{"id":3990,"date":"2024-11-26T06:19:17","date_gmt":"2024-11-26T06:19:17","guid":{"rendered":"https:\/\/21stcfs.co.za\/staging\/?page_id=3990"},"modified":"2026-01-15T21:03:29","modified_gmt":"2026-01-15T19:03:29","slug":"application-form","status":"publish","type":"page","link":"https:\/\/21stcfs.co.za\/staging\/application-form\/","title":{"rendered":"Quick Application Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3990\" class=\"elementor elementor-3990\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-62f7fe57 e-flex e-con-boxed e-con e-parent\" data-id=\"62f7fe57\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-ad0d378 e-con-full e-flex e-con e-child\" data-id=\"ad0d378\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t<div class=\"elementor-element elementor-element-6bcd628 e-con-full e-flex e-con e-child\" data-id=\"6bcd628\" data-element_type=\"container\">\n\t\t<div class=\"elementor-element elementor-element-fdc7f8c e-con-full e-flex e-con e-child\" data-id=\"fdc7f8c\" data-element_type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4d1e196 elementor-widget elementor-widget-heading\" data-id=\"4d1e196\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Trusted Funeral Service<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-690cc40 elementor-widget elementor-widget-heading\" data-id=\"690cc40\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">We've been doing this for 25 years, we've got you.<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-62344fe elementor-align-center elementor-widget elementor-widget-button\" data-id=\"62344fe\" data-element_type=\"widget\" data-widget_type=\"button.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"elementor-button-wrapper\">\n\t\t\t\t\t<a class=\"elementor-button elementor-button-link elementor-size-sm\" href=\"https:\/\/21stcfs.co.za\/staging\/?page_id=4774\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Get Quote<\/span>\n\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/a>\n\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-d50ac0b e-flex e-con-boxed e-con e-parent\" data-id=\"d50ac0b\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-790cc51 elementor-widget elementor-widget-shortcode\" data-id=\"790cc51\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-6221\"><form id=\"wpforms-form-6221\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"6221\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/staging\/wp-json\/wp\/v2\/pages\/3990?wpforms_form_id=6221\" data-token=\"977fa3deee086808611f9bc4e456bef6\" data-token-time=\"1779474019\"><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-page-indicator circles\" data-indicator=\"circles\" data-indicator-color=\"#857041\" data-scroll=\"1\" role=\"progressbar\" aria-valuenow=\"1\" aria-valuemin=\"1\" aria-valuemax=\"5\" tabindex=\"-1\"><div class=\"wpforms-page-indicator-page active wpforms-page-indicator-page-1\"><span class=\"wpforms-page-indicator-page-number\" style=\"background-color:#857041\">1<\/span><span class=\"wpforms-page-indicator-page-title\">Application Form<\/span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-2\"><span class=\"wpforms-page-indicator-page-number\">2<\/span><span class=\"wpforms-page-indicator-page-title\">Personal Details<\/span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-3\"><span class=\"wpforms-page-indicator-page-number\">3<\/span><span class=\"wpforms-page-indicator-page-title\">Dependants&#039;Details<\/span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-4\"><span class=\"wpforms-page-indicator-page-number\">4<\/span><span class=\"wpforms-page-indicator-page-title\">Active Record and Important Information<\/span><\/div><div class=\"wpforms-page-indicator-page  wpforms-page-indicator-page-5\"><span class=\"wpforms-page-indicator-page-number\">5<\/span><span class=\"wpforms-page-indicator-page-title\">Document Upload<\/span><\/div><\/div><div class=\"wpforms-field-container\"><div class=\"wpforms-page wpforms-page-1 \" data-page=\"1\"><div id=\"wpforms-6221-field_8-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"8\"><\/div><div id=\"wpforms-6221-field_67-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"67\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_67\">Who are you applying for?<\/label><select id=\"wpforms-6221-field_67\" class=\"wpforms-field-medium\" name=\"wpforms[fields][67]\"><option value=\"Myself\" >Myself<\/option><option value=\"Myself and Dependants\" >Myself and Dependants<\/option><option value=\"Dependants Only\" >Dependants Only<\/option><\/select><\/div><div id=\"wpforms-6221-field_66-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"66\"><div class=\"wpforms-clear wpforms-pagebreak-right\"><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"1\" data-formid=\"6221\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-2  \" data-page=\"2\" style=\"display:none;\"><div id=\"wpforms-6221-field_1-container\" class=\"wpforms-field wpforms-field-name no-numbers\" data-field-id=\"1\"><fieldset><legend class=\"wpforms-field-label\">Name &amp; Surname<\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-6221-field_1\" class=\"wpforms-field-name-first\" name=\"wpforms[fields][1][first]\" aria-errormessage=\"wpforms-6221-field_1-error\" ><label for=\"wpforms-6221-field_1\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-6221-field_1-last\" class=\"wpforms-field-name-last\" name=\"wpforms[fields][1][last]\" aria-errormessage=\"wpforms-6221-field_1-last-error\" ><label for=\"wpforms-6221-field_1-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-6221-field_15-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_15\">Policy Benafits<\/label><select id=\"wpforms-6221-field_15\" class=\"wpforms-field-medium\" name=\"wpforms[fields][15]\"><option value=\"Executive Plan\" >Executive Plan<\/option><option value=\"Prestige Plan\" >Prestige Plan<\/option><option value=\"Premier Plan\" >Premier Plan<\/option><option value=\"Family Protector Plan\" >Family Protector Plan<\/option><option value=\"Family Protector Delux Plan\" >Family Protector Delux Plan<\/option><\/select><\/div><div id=\"wpforms-6221-field_65-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"65\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_65\">Nationality<\/label><select