{"id":5519,"date":"2021-12-20T11:23:44","date_gmt":"2021-12-20T15:23:44","guid":{"rendered":"https:\/\/gulf.adept.sr\/forms\/?page_id=5519"},"modified":"2022-03-29T17:45:27","modified_gmt":"2022-03-29T21:45:27","slug":"indemnity-form","status":"publish","type":"page","link":"https:\/\/gulf.adept.sr\/forms\/withdrawal\/indemnity-form\/","title":{"rendered":"Indemnity Form"},"content":{"rendered":"\n<div class=\"wp-block-image\"><figure class=\"aligncenter\"><img loading=\"lazy\" decoding=\"async\" width=\"300\" height=\"117\" src=\"https:\/\/gulf.adept.sr\/forms\/wp-content\/uploads\/2021\/01\/Assuria_TT-logo-with-slogan-01-1-300x117.png\" alt=\"\" class=\"wp-image-5148\" 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\" \/><\/figure><\/div>\n\n\n\n<center><h2>Indemnity Form<\/h2><\/center>\n\n\n\n<!--more Slate -->\n\n\n\n<p class=\"wp-block-paragraph\">\n\n <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_98' style='display:none'><form method='post' enctype='multipart\/form-data'  id='gform_98' class='transaction-form gform_legacy_markup' action='\/forms\/wp-json\/wp\/v2\/pages\/5519' novalidate autocomplete=\"off\">\n                        <div class='gform_body gform-body'><ul id='gform_fields_98' class='gform_fields top_label form_sublabel_below description_below'><li id=\"field_98_145\"  class=\"gfield gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_145\"><h4>IN THE MATTER OF POLICY NO: GEM\/TD\/T0 : <\/h4>\n<p>\n<h4> Issued by <strong>Assuria Life (T&T) Ltd <\/strong>., formerly MEGA Insurance Company Limited, on the life of <\/li><li id=\"field_98_7\"  class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_7\"><label class='gfield_label screen-reader-text' for='input_98_7' >Full Name<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_7' id='input_98_7' type='text' value='' class='medium'   tabindex='49' placeholder='Full Name'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_98_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_98_72\"><h3>I<\/h3><input autocomplete=\"off\"  id=\"Name\"><\/input><\/li><li id=\"field_98_1\"  class=\"gfield salutation field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_1\"><label class='gfield_label' for='input_98_1' >Salutation<\/label><div class='ginput_container ginput_container_select'><select name='input_1' id='input_98_1' class='large gfield_select' tabindex='50'    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_98_2\"  class=\"gfield name gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_2\"><label class='gfield_label' for='input_98_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_98_2' type='text' value='' class='large'   tabindex='51' placeholder='First Name' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_98_6\"  class=\"gfield name field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_6\"><label class='gfield_label' for='input_98_6' >Middle Name<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_6' id='input_98_6' type='text' value='' class='large'   tabindex='52' placeholder='Middle Name'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_98_4\"  class=\"gfield name gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_4\"><label class='gfield_label' for='input_98_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_98_4' type='text' value='' class='large'   tabindex='53' placeholder='Last Name' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_98_8\"  class=\"gfield gf_middle_third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_8\"><label class='gfield_label' for='input_98_8' >Contact No.<\/label><div class='ginput_container ginput_container_phone'><input autocomplete=\"off\"  name='input_8' id='input_98_8' type='tel' value='' class='large' tabindex='54' placeholder='Contact No.'  aria-invalid=\"false\"   \/><\/div><\/li><li id=\"field_98_9\"  class=\"gfield gf_right_third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_9\"><label class='gfield_label' for='input_98_9' >Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input autocomplete=\"off\"  name='input_9' id='input_98_9' type='email' value='' class='large' tabindex='55'  placeholder='Email'  aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_98_11\"  class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_98_11\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_98_11' >Address 1<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_11' id='input_98_11' type='text' value='' class='medium'   tabindex='56' placeholder='Address 1'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_98_12\"  class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_98_12\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_98_12' >Address 2<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_12' id='input_98_12' type='text' value='' class='medium'   tabindex='57' placeholder='Address 2'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_98_13\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_98_13\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_98_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_98_13' type='text' value='' class='medium'   tabindex='58' placeholder='Town\/City' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_98_14\"  class=\"gfield gf_right_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_hidden\"  data-js-reload=\"field_98_14\"><div class='admin-hidden-markup'><i class='gform-icon gform-icon--hidden'><\/i><span>Hidden<\/span><\/div><label class='gfield_label' for='input_98_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_98_14' class='medium gfield_select' tabindex='59'   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_98_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_98_122\"><\/li><li id=\"field_98_121\"  class=\"gfield field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_121\"><label class='gfield_label'  >Is the policy assigned?