{"id":5169,"date":"2021-02-02T06:11:49","date_gmt":"2021-02-02T10:11:49","guid":{"rendered":"https:\/\/gulf.adept.sr\/forms\/?page_id=5169"},"modified":"2021-02-02T06:11:51","modified_gmt":"2021-02-02T10:11:51","slug":"surrender-policy","status":"publish","type":"page","link":"https:\/\/gulf.adept.sr\/forms\/surrender-policy\/","title":{"rendered":"Surrender Policy"},"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;\">Surrender Policy<\/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_78' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_78' class='transaction-form gform_legacy_markup' action='\/forms\/wp-json\/wp\/v2\/pages\/5169' novalidate autocomplete=\"off\">\n                        <div class='gform_body gform-body'><ul id='gform_fields_78' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_78_133\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_133\"><label class='gfield_label' for='input_78_133' >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_133' id='input_78_133' class='medium gfield_select' tabindex='49'   aria-required=\"true\" aria-invalid=\"false\" ><option value='GEM' >GEM<\/option><option value='URA' >URA<\/option><option value='ERA' >ERA<\/option><option value='D' >D<\/option><option value='T0' >T0<\/option><option value='TD' >TD<\/option><option value='EDM' >EDM<\/option><option value='RAP' >RAP<\/option><\/select><\/div><\/li><li id=\"field_78_7\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_7\"><label class='gfield_label' for='input_78_7' >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_7' id='input_78_7' type='text' value='' class='medium'  aria-describedby=\"gfield_description_78_7\" tabindex='50' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_78_7'>GEM Policy Number only<\/div><\/li><li id=\"field_78_150\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_150\"><label class='gfield_label' for='input_78_150' >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_150' id='input_78_150' type='text' value='' class='medium'  aria-describedby=\"gfield_description_78_150\" tabindex='51' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_78_150'>D Policy Number only<\/div><\/li><li id=\"field_78_136\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_136\"><label class='gfield_label' for='input_78_136' >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_136' id='input_78_136' type='text' value='' class='medium'  aria-describedby=\"gfield_description_78_136\" tabindex='52' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_78_136'>URA Policy Number only<\/div><\/li><li id=\"field_78_137\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_137\"><label class='gfield_label' for='input_78_137' >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_137' id='input_78_137' type='text' value='' class='medium'  aria-describedby=\"gfield_description_78_137\" tabindex='53' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_78_137'>ERA Policy Number only<\/div><\/li><li id=\"field_78_138\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_138\"><label class='gfield_label' for='input_78_138' >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_138' id='input_78_138' type='text' value='' class='medium'  aria-describedby=\"gfield_description_78_138\" tabindex='54' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_78_138'>T0 Policy Number only<\/div><\/li><li id=\"field_78_154\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_154\"><label class='gfield_label' for='input_78_154' >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_154' id='input_78_154' type='text' value='' class='medium'  aria-describedby=\"gfield_description_78_154\" tabindex='55' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_78_154'>RAP Policy Number only<\/div><\/li><li id=\"field_78_139\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_139\"><label class='gfield_label' for='input_78_139' >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_139' id='input_78_139' type='text' value='' class='medium'  aria-describedby=\"gfield_description_78_139\" tabindex='56' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_78_139'>TD Policy Number only<\/div><\/li><li id=\"field_78_151\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_151\"><label class='gfield_label' for='input_78_151' >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_151' id='input_78_151' type='text' value='' class='medium'  aria-describedby=\"gfield_description_78_151\" tabindex='57' placeholder='Policy No.' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_78_151'>EDM Policy Number only<\/div><\/li><li id=\"field_78_71\"  class=\"gfield gf_right_half checkboxes field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_78_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_78_71'><li class='gchoice gchoice_78_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_78_71_1' tabindex='58'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_71_1' id='label_78_71_1'><\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_78_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_78_72\"><\/li><li id=\"field_78_1\"  class=\"gfield salutation field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_1\"><label class='gfield_label' for='input_78_1' >Salutation<\/label><div class='ginput_container ginput_container_select'><select name='input_1' id='input_78_1' class='large gfield_select' tabindex='59'    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_78_2\"  class=\"gfield name gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_2\"><label