id=\"wpforms-6221-field_65\" class=\"wpforms-field-medium\" name=\"wpforms[fields][65]\"><option value=\"South Africa\" >South Africa<\/option><\/select><\/div><div id=\"wpforms-6221-field_63-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"63\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_63\">ID Number<\/label><input type=\"text\" id=\"wpforms-6221-field_63\" class=\"wpforms-field-medium wpforms-limit-characters-enabled\" data-form-id=\"6221\" data-field-id=\"63\" data-text-limit=\"13\" name=\"wpforms[fields][63]\" aria-errormessage=\"wpforms-6221-field_63-error\" maxlength=\"13\" ><\/div><div id=\"wpforms-6221-field_5-container\" class=\"wpforms-field wpforms-field-address\" data-field-id=\"5\"><fieldset><legend class=\"wpforms-field-label\">Address<\/legend><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-6221-field_5\" class=\"wpforms-field-address-address1\" name=\"wpforms[fields][5][address1]\" aria-errormessage=\"wpforms-6221-field_5-error\" ><label for=\"wpforms-6221-field_5\" class=\"wpforms-field-sublabel after\">Address Line 1<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div ><input type=\"text\" id=\"wpforms-6221-field_5-address2\" class=\"wpforms-field-address-address2\" name=\"wpforms[fields][5][address2]\" aria-errormessage=\"wpforms-6221-field_5-address2-error\" ><label for=\"wpforms-6221-field_5-address2\" class=\"wpforms-field-sublabel after\">Address Line 2<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-6221-field_5-city\" class=\"wpforms-field-address-city\" name=\"wpforms[fields][5][city]\" aria-errormessage=\"wpforms-6221-field_5-city-error\" ><label for=\"wpforms-6221-field_5-city\" class=\"wpforms-field-sublabel after\">City<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-6221-field_5-state\" class=\"wpforms-field-address-state\" name=\"wpforms[fields][5][state]\" aria-errormessage=\"wpforms-6221-field_5-state-error\" ><label for=\"wpforms-6221-field_5-state\" class=\"wpforms-field-sublabel after\">State \/ Province \/ Region<\/label><\/div><\/div><div class=\"wpforms-field-row wpforms-field-large\"><div class=\"wpforms-field-row-block wpforms-one-half wpforms-first\"><input type=\"text\" id=\"wpforms-6221-field_5-postal\" class=\"wpforms-field-address-postal\" name=\"wpforms[fields][5][postal]\" aria-errormessage=\"wpforms-6221-field_5-postal-error\" ><label for=\"wpforms-6221-field_5-postal\" class=\"wpforms-field-sublabel after\">Postal Code<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><select id=\"wpforms-6221-field_5-country\" class=\"wpforms-field-address-country\" name=\"wpforms[fields][5][country]\" value=\"ZA\" aria-errormessage=\"wpforms-6221-field_5-country-error\" ><option value=\"AF\" >Afghanistan<\/option><option value=\"AL\" >Albania<\/option><option value=\"DZ\" >Algeria<\/option><option value=\"AS\" >American Samoa<\/option><option value=\"AD\" >Andorra<\/option><option value=\"AO\" >Angola<\/option><option value=\"AI\" >Anguilla<\/option><option value=\"AQ\" >Antarctica<\/option><option value=\"AG\" >Antigua and Barbuda<\/option><option value=\"AR\" >Argentina<\/option><option value=\"AM\" >Armenia<\/option><option value=\"AW\" >Aruba<\/option><option value=\"AU\" >Australia<\/option><option value=\"AT\" >Austria<\/option><option value=\"AZ\" >Azerbaijan<\/option><option value=\"BS\" >Bahamas<\/option><option value=\"BH\" >Bahrain<\/option><option value=\"BD\" >Bangladesh<\/option><option value=\"BB\" >Barbados<\/option><option value=\"BY\" >Belarus<\/option><option value=\"BE\" >Belgium<\/option><option value=\"BZ\" >Belize<\/option><option value=\"BJ\" >Benin<\/option><option value=\"BM\" >Bermuda<\/option><option value=\"BT\" >Bhutan<\/option><option value=\"BO\" >Bolivia (Plurinational State of)<\/option><option value=\"BQ\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"BW\" >Botswana<\/option><option value=\"BV\" >Bouvet Island<\/option><option value=\"BR\" >Brazil<\/option><option value=\"IO\" >British Indian Ocean Territory<\/option><option value=\"BN\" >Brunei Darussalam<\/option><option value=\"BG\" >Bulgaria<\/option><option value=\"BF\" >Burkina Faso<\/option><option value=\"BI\" >Burundi<\/option><option value=\"CV\" >Cabo Verde<\/option><option value=\"KH\" >Cambodia<\/option><option value=\"CM\" >Cameroon<\/option><option value=\"CA\" >Canada<\/option><option value=\"KY\" >Cayman Islands<\/option><option value=\"CF\" >Central African Republic<\/option><option value=\"TD\" >Chad<\/option><option value=\"CL\" >Chile<\/option><option value=\"CN\" >China<\/option><option value=\"CX\" >Christmas Island<\/option><option value=\"CC\" >Cocos (Keeling) Islands<\/option><option value=\"CO\" >Colombia<\/option><option value=\"KM\" >Comoros<\/option><option value=\"CG\" >Congo<\/option><option value=\"CD\" >Congo (Democratic Republic of the)<\/option><option value=\"CK\" >Cook Islands<\/option><option value=\"CR\" >Costa Rica<\/option><option value=\"HR\" >Croatia<\/option><option value=\"CU\" >Cuba<\/option><option value=\"CW\" >Cura\u00e7ao<\/option><option value=\"CY\" >Cyprus<\/option><option value=\"CZ\" >Czech Republic<\/option><option value=\"CI\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"DK\" >Denmark<\/option><option value=\"DJ\" >Djibouti<\/option><option value=\"DM\" >Dominica<\/option><option value=\"DO\" >Dominican Republic<\/option><option value=\"EC\" >Ecuador<\/option><option value=\"EG\" >Egypt<\/option><option value=\"SV\" >El Salvador<\/option><option value=\"GQ\" >Equatorial Guinea<\/option><option value=\"ER\" >Eritrea<\/option><option value=\"EE\" >Estonia<\/option><option value=\"SZ\" >Eswatini (Kingdom of)<\/option><option value=\"ET\" >Ethiopia<\/option><option value=\"FK\" >Falkland Islands (Malvinas)<\/option><option value=\"FO\" >Faroe Islands<\/option><option value=\"FJ\" >Fiji<\/option><option value=\"FI\" >Finland<\/option><option value=\"FR\" >France<\/option><option value=\"GF\" >French Guiana<\/option><option value=\"PF\" >French Polynesia<\/option><option value=\"TF\" >French Southern Territories<\/option><option value=\"GA\" >Gabon<\/option><option value=\"GM\" >Gambia<\/option><option value=\"GE\" >Georgia<\/option><option