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    {"id":5816,"date":"2026-05-20T11:19:40","date_gmt":"2026-05-20T09:19:40","guid":{"rendered":"https:\/\/insbrok.com\/solicitud-de-la-union-madrilena\/"},"modified":"2026-05-20T11:19:40","modified_gmt":"2026-05-20T09:19:40","slug":"solicitud-de-la-union-madrilena","status":"publish","type":"page","link":"https:\/\/insbrok.com\/es\/solicitud-de-la-union-madrilena\/","title":{"rendered":"Solicitud de la Uni\u00f3n Madrile\u00f1a"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nationality<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_country ginput_container_address gform-grid-row' id='input_80_7' >\n                        <input type='hidden' class='gform_hidden' name='input_7.4' id='input_80_7_4' value=''\/><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_80_7_6_container' >\n                                        <select name='input_7.6' id='input_80_7_6'   aria-required='true'    ><option value='' selected='selected'>- Please select<\/option><option value='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' 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value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos 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value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados 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>Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >Zimbaue<\/option><\/select>\n                                        <label for='input_80_7_6' id='input_80_7_6_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_80_4\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_4'>\n\t\t\t<div class='gchoice gchoice_80_4_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Hombre'  id='choice_80_4_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_4_0' id='label_80_4_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_4_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_4' type='radio' value='Mujer'  id='choice_80_4_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_4_1' id='label_80_4_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_5\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >ID Document<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_5'>\n\t\t\t<div class='gchoice gchoice_80_5_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='Pasaporte'  id='choice_80_5_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_5_0' id='label_80_5_0' class='gform-field-label gform-field-label--type-inline'>Passport<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_5_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='NIE'  id='choice_80_5_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_5_1' id='label_80_5_1' class='gform-field-label gform-field-label--type-inline'>NIE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_5_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_5' type='radio' value='DNI'  id='choice_80_5_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_5_2' id='label_80_5_2' class='gform-field-label gform-field-label--type-inline'>DNI<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_6\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_6'>ID Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_6' id='input_80_6' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_8\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_8'>Email<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_8' id='input_80_8' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_80_9\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_9'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_9' id='input_80_9' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_80_10\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Policyholder&#039;s Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_80_10' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_80_10_1_container' >\n                                        <input type='text' name='input_10.1' id='input_80_10_1' value=''    aria-required='true'    \/>\n                                        <label for='input_80_10_1' id='input_80_10_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_80_10_3_container' >\n                                    <input type='text' name='input_10.3' id='input_80_10_3' value=''    aria-required='true'    \/>\n                                    <label for='input_80_10_3' id='input_80_10_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_80_10_4_container' >\n                                        <input type='text' name='input_10.4' id='input_80_10_4' value=''      aria-required='true'    \/>\n                                        <label for='input_80_10_4' id='input_80_10_4_label' class='gform-field-label gform-field-label--type-sub '>Estado \/ Provincia \/ Regi\u00f3n<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_80_10_5_container' >\n                                    <input type='text' name='input_10.5' id='input_80_10_5' value=''    aria-required='true'    \/>\n                                    <label for='input_80_10_5' id='input_80_10_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ C\u00f3digo Postal<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_80_10_6_container' >\n                                        <select name='input_10.6' id='input_80_10_6'   aria-required='true'    ><option value='' selected='selected'><\/option><option value='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antigua y Barbuda' >Antigua y Barbuda<\/option><option value='Ant\u00e1rtida' >Ant\u00e1rtida<\/option><option value='Arabia Saudita' >Arabia Saudita<\/option><option value='Argelia' >Argelia<\/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='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='Belice' >Belice<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos \u00c1rabes Unidos<\/option><option value='Eritrea' >Eritrea<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estados Unidos' >Estados Unidos<\/option><option value='Estonia' >Estonia<\/option><option value='Esuatini' >Esuatini<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Federaci\u00f3n Rusa' >Federaci\u00f3n Rusa<\/option><option value='Fiji' >Fiji<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Granada' >Granada<\/option><option value='Grecia' >Grecia<\/option><option value='Groenlandia' >Groenlandia<\/option><option value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Islas \u00c5land' >Islas \u00c5land<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jord\u00e1n' >Jord\u00e1n<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='LIbia' >LIbia<\/option><option value='Lesoto' >Lesoto<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituania' >Lituania<\/option><option value='Lituania' >Lituania<\/option><option value='Luxemburgo' >Luxemburgo<\/option><option value='L\u00edbano' >L\u00edbano<\/option><option value='Macau' >Macau<\/option><option value='Macedonia del Norte' >Macedonia del