class='gfield_label' for='input_77_83' >Select the appropriate policy<\/label><div class='ginput_container ginput_container_select'><select name='input_83' id='input_77_83' class='medium gfield_select' tabindex='74'    aria-invalid=\"false\" ><option value='20 Year level Term (20T)' >20 Year level Term (20T)<\/option><option value='Diamond Shield' >Diamond Shield<\/option><option value='Education Masterplan' >Education Masterplan<\/option><option value='Golden Enhanced Masterplan (GEM)' >Golden Enhanced Masterplan (GEM)<\/option><option value='Golden Sunset Plan (GSP)' >Golden Sunset Plan (GSP)<\/option><option value='Golden Term to 100 (TARP)' >Golden Term to 100 (TARP)<\/option><option value='Level Term to Age 65 (T65)' >Level Term to Age 65 (T65)<\/option><option value='Level Term to Age 70 (T70)' >Level Term to Age 70 (T70)<\/option><option value='Living Emerald (LE- Simplified Critical Illness Insurance)' >Living Emerald (LE- Simplified Critical Illness Insurance)<\/option><option value='Mortgage Protection' >Mortgage Protection<\/option><option value='Protecting Sapphire' >Protecting Sapphire<\/option><option value='Renewable Level Term 10 (10RT)' >Renewable Level Term 10 (10RT)<\/option><option value='Whole of Life' >Whole of Life<\/option><option value='Unregistered Annuity ( URA )' >Unregistered Annuity ( URA )<\/option><option value='Registered Annuity ( ERA )' >Registered Annuity ( ERA )<\/option><\/select><\/div><\/li><li id=\"field_77_95\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_95\"><label class='gfield_label' for='input_77_95' >Statement Years<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_95[]' id='input_77_95' class='medium gfield_select' tabindex='75'  aria-invalid=\"false\"  ><option value='2020' >2020<\/option><option value='2021' >2021<\/option><option value='2022' >2022<\/option><option value='2023' >2023<\/option><option value='2024' >2024<\/option><option value='2025' >2025<\/option><\/select><\/div><\/li><li id=\"field_77_84\"  class=\"gfield gf_middle_third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_84\"><label class='gfield_label' for='input_77_84' >Please state reason for request<\/label><div class='ginput_container ginput_container_select'><select name='input_84' id='input_77_84' class='medium gfield_select' tabindex='76'    aria-invalid=\"false\" ><option value='Personal' >Personal<\/option><option value='Financial Institution' >Financial Institution<\/option><\/select><\/div><\/li><li id=\"field_77_88\"  class=\"gfield clr gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_88\"><\/li><li id=\"field_77_85\"  class=\"gfield gf_left_third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_85\"><label class='gfield_label' for='input_77_85' >Please select the financial institution<\/label><div class='ginput_container ginput_container_select'><select name='input_85' id='input_77_85' class='medium gfield_select' tabindex='77'    aria-invalid=\"false\" ><option value='Agricultural Development Bank of T&amp;T' >Agricultural Development Bank of T&amp;T<\/option><option value='Assuria Life (T&amp;T) Limited' >Assuria Life (T&amp;T) Limited<\/option><option value='Eastern Credit Union' >Eastern Credit Union<\/option><option value='First Citizen Bank' >First Citizen Bank<\/option><option value='RBC Royal Bank' >RBC Royal Bank<\/option><option value='Republic Bank Limited' >Republic Bank Limited<\/option><option value='Rhand Credit Union' >Rhand Credit Union<\/option><option value='Scotiabank Trinidad and Tobago' >Scotiabank Trinidad and Tobago<\/option><option value='TECU Credit Union Co-Op Society' >TECU Credit Union Co-Op Society<\/option><option value='The Trinidad Building &amp; Loan Association' >The Trinidad Building &amp; Loan Association<\/option><option value='Trinidad and Tobago Mortgage Finance Company' >Trinidad and Tobago Mortgage Finance Company<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_77_87\"  class=\"gfield gf_middle_third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_87\"><label class='gfield_label' for='input_77_87' >Other<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_87' id='input_77_87' type='text' value='' class='medium'   tabindex='78' placeholder='Other'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_77_90\"  class=\"gfield clr gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_90\"><h3>Please enter the address of the financial institution<\/h3><\/li><li id=\"field_77_11\"  class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_11\"><label class='gfield_label' for='input_77_11' >Address 1<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_11' id='input_77_11' type='text' value='' class='medium'   tabindex='79' placeholder='Address 1'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_77_12\"  class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_12\"><label class='gfield_label' for='input_77_12' >Address 2<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_12' id='input_77_12' type='text' value='' class='medium'   tabindex='80' placeholder='Address 