value=\"DE\" >Germany<\/option><option value=\"GH\" >Ghana<\/option><option value=\"GI\" >Gibraltar<\/option><option value=\"GR\" >Greece<\/option><option value=\"GL\" >Greenland<\/option><option value=\"GD\" >Grenada<\/option><option value=\"GP\" >Guadeloupe<\/option><option value=\"GU\" >Guam<\/option><option value=\"GT\" >Guatemala<\/option><option value=\"GG\" >Guernsey<\/option><option value=\"GN\" >Guinea<\/option><option value=\"GW\" >Guinea-Bissau<\/option><option value=\"GY\" >Guyana<\/option><option value=\"HT\" >Haiti<\/option><option value=\"HM\" >Heard Island and McDonald Islands<\/option><option value=\"HN\" >Honduras<\/option><option value=\"HK\" >Hong Kong<\/option><option value=\"HU\" >Hungary<\/option><option value=\"IS\" >Iceland<\/option><option value=\"IN\" >India<\/option><option value=\"ID\" >Indonesia<\/option><option value=\"IR\" >Iran (Islamic Republic of)<\/option><option value=\"IQ\" >Iraq<\/option><option value=\"IE\" >Ireland (Republic of)<\/option><option value=\"IM\" >Isle of Man<\/option><option value=\"IL\" >Israel<\/option><option value=\"IT\" >Italy<\/option><option value=\"JM\" >Jamaica<\/option><option value=\"JP\" >Japan<\/option><option value=\"JE\" >Jersey<\/option><option value=\"JO\" >Jordan<\/option><option value=\"KZ\" >Kazakhstan<\/option><option value=\"KE\" >Kenya<\/option><option value=\"KI\" >Kiribati<\/option><option value=\"KP\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"KR\" >Korea (Republic of)<\/option><option value=\"XK\" >Kosovo<\/option><option value=\"KW\" >Kuwait<\/option><option value=\"KG\" >Kyrgyzstan<\/option><option value=\"LA\" >Lao People&#039;s Democratic Republic<\/option><option value=\"LV\" >Latvia<\/option><option value=\"LB\" >Lebanon<\/option><option value=\"LS\" >Lesotho<\/option><option value=\"LR\" >Liberia<\/option><option value=\"LY\" >Libya<\/option><option value=\"LI\" >Liechtenstein<\/option><option value=\"LT\" >Lithuania<\/option><option value=\"LU\" >Luxembourg<\/option><option value=\"MO\" >Macao<\/option><option value=\"MG\" >Madagascar<\/option><option value=\"MW\" >Malawi<\/option><option value=\"MY\" >Malaysia<\/option><option value=\"MV\" >Maldives<\/option><option value=\"ML\" >Mali<\/option><option value=\"MT\" >Malta<\/option><option value=\"MH\" >Marshall Islands<\/option><option value=\"MQ\" >Martinique<\/option><option value=\"MR\" >Mauritania<\/option><option value=\"MU\" >Mauritius<\/option><option value=\"YT\" >Mayotte<\/option><option value=\"MX\" >Mexico<\/option><option value=\"FM\" >Micronesia (Federated States of)<\/option><option value=\"MD\" >Moldova (Republic of)<\/option><option value=\"MC\" >Monaco<\/option><option value=\"MN\" >Mongolia<\/option><option value=\"ME\" >Montenegro<\/option><option value=\"MS\" >Montserrat<\/option><option value=\"MA\" >Morocco<\/option><option value=\"MZ\" >Mozambique<\/option><option value=\"MM\" >Myanmar<\/option><option value=\"NA\" >Namibia<\/option><option value=\"NR\" >Nauru<\/option><option value=\"NP\" >Nepal<\/option><option value=\"NL\" >Netherlands<\/option><option value=\"NC\" >New Caledonia<\/option><option value=\"NZ\" >New Zealand<\/option><option value=\"NI\" >Nicaragua<\/option><option value=\"NE\" >Niger<\/option><option value=\"NG\" >Nigeria<\/option><option value=\"NU\" >Niue<\/option><option value=\"NF\" >Norfolk Island<\/option><option value=\"MK\" >North Macedonia (Republic of)<\/option><option value=\"MP\" >Northern Mariana Islands<\/option><option value=\"NO\" >Norway<\/option><option value=\"OM\" >Oman<\/option><option value=\"PK\" >Pakistan<\/option><option value=\"PW\" >Palau<\/option><option value=\"PS\" >Palestine (State of)<\/option><option value=\"PA\" >Panama<\/option><option value=\"PG\" >Papua New Guinea<\/option><option value=\"PY\" >Paraguay<\/option><option value=\"PE\" >Peru<\/option><option value=\"PH\" >Philippines<\/option><option value=\"PN\" >Pitcairn<\/option><option value=\"PL\" >Poland<\/option><option value=\"PT\" >Portugal<\/option><option value=\"PR\" >Puerto Rico<\/option><option value=\"QA\" >Qatar<\/option><option value=\"RO\" >Romania<\/option><option value=\"RU\" >Russian Federation<\/option><option value=\"RW\" >Rwanda<\/option><option value=\"RE\" >R\u00e9union<\/option><option value=\"BL\" >Saint Barth\u00e9lemy<\/option><option value=\"SH\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"LC\" >Saint Lucia<\/option><option value=\"MF\" >Saint Martin (French part)<\/option><option value=\"PM\" >Saint Pierre and Miquelon<\/option><option value=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"WS\" >Samoa<\/option><option value=\"SM\" >San Marino<\/option><option value=\"ST\" >Sao Tome and Principe<\/option><option value=\"SA\" >Saudi Arabia<\/option><option value=\"SN\" >Senegal<\/option><option value=\"RS\" >Serbia<\/option><option value=\"SC\" >Seychelles<\/option><option value=\"SL\" >Sierra Leone<\/option><option value=\"SG\" >Singapore<\/option><option value=\"SX\" >Sint Maarten (Dutch part)<\/option><option value=\"SK\" >Slovakia<\/option><option value=\"SI\" >Slovenia<\/option><option value=\"SB\" >Solomon Islands<\/option><option value=\"SO\" >Somalia<\/option><option value=\"ZA\"  selected='selected'>South Africa<\/option><option value=\"GS\" >South Georgia and the South Sandwich Islands<\/option><option value=\"SS\" >South Sudan<\/option><option value=\"ES\" >Spain<\/option><option value=\"LK\" >Sri Lanka<\/option><option value=\"SD\" >Sudan<\/option><option value=\"SR\" >Suriname<\/option><option value=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"SE\" >Sweden<\/option><option value=\"CH\" >Switzerland<\/option><option value=\"SY\" >Syrian Arab Republic<\/option><option value=\"TW\" >Taiwan, Republic of China<\/option><option value=\"TJ\" >Tajikistan<\/option><option value=\"TZ\" >Tanzania (United Republic of)<\/option><option value=\"TH\" >Thailand<\/option><option value=\"TL\" >Timor-Leste<\/option><option value=\"TG\" >Togo<\/option><option value=\"TK\" >Tokelau<\/option><option value=\"TO\" >Tonga<\/option><option value=\"TT\" >Trinidad and Tobago<\/option><option value=\"TN\" >Tunisia<\/option><option value=\"TM\" >Turkmenistan<\/option><option value=\"TC\" >Turks and Caicos Islands<\/option><option value=\"TV\" >Tuvalu<\/option><option value=\"TR\" >T\u00fcrkiye<\/option><option value=\"UG\" >Uganda<\/option><option value=\"UA\" >Ukraine<\/option><option value=\"AE\" >United Arab Emirates<\/option><option value=\"GB\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"UM\" >United States Minor Outlying Islands<\/option><option value=\"US\" >United States of America<\/option><option value=\"UY\" >Uruguay<\/option><option value=\"UZ\" >Uzbekistan<\/option><option value=\"VU\" >Vanuatu<\/option><option value=\"VA\" >Vatican City State<\/option><option value=\"VE\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"VN\" >Vietnam<\/option><option value=\"VG\" >Virgin Islands (British)<\/option><option value=\"VI\" >Virgin Islands (U.S.)