Norte<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malawi' >Malawi<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Martinica' >Martinica<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mayotte' >Mayotte<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldavia' >Moldavia<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noruega' >Noruega<\/option><option value='Nueva Caledonia' >Nueva Caledonia<\/option><option value='Nueva Zelanda' >Nueva Zelanda<\/option><option value='N\u00edger' >N\u00edger<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Paises Bajos' >Paises Bajos<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Estado de' >Palestina, Estado de<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Pap\u00faa Nueva Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polinesia Francesa' >Polinesia Francesa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica Centroafricana' >Rep\u00fablica Centroafricana<\/option><option value='Rep\u00fablica Democr\u00e1tica Popular de Laos' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Rep\u00fablica \u00c1rabe de Siria' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='Reuni\u00f3n' >Reuni\u00f3n<\/option><option value='Ruanda' >Ruanda<\/option><option value='Ruman\u00eda' >Ruman\u00eda<\/option><option value='Sahara Occidental' >Sahara Occidental<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='San Bartolom\u00e9' >San Bartolom\u00e9<\/option><option value='San Crist\u00f3bal y Nieves' >San Crist\u00f3bal y Nieves<\/option><option value='San Marino' >San Marino<\/option><option value='San Mart\u00edn' >San Mart\u00edn<\/option><option value='San Pedro y Miquel\u00f3n' >San Pedro y Miquel\u00f3n<\/option><option value='San Vicente y las Granadinas' >San Vicente y las Granadinas<\/option><option value='Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='Santa Luc\u00eda' >Santa Luc\u00eda<\/option><option value='Santa Sede' >Santa Sede<\/option><option value='Santo Tom\u00e9 y Principe' >Santo Tom\u00e9 y Principe<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >Zimbaue<\/option><\/select>\n                                        <label for='input_80_10_6' id='input_80_10_6_label' class='gform-field-label gform-field-label--type-sub '>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_80_11\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insured persons<\/h3><div class='gsection_description' id='gfield_description_80_11'>How many people will be insured under this policy?<\/div><\/div><div id=\"field_80_12\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_12'>Number of Insured<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_12' id='input_80_12' type='number' step='any' min='1' max='6' value='1' class='small'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_80_12\" \/><div class='gfield_description instruction ' id='gfield_instruction_80_12'>Por favor, escribe un n\u00famero entre <strong>1<\/strong> y <strong>6<\/strong>.<\/div><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_80_13' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_80_2' class='gform_page um-insured-1-page' data-js='page-field-id-13' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_80_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_80_14\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insured 1 \u2014 Details<\/h3><div class='gsection_description' id='gfield_description_80_14'>If the Policyholder is also an insured person, list them as Insured 1.<\/div><\/div><fieldset id=\"field_80_15\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Insured Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_80_15'>\n                            \n                            <span id='input_80_15_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_15.3' id='input_80_15_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_80_15_3' class='gform-field-label gform-field-label--type-sub '>First name(s)<\/label>\n                                                <\/span>\n                            \n                            <span id='input_80_15_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_15.6' id='input_80_15_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_80_15_6' class='gform-field-label gform-field-label--type-sub '>Surname(s)<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_80_16\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_16'>\n\t\t\t<div class='gchoice gchoice_80_16_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Hombre'  id='choice_80_16_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_16_0' id='label_80_16_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_16_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_16' type='radio' value='Mujer'  id='choice_80_16_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_16_1' id='label_80_16_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_17\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half gcldf-field gcldf-field-date gcldf-date-format-dmy gfield_trigger_change gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_17'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_17' id='input_80_17' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_17_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_80_17_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_17' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_80_18\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-half gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nationality<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_country ginput_container_address gform-grid-row' id='input_80_18' >\n                        <input type='hidden' class='gform_hidden' name='input_18.4' id='input_80_18_4' value=''\/><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_80_18_6_container' >\n                                        <select name='input_18.6' id='input_80_18_6'   aria-required='true'    ><option value='' selected='selected'>- Please select<\/option><option value='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antigua y Barbuda' >Antigua y Barbuda<\/option><option value='Ant\u00e1rtida' >Ant\u00e1rtida<\/option><option value='Arabia Saudita' >Arabia Saudita<\/option><option value='Argelia' >Argelia<\/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='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='Belice' >Belice<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos \u00c1rabes Unidos<\/option><option value='Eritrea' >Eritrea<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estados Unidos' >Estados Unidos<\/option><option value='Estonia' >Estonia<\/option><option value='Esuatini' >Esuatini<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Federaci\u00f3n Rusa' >Federaci\u00f3n Rusa<\/option><option value='Fiji' >Fiji<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Granada' >Granada<\/option><option value='Grecia' >Grecia<\/option><option value='Groenlandia' >Groenlandia<\/option><option value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Islas \u00c5land' >Islas \u00c5land<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jord\u00e1n' >Jord\u00e1n<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='LIbia' >LIbia<\/option><option