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_98_121'>\n\t\t\t<li class='gchoice gchoice_98_121_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_121' type='radio' value='Yes'  id='choice_98_121_0' tabindex='60'   \/>\n\t\t\t\t<label for='choice_98_121_0' id='label_98_121_0'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_98_121_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_121' type='radio' value='No'  id='choice_98_121_1' tabindex='61'   \/>\n\t\t\t\t<label for='choice_98_121_1' id='label_98_121_1'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_98_132\"  class=\"gfield gf_left_third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_132\"><label class='gfield_label' for='input_98_132' >Please select assignee from listing below<\/label><div class='ginput_container ginput_container_select'><select name='input_132' id='input_98_132' class='medium gfield_select' tabindex='62'    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_98_133\"  class=\"gfield gf_middle_third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_133\"><label class='gfield_label' for='input_98_133' >Other<\/label><div class='ginput_container ginput_container_text'><input autocomplete=\"off\"  name='input_133' id='input_98_133' type='text' value='' class='medium'   tabindex='63' placeholder='Other'  aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_98_134\"  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_98_134\"><\/li><li id=\"field_98_137\"  class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_137\"><label class='gfield_label'  >Select withdrawal amount<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_98_137'>\n\t\t\t<li class='gchoice gchoice_98_137_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_137' type='radio' value='Maximum'  id='choice_98_137_0' tabindex='64'   \/>\n\t\t\t\t<label for='choice_98_137_0' id='label_98_137_0'>Maximum<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_98_137_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_137' type='radio' value='Specific Amount'  id='choice_98_137_1' tabindex='65'   \/>\n\t\t\t\t<label for='choice_98_137_1' id='label_98_137_1'>Specific Amount<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_98_138\"  class=\"gfield gf_right_half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_138\"><label class='gfield_label' for='input_98_138' >Type-in of numerical value<\/label><div class='ginput_container ginput_container_number'><input autocomplete=\"off\"  name='input_138' id='input_98_138' type='number' step='any'   value='' class='medium' tabindex='66'   placeholder='Type-in of numerical value'  aria-invalid=\"false\"  \/><\/div><\/li><li id=\"field_98_126\"  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_98_126\"><\/li><li id=\"field_98_22\"  class=\"gfield gf_left_half gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_22\"><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_98_22'>\n\t\t\t<li class='gchoice gchoice_98_22_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_22' type='radio' value='Type-in Signature'  id='choice_98_22_0' tabindex='67'   \/>\n\t\t\t\t<label for='choice_98_22_0' id='label_98_22_0'>Type-in Signature<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_98_22_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_22' type='radio' value='Digital Signature'  id='choice_98_22_1' tabindex='68'   \/>\n\t\t\t\t<label for='choice_98_22_1' id='label_98_22_1'>Digital Signature<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_98_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_98_28\"><\/li><li id=\"field_98_23\"  class=\"gfield gf_left_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_23\"><label class='gfield_label' for='input_98_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_98_23' type='text' value='' class='medium'   tabindex='69' placeholder='Signature' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_98_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_98_29\"><\/li><li id=\"field_98_17\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_17\"><label class='gfield_label' for='input_98_17' >Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_98_17_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input autocomplete=\"off\"  type='hidden' class='gform_hidden' name='input_98_17_valid' id='input_98_17_valid' \/><canvas id='input_98_17' width='300' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_98_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_98_33\"><\/li><li id=\"field_98_19\"  class=\"gfield gf_left_third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_19\"><label class='gfield_label' for='input_98_19' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input autocomplete=\"off\"  name='input_19' id='input_98_19' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='70'  placeholder='Date' aria-describedby=\"input_98_19_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_98_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_98_19' class='gform_hidden' value='https:\/\/gulf.adept.sr\/forms\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_98_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_98_30\"><\/li><li id=\"field_98_24\"  class=\"gfield gf_left_half field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_24\"><label class='gfield_label'  >Policy Owner Signature<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_98_24'>\n\t\t\t<li class='gchoice gchoice_98_24_0'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_24' type='radio' value='Type-in Signature'  id='choice_98_24_0' tabindex='71'   \/>\n\t\t\t\t<label for='choice_98_24_0' id='label_98_24_0'>Type-in Signature<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_98_24_1'>\n\t\t\t\t<input autocomplete=\"off\"  name='input_24' type='radio' value='Digital Signature'  id='choice_98_24_1' tabindex='72'   \/>\n\t\t\t\t<label for='choice_98_24_1' id='label_98_24_1'>Digital