<\/option><option value=\"WF\" >Wallis and Futuna<\/option><option value=\"EH\" >Western Sahara<\/option><option value=\"YE\" >Yemen<\/option><option value=\"ZM\" >Zambia<\/option><option value=\"ZW\" >Zimbabwe<\/option><option value=\"AX\" >\u00c5land Islands<\/option><\/select><label for=\"wpforms-6221-field_5-country\" class=\"wpforms-field-sublabel after\">Country<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-6221-field_6-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_6\">Email<\/label><input type=\"email\" id=\"wpforms-6221-field_6\" class=\"wpforms-field-medium\" name=\"wpforms[fields][6]\" spellcheck=\"false\" aria-errormessage=\"wpforms-6221-field_6-error\" ><\/div><div id=\"wpforms-6221-field_7-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"7\"><div class=\"wpforms-clear wpforms-pagebreak-right\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"2\" data-formid=\"6221\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"2\" data-formid=\"6221\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-3  \" data-page=\"3\" style=\"display:none;\"><div id=\"wpforms-6221-field_90-container\" class=\"wpforms-field wpforms-field-content wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"90\" style=\"display:none;\"><div id=\"wpforms-6221-field_90\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-6221-field_90-error\"><pre>No Dependents. Click Next.<\/pre>\n<h5><\/h5>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-6221-field_48-container\" class=\"wpforms-field wpforms-field-payment-select wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"48\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_48\">Number of Dependants<\/label><select id=\"wpforms-6221-field_48\" class=\"wpforms-payment-price wpforms-field-medium\" name=\"wpforms[fields][48]\"><option value=\"6\" data-amount=\"0.00\" >None<\/option><option value=\"2\" data-amount=\"25.00\" >1<\/option><option value=\"3\" data-amount=\"50.00\" >2<\/option><option value=\"4\" data-amount=\"0.00\" >3<\/option><option value=\"5\" data-amount=\"0.00\" >4<\/option><\/select><\/div><div id=\"wpforms-6221-field_10-container\" class=\"wpforms-field wpforms-field-number-slider wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"10\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_10\">Age Of Main Member<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-6221-field_10\" class=\"wpforms-field-medium\" name=\"wpforms[fields][10]\" value=\"0\" aria-errormessage=\"wpforms-6221-field_10-error\"\t\tmin=\"0\"\n\tmax=\"65\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>0<\/b><\/div>\n<\/div><div id=\"wpforms-6221-field_11-container\" class=\"wpforms-field wpforms-field-name no-numbers wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"11\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Name Of Dependant 1<\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-6221-field_11\" class=\"wpforms-field-name-first\" name=\"wpforms[fields][11][first]\" aria-errormessage=\"wpforms-6221-field_11-error\" aria-describedby=\"wpforms-6221-field_11-description\" ><label for=\"wpforms-6221-field_11\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-6221-field_11-last\" class=\"wpforms-field-name-last\" name=\"wpforms[fields][11][last]\" aria-errormessage=\"wpforms-6221-field_11-last-error\" aria-describedby=\"wpforms-6221-field_11-description\" ><label for=\"wpforms-6221-field_11-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><div id=\"wpforms-6221-field_11-description\" class=\"wpforms-field-description\">Dependant 1<\/div><\/fieldset><\/div><div id=\"wpforms-6221-field_91-container\" class=\"wpforms-field wpforms-field-number-slider wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"91\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_91\">Age Of Dependant 1<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-6221-field_91\" class=\"wpforms-field-medium\" name=\"wpforms[fields][91]\" value=\"0\" aria-errormessage=\"wpforms-6221-field_91-error\"\t\tmin=\"0\"\n\tmax=\"85\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>0<\/b><\/div>\n<\/div><div id=\"wpforms-6221-field_81-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"81\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_81\">Dependant 1 Date Of Birth<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-6221-field_81\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][81][date]\" aria-errormessage=\"wpforms-6221-field_81-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-6221-field_68-container\" class=\"wpforms-field wpforms-field-name no-numbers wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"68\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Name Of Dependant 2 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-6221-field_68\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][68][first]\" aria-errormessage=\"wpforms-6221-field_68-error\" aria-describedby=\"wpforms-6221-field_68-description\" required><label for=\"wpforms-6221-field_68\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-6221-field_68-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][68][last]\" aria-errormessage=\"wpforms-6221-field_68-last-error\" aria-describedby=\"wpforms-6221-field_68-description\" required><label for=\"wpforms-6221-field_68-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><div id=\"wpforms-6221-field_68-description\" class=\"wpforms-field-description\">Dependant 2<\/div><\/fieldset><\/div><div