value='Lesoto' >Lesoto<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituania' >Lituania<\/option><option value='Lituania' >Lituania<\/option><option value='Luxemburgo' >Luxemburgo<\/option><option value='L\u00edbano' >L\u00edbano<\/option><option value='Macau' >Macau<\/option><option value='Macedonia del Norte' >Macedonia del Norte<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malawi' >Malawi<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Martinica' >Martinica<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mayotte' >Mayotte<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldavia' >Moldavia<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noruega' >Noruega<\/option><option value='Nueva Caledonia' >Nueva Caledonia<\/option><option value='Nueva Zelanda' >Nueva Zelanda<\/option><option value='N\u00edger' >N\u00edger<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Paises Bajos' >Paises Bajos<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Estado de' >Palestina, Estado de<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Pap\u00faa Nueva Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polinesia Francesa' >Polinesia Francesa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica Centroafricana' >Rep\u00fablica Centroafricana<\/option><option value='Rep\u00fablica Democr\u00e1tica Popular de Laos' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Rep\u00fablica \u00c1rabe de Siria' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='Reuni\u00f3n' >Reuni\u00f3n<\/option><option value='Ruanda' >Ruanda<\/option><option value='Ruman\u00eda' >Ruman\u00eda<\/option><option value='Sahara Occidental' >Sahara Occidental<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='San Bartolom\u00e9' >San Bartolom\u00e9<\/option><option value='San Crist\u00f3bal y Nieves' >San Crist\u00f3bal y Nieves<\/option><option value='San Marino' >San Marino<\/option><option value='San Mart\u00edn' >San Mart\u00edn<\/option><option value='San Pedro y Miquel\u00f3n' >San Pedro y Miquel\u00f3n<\/option><option value='San Vicente y las Granadinas' >San Vicente y las Granadinas<\/option><option value='Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='Santa Luc\u00eda' >Santa Luc\u00eda<\/option><option value='Santa Sede' >Santa Sede<\/option><option value='Santo Tom\u00e9 y Principe' >Santo Tom\u00e9 y Principe<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >Zimbaue<\/option><\/select>\n                                        <label for='input_80_18_6' id='input_80_18_6_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_80_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_19'>Profession<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_80_19' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_80_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >ID Document<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_20'>\n\t\t\t<div class='gchoice gchoice_80_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='Pasaporte'  id='choice_80_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_20_0' id='label_80_20_0' class='gform-field-label gform-field-label--type-inline'>Passport<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='NIE'  id='choice_80_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_20_1' id='label_80_20_1' class='gform-field-label gform-field-label--type-inline'>NIE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_20_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='DNI'  id='choice_80_20_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_20_2' id='label_80_20_2' class='gform-field-label gform-field-label--type-inline'>DNI<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_21\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_21'>ID Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_80_21' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_727\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_727'>Please attach your passport or NIE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_80_727'>Please attach a scan or good quality photo of the document\n<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_727' id='input_80_727' type='file' class='large' aria-describedby=\"gfield_upload_rules_80_727 gfield_description_80_727\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_80_727'>Tipos de archivos aceptados: jpg, jpeg, png, pdf, m\u00e1x. tama\u00f1o del archivo: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_80_727'><\/div> <\/div><\/div><div id=\"field_80_24\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_24'>Height (cm)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_24' id='input_80_24' type='number' step='any' min='40'  value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_80_24\" \/><div class='gfield_description instruction ' id='gfield_instruction_80_24'>Por favor, escribe un n\u00famero mayor o igual a <strong>40<\/strong>.<\/div><\/div><\/div><div id=\"field_80_25\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_25'>Weight (kg)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_25' id='input_80_25' type='number' step='any' min='1'  value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_80_25\" \/><div class='gfield_description instruction ' id='gfield_instruction_80_25'>Por favor, escribe un n\u00famero mayor o igual a <strong>1<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_80_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you previously been insured by Uni\u00f3n Madrile\u00f1a?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_26'>\n\t\t\t<div class='gchoice gchoice_80_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='Yes'  id='choice_80_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_26_0' id='label_80_26_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No'  id='choice_80_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_26_1' id='label_80_26_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_27\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_27'>Previous policy number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_27' id='input_80_27' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_80_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you come from another insurance company?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_28'>\n\t\t\t<div class='gchoice gchoice_80_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Yes'  id='choice_80_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_28_0' id='label_80_28_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='No'  id='choice_80_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_28_1' id='label_80_28_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_29\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_29'>Which company?