2'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_77_13\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_13\"><label class='gfield_label' for='input_77_13' >Town\/City<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_13' id='input_77_13' type='text' value='' class='medium'   tabindex='81' placeholder='Town\/City' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_77_14\"  class=\"gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_14\"><label class='gfield_label' for='input_77_14' >Country<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_14' id='input_77_14' class='medium gfield_select' tabindex='82'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Country<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Afghanistan' >Afghanistan<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darrussalam' >Brunei Darrussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czech Republic' >Czech Republic<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini (Swaziland)' >Eswatini (Swaziland)<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard and McDonald Islands' >Heard and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macau' >Macau<\/option><option value='Macedonia' >Macedonia<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Korea' >North Korea<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Romania' >Romania<\/option><option value='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena' >Saint Helena<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia' >South Georgia<\/option><option value='South Korea' >South Korea<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen Islands' >Svalbard and Jan Mayen Islands<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/li><li id=\"field_77_91\"  class=\"gfield clr gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_91\"><\/li><li id=\"field_77_96\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_96\"><label class='gfield_label' for='input_77_96' >Additional Comments<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_96' id='input_77_96' type='text' value='' class='medium' maxlength='200'  tabindex='83'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_77_22\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_77_22\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label'  >Signature of Policyholder<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_77_22'>\n\t\t\t<li class='gchoice gchoice_77_22_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_22' type='radio' value='Type-in Signature'  id='choice_77_22_0' tabindex='84'   \/>\n\t\t\t\t<label for='choice_77_22_0' id='label_77_22_0'>Type-in Signature<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_77_22_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_22' type='radio' value='Digital Signature'  id='choice_77_22_1' tabindex='85'   \/>\n\t\t\t\t<label for='choice_77_22_1' id='label_77_22_1'>Digital Signature<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_77_28\"  class=\"gfield clr gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_28\"><\/li><li id=\"field_77_23\"  class=\"gfield gf_left_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_77_23\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_77_23' >Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_23' id='input_77_23' type='text' value='' class='medium'   tabindex='86' placeholder='Signature' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_77_29\"  class=\"gfield clr gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_29\"><\/li><li id=\"field_77_17\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_17\"><label class='gfield_label' for='input_77_17' >Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_77_17_Container' class='gfield_signature_container ginput_container' style='height:180px; width:800px; ' ><input autocomplete=\"off\"  type='hidden' class='gform_hidden' name='input_77_17_valid' id='input_77_17_valid' \/><canvas id='input_77_17' width='800' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_77_33\"  class=\"gfield clr gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_33\"><\/li><li id=\"field_77_19\"  class=\"gfield gf_left_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_77_19\"><label class='gfield_label' for='input_77_19' >Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input autocomplete=\"off\"  name='input_19' id='input_77_19' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='87'  placeholder='Date' aria-describedby=\"input_77_19_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_77_19_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input autocomplete=\"off\"  type='hidden' id='gforms_calendar_icon_input_77_19' class='gform_hidden' value='https:\/\/gulf.adept.sr\/forms\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_77' class='gform_button button' value='Submit' tabindex='88' onclick='if(window[\"gf_submitting_77\"]){return false;}  if( !jQuery(\"#gform_77\")[0].checkValidity || 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