id=\"wpforms-6221-field_75-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"75\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_75\">Relationship To Payer<\/label><select id=\"wpforms-6221-field_75\" class=\"wpforms-field-medium\" name=\"wpforms[fields][75]\"><option value=\"Parent\" >Parent<\/option><option value=\"Grandparent\" >Grandparent<\/option><option value=\"Child\" >Child<\/option><option value=\"Spouse\" >Spouse<\/option><option value=\"Unlce\" >Unlce<\/option><option value=\"Aunt\" >Aunt<\/option><option value=\"Nephew\" >Nephew<\/option><option value=\"Niece\" >Niece<\/option><option value=\"Sibling\" >Sibling<\/option><option value=\"Cousin\" >Cousin<\/option><option value=\"Grandchild\" >Grandchild<\/option><option value=\"Other\" >Other<\/option><\/select><\/div><div id=\"wpforms-6221-field_95-container\" class=\"wpforms-field wpforms-field-number-slider wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"95\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_95\">Age Of Dependant 2<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-6221-field_95\" class=\"wpforms-field-medium\" name=\"wpforms[fields][95]\" value=\"0\" aria-errormessage=\"wpforms-6221-field_95-error\"\t\tmin=\"0\"\n\tmax=\"85\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>0<\/b><\/div>\n<\/div><div id=\"wpforms-6221-field_87-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"87\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_87\">Dependant 2 Date Of Birth<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-6221-field_87\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][87][date]\" aria-errormessage=\"wpforms-6221-field_87-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-6221-field_101-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"101\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_101\">Relationship To Payer D2<\/label><select id=\"wpforms-6221-field_101\" class=\"wpforms-field-medium\" name=\"wpforms[fields][101]\"><option value=\"Parent\" >Parent<\/option><option value=\"Grandparent\" >Grandparent<\/option><option value=\"Child\" >Child<\/option><option value=\"Spouse\" >Spouse<\/option><option value=\"Unlce\" >Unlce<\/option><option value=\"Aunt\" >Aunt<\/option><option value=\"Nephew\" >Nephew<\/option><option value=\"Niece\" >Niece<\/option><option value=\"Sibling\" >Sibling<\/option><option value=\"Cousin\" >Cousin<\/option><option value=\"Grandchild\" >Grandchild<\/option><option value=\"Other\" >Other<\/option><\/select><\/div><div id=\"wpforms-6221-field_69-container\" class=\"wpforms-field wpforms-field-name no-numbers wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"69\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Name Of Dependant 3 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-6221-field_69\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][69][first]\" aria-errormessage=\"wpforms-6221-field_69-error\" aria-describedby=\"wpforms-6221-field_69-description\" required><label for=\"wpforms-6221-field_69\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-6221-field_69-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][69][last]\" aria-errormessage=\"wpforms-6221-field_69-last-error\" aria-describedby=\"wpforms-6221-field_69-description\" required><label for=\"wpforms-6221-field_69-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><div id=\"wpforms-6221-field_69-description\" class=\"wpforms-field-description\">Dependant 3<\/div><\/fieldset><\/div><div id=\"wpforms-6221-field_96-container\" class=\"wpforms-field wpforms-field-number-slider wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"96\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_96\">Age Of Dependant 3<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-6221-field_96\" class=\"wpforms-field-medium\" name=\"wpforms[fields][96]\" value=\"0\" aria-errormessage=\"wpforms-6221-field_96-error\"\t\tmin=\"0\"\n\tmax=\"85\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>0<\/b><\/div>\n<\/div><div id=\"wpforms-6221-field_86-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"86\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_86\">Dependant 3 Date Of Birth<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-6221-field_86\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][86][date]\" aria-errormessage=\"wpforms-6221-field_86-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-6221-field_102-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"102\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_102\">Relationship To Payer D3<\/label><select id=\"wpforms-6221-field_102\" class=\"wpforms-field-medium\" name=\"wpforms[fields][102]\"><option value=\"Parent\" >Parent<\/option><option value=\"Grandparent\" >Grandparent<\/option><option value=\"Child\" >Child<\/option><option value=\"Spouse\" >Spouse<\/option><option value=\"Unlce\" >Unlce<\/option><option value=\"Aunt\" >Aunt<\/option><option value=\"Nephew\" >Nephew<\/option><option value=\"Niece\" >Niece<\/option><option value=\"Sibling\" >Sibling<\/option><option value=\"Cousin\" >Cousin<\/option><option value=\"Grandchild\" >Grandchild<\/option><option value=\"Other\" >Other<\/option><\/select><\/div><div id=\"wpforms-6221-field_70-container\" class=\"wpforms-field wpforms-field-name no-numbers wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"70\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Name Of Dependant 4 <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-6221-field_70\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][70][first]\" aria-errormessage=\"wpforms-6221-field_70-error\" aria-describedby=\"wpforms-6221-field_70-description\" required><label for=\"wpforms-6221-field_70\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-6221-field_70-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][70][last]\" aria-errormessage=\"wpforms-6221-field_70-last-error\" aria-describedby=\"wpforms-6221-field_70-description\" required><label for=\"wpforms-6221-field_70-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><div id=\"wpforms-6221-field_70-description\" class=\"wpforms-field-description\">Dependant 4<\/div><\/fieldset><\/div><div id=\"wpforms-6221-field_100-container\" class=\"wpforms-field