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_29' id='input_80_29' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_30\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insured 1 \u2014 Confidential Medical Information<\/h3><\/div><fieldset id=\"field_80_31\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you been hospitalised, admitted to a clinic, or had surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_31'>\n\t\t\t<div class='gchoice gchoice_80_31_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='Yes'  id='choice_80_31_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_31_0' id='label_80_31_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_31_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_31' type='radio' value='No'  id='choice_80_31_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_31_1' id='label_80_31_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_32\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_32'>If yes, please detail (including dates)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_80_32' class='textarea large'   maxlength='280'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_80_33\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have any diagnostic test, medical treatment, or surgery scheduled?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_33'>\n\t\t\t<div class='gchoice gchoice_80_33_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='Yes'  id='choice_80_33_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_33_0' id='label_80_33_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_33_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_33' type='radio' value='No'  id='choice_80_33_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_33_1' id='label_80_33_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_34\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_34'>If yes, please detail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_34' id='input_80_34' class='textarea large'   maxlength='230'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_80_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you currently receiving medical treatment or under medical supervision?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_35'>\n\t\t\t<div class='gchoice gchoice_80_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_80_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_35_0' id='label_80_35_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_80_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_35_1' id='label_80_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_36\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_36'>If yes, please detail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_36' id='input_80_36' class='textarea large'   maxlength='300'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_80_37\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If female, are you currently pregnant?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_37'>\n\t\t\t<div class='gchoice gchoice_80_37_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='Yes'  id='choice_80_37_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_37_0' id='label_80_37_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_37_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_37' type='radio' value='No'  id='choice_80_37_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_37_1' id='label_80_37_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_38\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_38'>How many weeks?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_38' id='input_80_38' type='number' step='any' min='0' max='42' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_80_38\" \/><div class='gfield_description instruction ' id='gfield_instruction_80_38'>Por favor, escribe un n\u00famero entre <strong>0<\/strong> y <strong>42<\/strong>.<\/div><\/div><\/div><div id=\"field_80_39\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>Declaration of other illnesses<\/strong><br>Have you suffered, or do you currently suffer, any of the following? Tick all that apply.<\/p><\/div><fieldset id=\"field_80_40\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cancer \/ oncological processes<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_40'><div class='gchoice gchoice_80_40_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_40.1' type='checkbox'  value='Cancer \/ oncological processes'  id='choice_80_40_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_40_1' id='label_80_40_1' class='gform-field-label gform-field-label--type-inline'>Cancer \/ oncological processes<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_41\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Congenital diseases<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_41'><div class='gchoice gchoice_80_41_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_41.1' type='checkbox'  value='Congenital diseases'  id='choice_80_41_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_41_1' id='label_80_41_1' class='gform-field-label gform-field-label--type-inline'>Congenital diseases<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_42\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Demyelinating diseases<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_42'><div class='gchoice gchoice_80_42_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_42.1' type='checkbox'  value='Demyelinating diseases'  id='choice_80_42_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_42_1' id='label_80_42_1' class='gform-field-label gform-field-label--type-inline'>Demyelinating diseases<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_43\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Parkinson&#039;s disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_43'><div class='gchoice gchoice_80_43_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_43.1' type='checkbox'  value='Parkinson&#039;s disease'  id='choice_80_43_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_43_1' id='label_80_43_1' class='gform-field-label gform-field-label--type-inline'>Parkinson's disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_44\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Epilepsy<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_44'><div class='gchoice gchoice_80_44_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_44.1' type='checkbox'  value='Epilepsy'  id='choice_80_44_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_44_1' id='label_80_44_1' class='gform-field-label gform-field-label--type-inline'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_45\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Intramedullary \/ intracranial pathology<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_45'><div class='gchoice gchoice_80_45_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_45.1' type='checkbox'  value='Intramedullary \/ intracranial pathology'  id='choice_80_45_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_45_1' id='label_80_45_1' class='gform-field-label gform-field-label--type-inline'>Intramedullary \/ intracranial pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_46\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Paraplegia \/ hemiplegia \/ tetraplegia<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_46'><div class='gchoice gchoice_80_46_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_46.1' type='checkbox'  value='Paraplegia \/ hemiplegia \/ tetraplegia'  id='choice_80_46_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_46_1' id='label_80_46_1' class='gform-field-label gform-field-label--type-inline'>Paraplegia \/ hemiplegia \/ tetraplegia<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_47\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Arteriosclerosis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_47'><div class='gchoice gchoice_80_47_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_47.1' type='checkbox'  value='Arteriosclerosis'  id='choice_80_47_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_47_1' id='label_80_47_1' class='gform-field-label gform-field-label--type-inline'>Arteriosclerosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_48\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Aortic aneurysm<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_48'><div class='gchoice gchoice_80_48_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_48.1' type='checkbox'  value='Aortic aneurysm'  id='choice_80_48_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_48_1' id='label_80_48_1' class='gform-field-label gform-field-label--type-inline'>Aortic aneurysm<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_49\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ischemic \/ valvular \/ cardiomyopathic heart disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_49'><div class='gchoice gchoice_80_49_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_49.1' type='checkbox'  value='Ischemic \/ valvular \/ cardiomyopathic heart disease'  id='choice_80_49_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_49_1' id='label_80_49_1' class='gform-field-label gform-field-label--type-inline'>Ischemic \/ valvular \/ cardiomyopathic heart disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_50\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Malignant hypertension<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_50'><div class='gchoice gchoice_80_50_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.1' type='checkbox'  value='Malignant hypertension'  id='choice_80_50_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_50_1' id='label_80_50_1' class='gform-field-label gform-field-label--type-inline'>Malignant hypertension<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_51\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Pulmonary fibrosis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_51'><div class='gchoice gchoice_80_51_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_51.1' type='checkbox'  value='Pulmonary fibrosis'  id='choice_80_51_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_51_1' id='label_80_51_1' class='gform-field-label gform-field-label--type-inline'>Pulmonary fibrosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_52\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chronic respiratory failure<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_52'><div class='gchoice gchoice_80_52_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_52.1' type='checkbox'  value='Chronic respiratory failure'  id='choice_80_52_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_52_1' id='label_80_52_1' class='gform-field-label gform-field-label--type-inline'>Chronic respiratory failure<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_53\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cerebrovascular disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_53'><div class='gchoice gchoice_80_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='Cerebrovascular disease'  id='choice_80_53_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_53_1' id='label_80_53_1' class='gform-field-label gform-field-label--type-inline'>Cerebrovascular disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_54\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chronic kidney failure<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_54'><div class='gchoice gchoice_80_54_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.1' type='checkbox'  value='Chronic kidney failure'  id='choice_80_54_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_54_1' id='label_80_54_1' class='gform-field-label gform-field-label--type-inline'>Chronic kidney failure<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_55\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chronic hepatopathy or pancreatitis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_55'><div class='gchoice gchoice_80_55_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_55.1' type='checkbox'  value='Chronic hepatopathy or pancreatitis'  id='choice_80_55_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_55_1' id='label_80_55_1' class='gform-field-label gform-field-label--type-inline'>Chronic hepatopathy or pancreatitis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_56\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Endocrine-metabolic pathology<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_56'><div class='gchoice gchoice_80_56_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.1' type='checkbox'  value='Endocrine-metabolic pathology'  id='choice_80_56_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_56_1' id='label_80_56_1' class='gform-field-label gform-field-label--type-inline'>Endocrine-metabolic pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_57\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ulcerative colitis \/ Crohn&#039;s disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_57'><div class='gchoice gchoice_80_57_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_57.1' type='checkbox'  value='Ulcerative colitis \/ Crohn&#039;s disease'  id='choice_80_57_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_57_1' id='label_80_57_1' class='gform-field-label gform-field-label--type-inline'>Ulcerative colitis \/ Crohn's disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_58\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Endometriosis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_58'><div class='gchoice gchoice_80_58_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_58.1' type='checkbox'  value='Endometriosis'  id='choice_80_58_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_58_1' id='label_80_58_1' class='gform-field-label gform-field-label--type-inline'>Endometriosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_59\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Rheumatoid or psoriatic arthritis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_59'><div class='gchoice gchoice_80_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Rheumatoid or psoriatic arthritis'  id='choice_80_59_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_59_1' id='label_80_59_1' class='gform-field-label gform-field-label--type-inline'>Rheumatoid or psoriatic arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_60\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Muscular dystrophy<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_60'><div class='gchoice gchoice_80_60_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_60.1' type='checkbox'  