class='gfield_label' for='input_78_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_78_2' type='text' value='' class='large'   tabindex='60' placeholder='First Name' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_78_6\"  class=\"gfield name field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_6\"><label class='gfield_label' for='input_78_6' >Middle Name<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_6' id='input_78_6' type='text' value='' class='large'   tabindex='61' placeholder='Middle Name'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_78_4\"  class=\"gfield name gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_4\"><label class='gfield_label' for='input_78_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_78_4' type='text' value='' class='large'   tabindex='62' placeholder='Last Name' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_78_142\"  class=\"gfield gf_left_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_142\"><label class='gfield_label' for='input_78_142' >BIR Number<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_142' id='input_78_142' type='text' value='' class='medium'   tabindex='63' placeholder='BIR Number' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_78_146\"  class=\"gfield gf_middle_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_146\"><label class='gfield_label' for='input_78_146' >Identification 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_146' id='input_78_146' class='medium gfield_select' tabindex='64'   aria-required=\"true\" aria-invalid=\"false\" ><option value='Driver&#039;s Permit' >Driver&#039;s Permit<\/option><option value='National ID' >National ID<\/option><option value='Passport' >Passport<\/option><\/select><\/div><\/li><li id=\"field_78_143\"  class=\"gfield gf_right_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_143\"><label class='gfield_label' for='input_78_143' >Identification Number<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_143' id='input_78_143' type='text' value='' class='medium'   tabindex='65' placeholder='Identification #' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_78_8\"  class=\"gfield gf_middle_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_8\"><label class='gfield_label' for='input_78_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_78_8' type='tel' value='' class='large' tabindex='66' placeholder='Contact No.' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_78_9\"  class=\"gfield gf_right_third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_9\"><label class='gfield_label' for='input_78_9' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input autocomplete=\"off\"  name='input_9' id='input_78_9' type='email' value='' class='large' tabindex='67'  placeholder='Email'  aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_78_11\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_11\"><label class='gfield_label' for='input_78_11' >Address 1<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_11' id='input_78_11' type='text' value='' class='medium'   tabindex='68' placeholder='Address 1' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_78_12\"  class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_78_12\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_78_12' >Address 2<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_12' id='input_78_12' type='text' value='' class='medium'   tabindex='69' placeholder='Address 2'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_78_13\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_13\"><label class='gfield_label' for='input_78_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_78_13' type='text' value='' class='medium'   tabindex='70' placeholder='Town\/City' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_78_14\"  class=\"gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_14\"><label class='gfield_label' for='input_78_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_78_14' class='medium gfield_select' tabindex='71'   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_78_111\"  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_78_111\"><\/li><li id=\"field_78_37\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_37\"><label class='gfield_label'  >Is the policy assigned?<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_78_37'>\n\t\t\t<li class='gchoice gchoice_78_37_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_37' type='radio' value='Yes'  id='choice_78_37_0' tabindex='72'   \/>\n\t\t\t\t<label for='choice_78_37_0' id='label_78_37_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_78_37_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_37' type='radio' value='No'  id='choice_78_37_1' tabindex='73'   \/>\n\t\t\t\t<label for='choice_78_37_1' id='label_78_37_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_78_109\"  class=\"gfield gf_left_third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_109\"><label class='gfield_label' for='input_78_109' >Please select assignee from listing below<\/label><div class='ginput_container ginput_container_select'><select name='input_109' id='input_78_109' class='medium gfield_select' tabindex='74'    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_78_110\"  class=\"gfield gf_left_third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_110\"><label class='gfield_label' for='input_78_110' >Other<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_110' id='input_78_110' type='text' value='' class='medium'   tabindex='75' placeholder='Other'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_78_112\"  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_78_112\"><\/li><li id=\"field_78_114\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_114\"><label class='gfield_label'  >Are you in possession of the policy contract?