wpforms-field-number-slider wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"100\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_100\">Age Of Dependant 4<\/label>\n<input\n\ttype=\"range\"\n\tid=\"wpforms-6221-field_100\" class=\"wpforms-field-medium\" name=\"wpforms[fields][100]\" value=\"0\" aria-errormessage=\"wpforms-6221-field_100-error\"\t\tmin=\"0\"\n\tmax=\"85\"\n\tstep=\"1\">\n\n<div class=\"wpforms-field-number-slider-hint\"\n\tdata-hint=\"Selected Value: {value}\">\n\tSelected Value: <b>0<\/b><\/div>\n<\/div><div id=\"wpforms-6221-field_85-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"85\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_85\">Dependant 4 Date Of Birth<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-6221-field_85\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][85][date]\" aria-errormessage=\"wpforms-6221-field_85-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-6221-field_103-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"103\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_103\">Relationship To Payer D4<\/label><select id=\"wpforms-6221-field_103\" class=\"wpforms-field-medium\" name=\"wpforms[fields][103]\"><option value=\"Parent\" >Parent<\/option><option value=\"Grandparent\" >Grandparent<\/option><option value=\"Child\" >Child<\/option><option value=\"Spouse\" >Spouse<\/option><option value=\"Unlce\" >Unlce<\/option><option value=\"Aunt\" >Aunt<\/option><option value=\"Nephew\" >Nephew<\/option><option value=\"Niece\" >Niece<\/option><option value=\"Sibling\" >Sibling<\/option><option value=\"Cousin\" >Cousin<\/option><option value=\"Grandchild\" >Grandchild<\/option><option value=\"Other\" >Other<\/option><\/select><\/div><div id=\"wpforms-6221-field_76-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"76\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_76\">Please specify other relationship <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6221-field_76\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][76]\" aria-errormessage=\"wpforms-6221-field_76-error\" required><\/div><div id=\"wpforms-6221-field_14-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"14\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_14\">Cover<\/label><select id=\"wpforms-6221-field_14\" class=\"wpforms-field-medium\" name=\"wpforms[fields][14]\"><option value=\"Executive Plan\" >Executive Plan<\/option><option value=\"Prestige Plan\" >Prestige Plan<\/option><option value=\"Premier Plan\" >Premier Plan<\/option><option value=\"Family Protector Plan\" >Family Protector Plan<\/option><option value=\"Family Protector Delux Plan\" >Family Protector Delux Plan<\/option><\/select><\/div><div id=\"wpforms-6221-field_17-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"17\"><div class=\"wpforms-clear wpforms-pagebreak-right\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"3\" data-formid=\"6221\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"3\" data-formid=\"6221\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-4  \" data-page=\"4\" style=\"display:none;\"><div id=\"wpforms-6221-field_18-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"18\"><fieldset><legend class=\"wpforms-field-label\">Is this policy replacing an existing policy?<\/legend><ul id=\"wpforms-6221-field_18\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-6221-field_18_1\" name=\"wpforms[fields][18][]\" value=\"Yes\" aria-errormessage=\"wpforms-6221-field_18_1-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6221-field_18_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-6221-field_18_2\" name=\"wpforms[fields][18][]\" value=\"No\" aria-errormessage=\"wpforms-6221-field_18_2-error\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6221-field_18_2\">No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-6221-field_20-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_20\">Payment Method <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-6221-field_20\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][20]\" required=\"required\"><option value=\"Debit Order\" >Debit Order<\/option><option value=\"Stop Order\" >Stop Order<\/option><option value=\"Cash\" >Cash<\/option><option value=\"EFT\" >EFT<\/option><\/select><\/div><div id=\"wpforms-6221-field_34-container\" class=\"wpforms-field wpforms-field-divider wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"34\" style=\"display:none;\"><h3 id=\"wpforms-6221-field_34\" aria-errormessage=\"wpforms-6221-field_34-error\">Debit Order Form<\/h3><\/div><div id=\"wpforms-6221-field_64-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"64\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_64\">Bank Name<\/label><select id=\"wpforms-6221-field_64\" class=\"wpforms-field-medium\" name=\"wpforms[fields][64]\"><option value=\"ABSA Bank\" >ABSA Bank<\/option><option value=\"First National Bank\" >First National Bank<\/option><option value=\"Nedbank\" >Nedbank<\/option><option value=\"Standard Bank\" >Standard Bank<\/option><option value=\"Capitec\" >Capitec<\/option><option value=\"African Bank\" >African Bank<\/option><option value=\"Discovery Bank\" >Discovery Bank<\/option><option value=\"Tyme Bank\" >Tyme Bank<\/option><option value=\"Investec\" >Investec<\/option><option value=\"Sasfin\" >Sasfin<\/option><\/select><\/div><div id=\"wpforms-6221-field_25-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"25\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_25\">Account Holder<\/label><input type=\"text\" id=\"wpforms-6221-field_25\" class=\"wpforms-field-medium\" name=\"wpforms[fields][25]\" aria-errormessage=\"wpforms-6221-field_25-error\" ><\/div><div id=\"wpforms-6221-field_26-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"26\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_26\">Account Number<\/label><input type=\"text\" id=\"wpforms-6221-field_26\" class=\"wpforms-field-medium\" name=\"wpforms[fields][26]\" aria-errormessage=\"wpforms-6221-field_26-error\" ><\/div><div id=\"wpforms-6221-field_27-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"27\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_27\">Branch Name<\/label><input