Signature<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_98_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_98_31\"><\/li><li id=\"field_98_26\"  class=\"gfield gf_left_third gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_26\"><label class='gfield_label' for='input_98_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_98_26' type='text' value='' class='medium'   tabindex='73' placeholder='Signature' aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_98_18\"  class=\"gfield gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_18\"><label class='gfield_label' for='input_98_18' >Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div ><div id='input_98_18_Container' class='gfield_signature_container ginput_container' style='height:180px; width:300px; ' ><input autocomplete=\"off\"  type='hidden' class='gform_hidden' name='input_98_18_valid' id='input_98_18_valid' \/><canvas id='input_98_18' width='300' height='180'><\/canvas><\/div><\/div><\/li><li id=\"field_98_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_98_32\"><\/li><li id=\"field_98_20\"  class=\"gfield gf_left_third field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_20\"><label class='gfield_label' for='input_98_20' >Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input autocomplete=\"off\"  name='input_20' id='input_98_20' type='text' value='' class='datepicker mdy datepicker_no_icon gdatepicker-no-icon' tabindex='74'  placeholder='Date' aria-describedby=\"input_98_20_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_98_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_98_20' class='gform_hidden' value='https:\/\/gulf.adept.sr\/forms\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_98_117\"  class=\"gfield checkboxes gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible\"  data-js-reload=\"field_98_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_98_117'><li class='gchoice gchoice_98_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 any withdrawal from this policy may have an adverse effect on the Policy&#039;s current and future accumulated net fund value.'  id='choice_98_117_1' tabindex='75'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_98_117_1' id='label_98_117_1'>I hereby agree that any withdrawal from this policy may have an adverse effect on the Policy's current and future accumulated net fund value.<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_98_117_2'>\n\t\t\t\t\t\t\t\t<input autocomplete=\"off\"  class='gfield-choice-input' name='input_117.2' type='checkbox'  value='I hereby agree that as my Cost of Insurance increases annually, the monthly premium currently being paid may be insufficient to cover the increased contractual monthly cost of this policy and may  result in a negative net fund value, at which time the policy will automatically lapse.'  id='choice_98_117_2' tabindex='76'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_98_117_2' id='label_98_117_2'>I hereby agree that as my Cost of Insurance increases annually, the monthly premium currently being paid may be insufficient to cover the increased contractual monthly cost of this policy and may  result in a negative net fund value, at which time the policy will automatically lapse.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_98_131\"  class=\"gfield checkboxes field_sublabel_below field_description_below hidden_label gfield_visibility_visible\"  data-js-reload=\"field_98_131\"><label class='gfield_label gfield_label_before_complex'  >Declaration<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_98_131'><li class='gchoice gchoice_98_131_1'>\n\t\t\t\t\t\t\t\t<input autocomplete=\"off\"  class='gfield-choice-input' name='input_131.1' type='checkbox'  value='I confirm that I am the owner and payor of the above-mentioned policy, and would like to request a withdrawal from the policy, for the sole benefit of my named beneficiary.'  id='choice_98_131_1' tabindex='77'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_98_131_1' id='label_98_131_1'>I confirm that I am the owner and payor of the above-mentioned policy, and would like to request a withdrawal from the policy, for the sole benefit of my named beneficiary.<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><\/ul><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_98' class='gform_button button' value='Submit' tabindex='78' onclick='if(window[\"gf_submitting_98\"]){return false;}  if( !jQuery(\"#gform_98\")[0].checkValidity || jQuery(\"#gform_98\")[0].checkValidity()){window[\"gf_submitting_98\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_98\"]){return false;} if( !jQuery(\"#gform_98\")[0].checkValidity || 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<\/div> \n\n<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Indemnity Form<\/p>\n","protected":false},"author":12,"featured_media":0,"parent":5183,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-5519","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/gulf.adept.sr\/forms\/wp-json\/wp\/v2\/pages\/5519","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/gulf.adept.sr\/forms\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/gulf.adept.sr\/forms\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/gulf.adept.sr\/forms\/wp-json\/wp\/v2\/users\/12"}],"replies":[{"embeddable":true,"href":"https:\/\/gulf.adept.sr\/forms\/wp-json\/wp\/v2\/comments?post=5519"}],"version-history":[{"count":16,"href":"https:\/\/gulf.adept.sr\/forms\/wp-json\/wp\/v2\/pages\/5519\/revisions"}],"predecessor-version":[{"id":5585,"href":"https:\/\/gulf.adept.sr\/forms\/wp-json\/wp\/v2\/pages\/5519\/revisions\/5585"}],"up":[{"embeddable":true,"href":"https:\/\/gulf.adept.sr\/forms\/wp-json\/wp\/v2\/pages\/5183"}],"wp:attachment":[{"href":"https:\/\/gulf.adept.sr\/forms\/wp-json\/wp\/v2\/media?parent=5519"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}