<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_78_114'>\n\t\t\t<li class='gchoice gchoice_78_114_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_114' type='radio' value='Yes'  id='choice_78_114_0' tabindex='76'   \/>\n\t\t\t\t<label for='choice_78_114_0' id='label_78_114_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_78_114_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_114' type='radio' value='No'  id='choice_78_114_1' tabindex='77'   \/>\n\t\t\t\t<label for='choice_78_114_1' id='label_78_114_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_78_152\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_152\"><label class='gfield_label'  >Was a Lost Policy Declaration Form Completed?<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_78_152'>\n\t\t\t<li class='gchoice gchoice_78_152_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_152' type='radio' value='Yes'  id='choice_78_152_0' tabindex='78'   \/>\n\t\t\t\t<label for='choice_78_152_0' id='label_78_152_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_78_152_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_152' type='radio' value='No'  id='choice_78_152_1' tabindex='79'   \/>\n\t\t\t\t<label for='choice_78_152_1' id='label_78_152_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_78_153\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_153\"><h1 style=\"color:Red\"> <strong>Please Do Not Continue Request UNLESS a Lost Declaration Form was completed.<\/strong><\/h1><\/li><li id=\"field_78_113\"  class=\"gfield gf_left_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_113\"><label class='gfield_label' for='input_78_113' >Please select reason for Surrender<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_113' id='input_78_113' class='medium gfield_select' tabindex='80'   aria-required=\"true\" aria-invalid=\"false\" ><option value='No longer necessary' >No longer necessary<\/option><option value='Financial Difficulty' >Financial Difficulty<\/option><option value='Only option at this time.' >Only option at this time.<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_78_116\"  class=\"gfield gf_middle_third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_116\"><label class='gfield_label' for='input_78_116' >Other<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_116' id='input_78_116' type='text' value='' class='medium'   tabindex='81' placeholder='Other'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_78_36\"  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_78_36\"><\/li><li id=\"field_78_34\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_34\"><label class='gfield_label'  >Were any of the Beneficiaries added from inception of the policy?<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_78_34'>\n\t\t\t<li class='gchoice gchoice_78_34_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_34' type='radio' value='Yes'  id='choice_78_34_0' tabindex='82'   \/>\n\t\t\t\t<label for='choice_78_34_0' id='label_78_34_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_78_34_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_34' type='radio' value='No'  id='choice_78_34_1' tabindex='83'   \/>\n\t\t\t\t<label for='choice_78_34_1' id='label_78_34_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_78_120\"  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_78_120\"><\/li><li id=\"field_78_119\"  class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_119\"><label class='gfield_label' for='input_78_119' >Please select the relationship of the Beneficiaries<\/label><div class='ginput_container ginput_container_multiselect'><select multiple='multiple'  size='7' name='input_119[]' id='input_78_119' class='medium gfield_select' tabindex='84'  aria-invalid=\"false\"  ><option value='Husband' >Husband<\/option><option value='Wife' >Wife<\/option><option value='Son\/Daughter' >Son\/Daughter<\/option><option value='Other' >Other<\/option><\/select><\/div><\/li><li id=\"field_78_121\"  class=\"gfield gf_middle_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_121\"><label class='gfield_label'  >Is Beneficiary still a minor?<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_78_121'>\n\t\t\t<li class='gchoice gchoice_78_121_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_121' type='radio' value='Yes'  id='choice_78_121_0' tabindex='85'   \/>\n\t\t\t\t<label for='choice_78_121_0' id='label_78_121_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_78_121_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_121' type='radio' value='No'  id='choice_78_121_1' tabindex='86'   \/>\n\t\t\t\t<label for='choice_78_121_1' id='label_78_121_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_78_147\"  class=\"gfield gf_middle_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_147\"><label class='gfield_label'  >Was a Minor\/Child Letter Completed?<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_78_147'>\n\t\t\t<li class='gchoice gchoice_78_147_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_147' type='radio' value='Yes'  id='choice_78_147_0' tabindex='87'   \/>\n\t\t\t\t<label for='choice_78_147_0' id='label_78_147_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_78_147_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_147' type='radio' value='No'  id='choice_78_147_1' tabindex='88'   \/>\n\t\t\t\t<label for='choice_78_147_1' id='label_78_147_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_78_79\"  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_78_79\"><\/li><li id=\"field_78_149\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_149\"><h1 style=\"color:Red\"> <strong>Please Do Not Continue Request UNLESS a Minor Letter was completed.