type=\"text\" id=\"wpforms-6221-field_27\" class=\"wpforms-field-medium\" name=\"wpforms[fields][27]\" aria-errormessage=\"wpforms-6221-field_27-error\" ><\/div><div id=\"wpforms-6221-field_29-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"29\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_29\">Account Type<\/label><select id=\"wpforms-6221-field_29\" class=\"wpforms-field-medium\" name=\"wpforms[fields][29]\"><option value=\"Cheque\" >Cheque<\/option><option value=\"Savings\" >Savings<\/option><option value=\"Transmission\" >Transmission<\/option><\/select><\/div><div id=\"wpforms-6221-field_98-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"98\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_98\">Debit Order Date<\/label><select id=\"wpforms-6221-field_98\" class=\"wpforms-field-medium\" name=\"wpforms[fields][98]\"><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><div id=\"wpforms-6221-field_98-description\" class=\"wpforms-field-description\">Please choose the debit order date.<\/div><\/div><div id=\"wpforms-6221-field_30-container\" class=\"wpforms-field wpforms-field-date-time wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"30\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_30\">Date<\/label><div class=\"wpforms-datepicker-wrap\"><input type=\"text\" id=\"wpforms-6221-field_30\" class=\"wpforms-field-date-time-date wpforms-datepicker wpforms-field-medium\" data-date-format=\"m\/d\/Y\" data-disable-past-dates=\"0\" data-input=\"true\" name=\"wpforms[fields][30][date]\" aria-errormessage=\"wpforms-6221-field_30-error\" ><a title=\"Clear Date\" data-clear class=\"wpforms-datepicker-clear\" style=\"display:none;\"><\/a><\/div><\/div><div id=\"wpforms-6221-field_31-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"31\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_31\">Place<\/label><input type=\"text\" id=\"wpforms-6221-field_31\" class=\"wpforms-field-medium\" name=\"wpforms[fields][31]\" aria-errormessage=\"wpforms-6221-field_31-error\" ><\/div><div id=\"wpforms-6221-field_32-container\" class=\"wpforms-field wpforms-field-signature wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"32\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_32\">Signature<\/label><div class=\"wpforms-signature-wrap wpforms-field-large\"><canvas class=\"wpforms-signature-canvas\" id=\"wpforms-6221-field_32-signature\" data-color=\"#000000\"><\/canvas><button class=\"wpforms-signature-clear\" title=\"Clear Signature\">Clear Signature<\/button><\/div><input type=\"text\" id=\"wpforms-6221-field_32\" class=\"wpforms-signature-input wpforms-screen-reader-element\" name=\"wpforms[fields][32]\" aria-errormessage=\"wpforms-6221-field_32-error\" ><\/div><div id=\"wpforms-6221-field_35-container\" class=\"wpforms-field wpforms-field-divider wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"35\" style=\"display:none;\"><h3 id=\"wpforms-6221-field_35\" aria-errormessage=\"wpforms-6221-field_35-error\">Stop Order Form<\/h3><\/div><div id=\"wpforms-6221-field_36-container\" class=\"wpforms-field wpforms-field-name wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"36\" style=\"display:none;\"><fieldset><legend class=\"wpforms-field-label\">Full Name <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-6221-field_36\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][36][first]\" aria-errormessage=\"wpforms-6221-field_36-error\" required><label for=\"wpforms-6221-field_36\" class=\"wpforms-field-sublabel after\">First<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-6221-field_36-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][36][last]\" aria-errormessage=\"wpforms-6221-field_36-last-error\" required><label for=\"wpforms-6221-field_36-last\" class=\"wpforms-field-sublabel after\">Last<\/label><\/div><\/div><\/fieldset><\/div><div id=\"wpforms-6221-field_37-container\" class=\"wpforms-field wpforms-field-number wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"37\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_37\">ID Number<\/label><input type=\"number\" id=\"wpforms-6221-field_37\" class=\"wpforms-field-medium\" name=\"wpforms[fields][37]\" aria-errormessage=\"wpforms-6221-field_37-error\" ><\/div><div id=\"wpforms-6221-field_38-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"38\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_38\">Employer<\/label><input type=\"text\" id=\"wpforms-6221-field_38\" class=\"wpforms-field-medium\" name=\"wpforms[fields][38]\" aria-errormessage=\"wpforms-6221-field_38-error\" ><\/div><div id=\"wpforms-6221-field_39-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-field-select-style-classic\" data-field-id=\"39\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_39\">Pay Day<\/label><select id=\"wpforms-6221-field_39\" class=\"wpforms-field-medium\" name=\"wpforms[fields][39]\"><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><\/div><div id=\"wpforms-6221-field_40-container\" class=\"wpforms-field wpforms-field-text wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"40\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_40\">Employee\/Salary Number<\/label><input type=\"text\" id=\"wpforms-6221-field_40\" class=\"wpforms-field-medium\" name=\"wpforms[fields][40]\" aria-errormessage=\"wpforms-6221-field_40-error\" ><\/div><div id=\"wpforms-6221-field_47-container\" class=\"wpforms-field wpforms-field-content wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"47\" style=\"display:none;\"><div id=\"wpforms-6221-field_47\" class=\"wpforms-field-medium wpforms-field-row\" aria-errormessage=\"wpforms-6221-field_47-error\"><h4>Banking Details<\/h4>\n<p>Please save these banking details to make your monthly payments.