value='Muscular dystrophy'  id='choice_80_60_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_60_1' id='label_80_60_1' class='gform-field-label gform-field-label--type-inline'>Muscular dystrophy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_61\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Systemic lupus<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_61'><div class='gchoice gchoice_80_61_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.1' type='checkbox'  value='Systemic lupus'  id='choice_80_61_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_61_1' id='label_80_61_1' class='gform-field-label gform-field-label--type-inline'>Systemic lupus<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_62\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Dermatomyositis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_62'><div class='gchoice gchoice_80_62_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.1' type='checkbox'  value='Dermatomyositis'  id='choice_80_62_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_62_1' id='label_80_62_1' class='gform-field-label gform-field-label--type-inline'>Dermatomyositis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_63\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ankylosing spondylitis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_63'><div class='gchoice gchoice_80_63_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_63.1' type='checkbox'  value='Ankylosing spondylitis'  id='choice_80_63_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_63_1' id='label_80_63_1' class='gform-field-label gform-field-label--type-inline'>Ankylosing spondylitis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_64\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Severe haematological disorders<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_64'><div class='gchoice gchoice_80_64_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_64.1' type='checkbox'  value='Severe haematological disorders'  id='choice_80_64_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_64_1' id='label_80_64_1' class='gform-field-label gform-field-label--type-inline'>Severe haematological disorders<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_65\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Osteoarticular surgery with prosthesis or implants<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_65'><div class='gchoice gchoice_80_65_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.1' type='checkbox'  value='Osteoarticular surgery with prosthesis or implants'  id='choice_80_65_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_65_1' id='label_80_65_1' class='gform-field-label gform-field-label--type-inline'>Osteoarticular surgery with prosthesis or implants<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_66\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Degenerative \/ accidental spine, hip, knee, shoulder or foot pathology<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_66'><div class='gchoice gchoice_80_66_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_66.1' type='checkbox'  value='Degenerative \/ accidental spine, hip, knee, shoulder or foot pathology'  id='choice_80_66_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_66_1' id='label_80_66_1' class='gform-field-label gform-field-label--type-inline'>Degenerative \/ accidental spine, hip, knee, shoulder or foot pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_67\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Psychiatric disorders<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_67'><div class='gchoice gchoice_80_67_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_67.1' type='checkbox'  value='Psychiatric disorders'  id='choice_80_67_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_67_1' id='label_80_67_1' class='gform-field-label gform-field-label--type-inline'>Psychiatric disorders<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_68\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Eating disorders<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_68'><div class='gchoice gchoice_80_68_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_68.1' type='checkbox'  value='Eating disorders'  id='choice_80_68_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_68_1' id='label_80_68_1' class='gform-field-label gform-field-label--type-inline'>Eating disorders<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_69\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Transplants<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_69'><div class='gchoice gchoice_80_69_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.1' type='checkbox'  value='Transplants'  id='choice_80_69_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_69_1' id='label_80_69_1' class='gform-field-label gform-field-label--type-inline'>Transplants<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_70\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Allergies \/ Intolerances<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_70'><div class='gchoice gchoice_80_70_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_70.1' type='checkbox'  value='Allergies \/ Intolerances'  id='choice_80_70_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_70_1' id='label_80_70_1' class='gform-field-label gform-field-label--type-inline'>Allergies \/ Intolerances<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_80_71' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_80_71' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_80_3' class='gform_page um-cuest-1-page' data-js='page-field-id-71' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_80_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_80_72\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insured 1 \u2014 Additional Confidential Medical Questionnaire<\/h3><div class='gsection_description' id='gfield_description_80_72'>Complete this questionnaire because you have flagged at least one health issue above. Up to 4 separate problems. For paired organs or limbs, indicate the side.<\/div><\/div><div id=\"field_80_73\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 1<\/h4><\/div><fieldset id=\"field_80_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 1: Current or Past?