<\/strong><\/h1><\/li><li id=\"field_78_123\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_123\"><label class='gfield_label' for='input_78_123' >Please select your preferred method of payment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_123' id='input_78_123' class='medium gfield_select' tabindex='89'   aria-required=\"true\" aria-invalid=\"false\" ><option value='Cheque' >Cheque<\/option><option value='Direct Deposit' >Direct Deposit<\/option><\/select><\/div><\/li><li id=\"field_78_124\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_124\"><h3>Please enter your account details<\/h3><\/li><li id=\"field_78_140\"  class=\"gfield gf_left_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_140\"><label class='gfield_label' for='input_78_140' >Name of Institution<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_140' id='input_78_140' class='medium gfield_select' tabindex='90'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Name of Institution<\/option><option value='First Citizens Bank Ltd.' >First Citizens Bank Ltd.<\/option><option value='RBC Bank Ltd.' >RBC Bank Ltd.<\/option><option value='Republic Bank Ltd.' >Republic Bank Ltd.<\/option><option value='Scotiabank T&amp;T Ltd.' >Scotiabank T&amp;T Ltd.<\/option><option value='JMMB Bank' >JMMB Bank<\/option><option value='Intercommercial Bank' >Intercommercial Bank<\/option><option value='Credit Union\/Other' >Credit Union\/Other<\/option><\/select><\/div><\/li><li id=\"field_78_141\"  class=\"gfield gf_left_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_141\"><label class='gfield_label' for='input_78_141' >Other\/Credit Union<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_141' id='input_78_141' type='text' value='' class='medium'   tabindex='91' placeholder='Other\/Credit Union' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_78_126\"  class=\"gfield gf_middle_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_126\"><label class='gfield_label' for='input_78_126' >Account number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input autocomplete=\"off\"  name='input_126' id='input_78_126' type='number' step='any' min='0'  value='' class='medium' tabindex='92'   placeholder='Account number' aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_78_126\" \/><div class='instruction ' id='gfield_instruction_78_126'>Please enter a number greater than or equal to <strong>0<\/strong>.<\/div><\/div><\/li><li id=\"field_78_132\"  class=\"gfield gf_left_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_132\"><label class='gfield_label' for='input_78_132' >Branch of Account<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_132' id='input_78_132' type='text' value='' class='medium'   tabindex='93' placeholder='Branch of Account' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_78_122\"  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_78_122\"><\/li><li id=\"field_78_130\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_130\"><label class='gfield_label' for='input_78_130' >Branch of Request\/CSR<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_130' id='input_78_130' class='medium gfield_select' tabindex='94'   aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Branch of Request<\/option><option value='Arima' >Arima<\/option><option value='Chaguanas' >Chaguanas<\/option><option value='Port of Spain' >Port of Spain<\/option><option value='San Fernando' >San Fernando<\/option><option value='Tobago' >Tobago<\/option><\/select><\/div><\/li><li id=\"field_78_135\"  class=\"gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_135\"><label class='gfield_label' for='input_78_135' >Preferred Branch to Collect Payment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_135' id='input_78_135' class='medium gfield_select' tabindex='95'   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_78_129\"  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_78_129\"><\/li><li id=\"field_78_22\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_78_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_78_22'>\n\t\t\t<li class='gchoice gchoice_78_22_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_22' type='radio' value='Type-in Signature'  id='choice_78_22_0' tabindex='96'   \/>\n\t\t\t\t<label for='choice_78_22_0' id='label_78_22_0'>Type-in Signature<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_78_22_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_22' type='radio' value='Digital Signature'  id='choice_78_22_1' tabindex='97'   \/>\n\t\t\t\t<label for='choice_78_22_1' id='label_78_22_1'>Digital Signature<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_78_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_78_28\"><\/li><li id=\"field_78_23\"  class=\"gfield gf_left_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_78_23\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_78_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_78_23' type='text' value='' class='medium'   tabindex='98' placeholder='Signature' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_78_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_78_29\"><\/li><li id=\"field_78_17\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_17\"><label