<\/p>\n<p>&nbsp;<\/p>\n<p>Bank : FNB<\/p>\n<p>Name : 21st Century Funeral Services<\/p>\n<p>Account :&nbsp; &nbsp;62572852400<\/p>\n<p>Account Type : Cheque Account<\/p>\n<p>Branch Code : 250655<\/p>\n<div class=\"wpforms-field-content-display-frontend-clear\"><\/div><\/div><\/div><div id=\"wpforms-6221-field_41-container\" class=\"wpforms-field wpforms-field-pagebreak\" data-field-id=\"41\"><div class=\"wpforms-clear wpforms-pagebreak-right\"><button class=\"wpforms-page-button wpforms-page-prev wpforms-disabled\"\n\t\t\t\t\tdata-action=\"prev\" data-page=\"4\" data-formid=\"6221\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Previous<\/button><button class=\"wpforms-page-button wpforms-page-next wpforms-disabled\"\n\t\t\t\t\tdata-action=\"next\" data-page=\"4\" data-formid=\"6221\" aria-disabled=\"true\" aria-describedby=\"wpforms-error-noscript\">Next<\/button><\/div><\/div><\/div><div class=\"wpforms-page wpforms-page-5 last \" data-page=\"5\" style=\"display:none;\"><div id=\"wpforms-6221-field_42-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_42\">Main Member Identity Document <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader\"\n\t\tdata-field-id=\"42\"\n\t\tdata-form-id=\"6221\"\n\t\tdata-input-name=\"wpforms_6221_42\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages,ttf,otf,eot,woff,woff2,svg,redux\"\n\t\tdata-max-size=\"134217728\"\n\t\tdata-max-file-number=\"2\"\n\t\tdata-post-max-size=\"134217728\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg viewBox=\"0 0 1024 1024\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M885.2 446.3l-.2-.8-112.2-285.1c-5-16.1-19.9-27.2-36.8-27.2H281.2c-17 0-32.1 11.3-36.9 27.6L139.4 443l-.3.7-.2.8c-1.3 4.9-1.7 9.9-1 14.8-.1 1.6-.2 3.2-.2 4.8V830a60.9 60.9 0 0 0 60.8 60.8h627.2c33.5 0 60.8-27.3 60.9-60.8V464.1c0-1.3 0-2.6-.1-3.7.4-4.9 0-9.6-1.3-14.1zm-295.8-43l-.3 15.7c-.8 44.9-31.8 75.1-77.1 75.1-22.1 0-41.1-7.1-54.8-20.6S436 441.2 435.6 419l-.3-15.7H229.5L309 210h399.2l81.7 193.3H589.4zm-375 76.8h157.3c24.3 57.1 76 90.8 140.4 90.8 33.7 0 65-9.4 90.3-27.2 22.2-15.6 39.5-37.4 50.7-63.6h156.5V814H214.4V480.1z\"><\/path>\n\t\t<\/svg>\n\t\t<span class=\"modern-title\">Click or drag files to this area to upload.<\/span>\n\n\t\t\t\t\t<span class=\"modern-hint\">You can upload up to 2 files.<\/span>\n\t\t\t<\/div>\n<\/div>\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-6221-field_42\"\n\t\tname=\"wpforms_6221_42\" required\t\tvalue=\"\">\n<\/div><div id=\"wpforms-6221-field_44-container\" class=\"wpforms-field wpforms-field-file-upload\" data-field-id=\"44\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_44\">Dependant Identity Document <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader\"\n\t\tdata-field-id=\"44\"\n\t\tdata-form-id=\"6221\"\n\t\tdata-input-name=\"wpforms_6221_44\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages,ttf,otf,eot,woff,woff2,svg,redux\"\n\t\tdata-max-size=\"134217728\"\n\t\tdata-max-file-number=\"5\"\n\t\tdata-post-max-size=\"134217728\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg viewBox=\"0 0 1024 1024\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M885.2 446.3l-.2-.8-112.2-285.1c-5-16.1-19.9-27.2-36.8-27.2H281.2c-17 0-32.1 11.3-36.9 27.6L139.4 443l-.3.7-.2.8c-1.3 4.9-1.7 9.9-1 14.8-.1 1.6-.2 3.2-.2 4.8V830a60.9 60.9 0 0 0 60.8 60.8h627.2c33.5 0 60.8-27.3 60.9-60.8V464.1c0-1.3 0-2.6-.1-3.7.4-4.9 0-9.6-1.3-14.1zm-295.8-43l-.3 15.7c-.8 44.9-31.8 75.1-77.1 75.1-22.1 0-41.1-7.1-54.8-20.6S436 441.2 435.6 419l-.3-15.7H229.5L309 210h399.2l81.7 193.3H589.4zm-375 76.8h157.3c24.3 57.1 76 90.8 140.4 90.8 33.7 0 65-9.4 90.3-27.2 22.2-15.6 39.5-37.4 50.7-63.6h156.5V814H214.4V480.1z\"><\/path>\n\t\t<\/svg>\n\t\t<span class=\"modern-title\">Click or drag files to this area to upload.<\/span>\n\n\t\t\t\t\t<span class=\"modern-hint\">You can upload up to 5 files.<\/span>\n\t\t\t<\/div>\n<\/div>\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-6221-field_44\"\n\t\tname=\"wpforms_6221_44\" required\t\tvalue=\"\">\n<\/div><div id=\"wpforms-6221-field_43-container\" class=\"wpforms-field wpforms-field-file-upload wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"43\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_43\">Bank Letter Confirmation <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><div\n\t\tclass=\"wpforms-uploader\"\n\t\tdata-field-id=\"43\"\n\t\tdata-form-id=\"6221\"\n\t\tdata-input-name=\"wpforms_6221_43\"\n\t\tdata-extensions=\"jpg,jpeg,jpe,gif,png,bmp,tiff,tif,webp,avif,ico,heic,heif,heics,heifs,asf,asx,wmv,wmx,wm,avi,divx,mov,qt,mpeg,mpg,mpe,mp4,m4v,ogv,webm,mkv,3gp,3gpp,3g2,3gp2,txt,asc,c,cc,h,srt,csv,tsv,ics,rtx,css,vtt,mp3,m4a,m4b,aac,ra,ram,wav,x-wav,ogg,oga,flac,mid,midi,wma,wax,mka,rtf,pdf,class,tar,zip,gz,gzip,rar,7z,psd,xcf,doc,pot,pps,ppt,wri,xla,xls,xlt,xlw,mpp,docx,docm,dotx,dotm,xlsx,xlsm,xlsb,xltx,xltm,xlam,pptx,pptm,ppsx,ppsm,potx,potm,ppam,sldx,sldm,onetoc,onetoc2,onepkg,oxps,xps,odt,odp,ods,odg,odc,odb,odf,wp,wpd,key,numbers,pages,ttf,otf,eot,woff,woff2,svg,redux\"\n\t\tdata-max-size=\"134217728\"\n\t\tdata-max-file-number=\"1\"\n\t\tdata-post-max-size=\"134217728\"\n\t\tdata-max-parallel-uploads=\"4\"\n\t\tdata-parallel-uploads=\"true\"\n\t\tdata-file-chunk-size=\"2097152\">\n\t<div class=\"dz-message\">\n\t\t<svg viewBox=\"0 0 1024 1024\" focusable=\"false\" data-icon=\"inbox\" width=\"50px\" height=\"50px\" fill=\"currentColor\" aria-hidden=\"true\">\n\t\t\t<path d=\"M885.2 446.3l-.2-.8-112.2-285.1c-5-16.1-19.9-27.2-36.8-27.2H281.2c-17 0-32.1 11.3-36.9 27.6L139.4 443l-.3.7-.2.8c-1.3 4.9-1.7 9.9-1 14.8-.1 1.6-.2 3.2-.2 4.8V830a60.9 60.9 0 0 0 60.8 60.8h627.2c33.5 0 60.8-27.3 60.9-60.8V464.1c0-1.3 0-2.6-.1-3.7.4-4.9 0-9.6-1.3-14.1zm-295.8-43l-.3 15.7c-.8 44.9-31.8 75.1-77.1 75.1-22.1 0-41.1-7.1-54.8-20.6S436 441.2 435.6 419l-.3-15.7H229.5L309 210h399.2l81.7 193.3H589.4zm-375 76.8h157.3c24.3 57.1 76 90.8 140.4 90.8 33.7 0 65-9.4 90.3-27.2 22.2-15.6 39.5-37.4 50.7-63.6h156.5V814H214.4V480.1z\"><\/path>\n\t\t<\/svg>\n\t\t<span class=\"modern-title\">Click or drag a file to this area to upload.<\/span>\n\n\t\t\t<\/div>\n<\/div>\n<input\n\t\ttype=\"text\"\n\t\tautocomplete=\"off\"\n\t\treadonly\n\t\tclass=\"dropzone-input\"\n\t\tstyle=\"position:absolute!important;clip:rect(0,0,0,0)!important;height:1px!important;width:1px!important;border:0!important;overflow:hidden!important;padding:0!important;margin:0!important;\"\n\t\tid=\"wpforms-6221-field_43\"\n\t\tname=\"wpforms_6221_43\" required\t\tvalue=\"\">\n<\/div><div id=\"wpforms-6221-field_45-container\" class=\"wpforms-field wpforms-field-file-upload wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"45\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-6221-field_45\">Payslip Not Older Than 3 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