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_74'>\n\t\t\t<div class='gchoice gchoice_80_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Current'  id='choice_80_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_74_0' id='label_80_74_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Past'  id='choice_80_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_74_1' id='label_80_74_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_75\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_75'>Start date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_75' id='input_80_75' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_75_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_80_75_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_75' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_76\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_76'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_76' id='input_80_76' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_76_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_76_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_76' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_77\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_77'>Describe the problem<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_77' id='input_80_77' class='textarea large'   maxlength='40'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_78\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_78'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_78' id='input_80_78' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_79\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_79'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_79' id='input_80_79' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_80\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_80'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_80' id='input_80_80' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_81\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_81'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_81' id='input_80_81' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_82\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_82'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_82' id='input_80_82' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_83\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_83'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_83' id='input_80_83' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_84\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 2<\/h4><\/div><fieldset id=\"field_80_85\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 2: Current or Past?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_85'>\n\t\t\t<div class='gchoice gchoice_80_85_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='Current'  id='choice_80_85_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_85_0' id='label_80_85_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_85_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_85' type='radio' value='Past'  id='choice_80_85_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_85_1' id='label_80_85_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_86\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_86'>Start date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_86' id='input_80_86' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_86_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_86_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_86' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_87\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_87'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_87' id='input_80_87' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_87_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_87_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_87' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_88\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_88'>Describe the problem<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_88' id='input_80_88' class='textarea large'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_89\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_89'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_89' id='input_80_89' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_90\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_90'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_90' id='input_80_90' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_91\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_91'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_91' id='input_80_91' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_92\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_92'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_92' id='input_80_92' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_93\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_93'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_93' id='input_80_93' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_94\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_94'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_94' id='input_80_94' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_95\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 3<\/h4><\/div><fieldset id=\"field_80_96\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 3: Current or Past?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_96'>\n\t\t\t<div class='gchoice gchoice_80_96_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='Current'  id='choice_80_96_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_96_0' id='label_80_96_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_96_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='Past'  id='choice_80_96_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_96_1' id='label_80_96_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_97\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_97'>Start date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_97' id='input_80_97' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_97_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_97_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_97' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_98\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_98'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_98' id='input_80_98' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_98_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_98_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_98' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_99\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_99'>Describe the problem<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_99' id='input_80_99' class='textarea large'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_100\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_100'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_100' id='input_80_100' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_101\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_101'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_101' id='input_80_101' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_102\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_102'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_102' id='input_80_102' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_103\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_103'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_103' id='input_80_103' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_104\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_104'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_104' id='input_80_104' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_105\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_105'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_105' id='input_80_105' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_106\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 4<\/h4><\/div><fieldset id=\"field_80_107\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 4: Current or Past?