class='gfield_label' for='input_78_17' >Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_78_17_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><input autocomplete=\"off\"  type='hidden' class='gform_hidden' name='input_78_17_valid' id='input_78_17_valid' \/><canvas id='input_78_17' width='600' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_78_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_78_33\"><\/li><li id=\"field_78_19\"  class=\"gfield gf_left_third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_19\"><label class='gfield_label' for='input_78_19' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input autocomplete=\"off\"  name='input_19' id='input_78_19' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='99'  placeholder='Date' aria-describedby=\"input_78_19_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_78_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_78_19' class='gform_hidden' value='https:\/\/gulf.adept.sr\/forms\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_78_30\"  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_78_30\"><\/li><li id=\"field_78_24\"  class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_78_24\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label'  >Signature of Beneficiary<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_78_24'>\n\t\t\t<li class='gchoice gchoice_78_24_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_24' type='radio' value='Type-in Signature'  id='choice_78_24_0' tabindex='100'   \/>\n\t\t\t\t<label for='choice_78_24_0' id='label_78_24_0'>Type-in Signature<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_78_24_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_24' type='radio' value='Digital Signature'  id='choice_78_24_1' tabindex='101'   \/>\n\t\t\t\t<label for='choice_78_24_1' id='label_78_24_1'>Digital Signature<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_78_31\"  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_78_31\"><\/li><li id=\"field_78_26\"  class=\"gfield gf_left_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_78_26\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_78_26' >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_26' id='input_78_26' type='text' value='' class='medium'   tabindex='102' placeholder='Signature' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_78_18\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_18\"><label class='gfield_label' for='input_78_18' >Beneficiary Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_78_18_Container' class='gfield_signature_container ginput_container' style='height:180px; width:600px; ' ><input autocomplete=\"off\"  type='hidden' class='gform_hidden' name='input_78_18_valid' id='input_78_18_valid' \/><canvas id='input_78_18' width='600' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_78_32\"  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_78_32\"><\/li><li id=\"field_78_145\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_145\"><label class='gfield_label' for='input_78_145' >Additional Comments<\/label><div class='ginput_container ginput_container_textarea'><textarea autocomplete=\"off\"  name='input_145' id='input_78_145' class='textarea small' tabindex='103'  maxlength='500'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_78_117\"  class=\"gfield checkboxes gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_117\"><label class='gfield_label gfield_label_before_complex'  >Declaration<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_78_117'><li class='gchoice gchoice_78_117_1'>\n\t\t\t\t\t\t\t\t<input autocomplete=\"off\"  class='gfield-choice-input' name='input_117.1' type='checkbox'  value='I hereby agree that by surrendering my policy the cost of insurance may be subject to change should I decide to effect new coverage with the Company.'  id='choice_78_117_1' tabindex='104'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_117_1' id='label_78_117_1'>I hereby agree that by surrendering my policy the cost of insurance may be subject to change should I decide to effect new coverage with the Company.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_78_127\"  class=\"gfield checkboxes gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_78_127\"><label class='gfield_label gfield_label_before_complex'  >Declaration<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_78_127'><li class='gchoice gchoice_78_127_1'>\n\t\t\t\t\t\t\t\t<input autocomplete=\"off\"  class='gfield-choice-input' name='input_127.1' type='checkbox'  value='I confirm that I am the owner and payor of the above-mentioned policy, and would like to request the Cash Surrender Value of the policy, for the sole benefit of my named beneficiary.'  id='choice_78_127_1' tabindex='105'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_78_127_1' id='label_78_127_1'>I confirm that I am the owner and payor of the above-mentioned policy, and would like to request the Cash Surrender Value of the policy, for the sole benefit of my named beneficiary.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_78_20\"  class=\"gfield gf_left_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_78_20\"><label class='gfield_label' for='input_78_20' >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_20' id='input_78_20' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='106'  placeholder='Date' aria-describedby=\"input_78_20_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_78_20_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_78_20' class='gform_hidden' 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