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_107'>\n\t\t\t<div class='gchoice gchoice_80_107_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='Current'  id='choice_80_107_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_107_0' id='label_80_107_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_107_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_107' type='radio' value='Past'  id='choice_80_107_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_107_1' id='label_80_107_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_108\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_108'>Start date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_108' id='input_80_108' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_108_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_108_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_108' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_109\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_109'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_109' id='input_80_109' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_109_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_109_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_109' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_110\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_110'>Describe the problem<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_110' id='input_80_110' class='textarea large'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_111\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_111'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_111' id='input_80_111' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_112\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_112'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_112' id='input_80_112' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_113\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_113'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_113' id='input_80_113' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_114\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_114'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_114' id='input_80_114' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_115\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_115'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_115' id='input_80_115' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_116\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_116'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_116' id='input_80_116' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_117\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>7th \u2014 Refractive eye defect<\/h4><\/div><div id=\"field_80_118\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_118'>Specify (myopia, hyperopia, astigmatism, etc.)<\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_80_118' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_120\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_120'>Dioptres left eye<\/label><div class='ginput_container ginput_container_text'><input name='input_120' id='input_80_120' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_119\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_119'>Dioptres right eye<\/label><div class='ginput_container ginput_container_text'><input name='input_119' id='input_80_119' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_705\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Newborn<\/h3><\/div><div id=\"field_80_711\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_711'>Week of gestation at birth<\/label><div class='ginput_container ginput_container_number'><input name='input_711' id='input_80_711' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_80_712\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_712'>Birth weight (kg)<\/label><div class='ginput_container ginput_container_number'><input name='input_712' id='input_80_712' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_80_124\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Type of assistance received or required<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_124'><div class='gchoice gchoice_80_124_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.1' type='checkbox'  value='Incubator'  id='choice_80_124_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_124_1' id='label_80_124_1' class='gform-field-label gform-field-label--type-inline'>Incubator<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_80_124_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.2' type='checkbox'  value='Intermediate care'  id='choice_80_124_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_124_2' id='label_80_124_2' class='gform-field-label gform-field-label--type-inline'>Intermediate care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_80_124_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.3' type='checkbox'  value='ICU'  id='choice_80_124_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_124_3' id='label_80_124_3' class='gform-field-label gform-field-label--type-inline'>ICU<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_80_124_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_124.4' type='checkbox'  value='Paediatric consultations'  id='choice_80_124_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_124_4' id='label_80_124_4' class='gform-field-label gform-field-label--type-inline'>Paediatric consultations<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_125\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_125'>Paediatric specialty<\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_80_125' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_126\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_126'>Specify congenital condition<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_126' id='input_80_126' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_80_127' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_80_127' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_80_4' class='gform_page um-insured-2-page' data-js='page-field-id-127' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_80_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_80_128\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insured 2 \u2014 Details<\/h3><\/div><fieldset id=\"field_80_129\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Insured Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_80_129'>\n                            \n                            <span id='input_80_129_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_129.3' id='input_80_129_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_80_129_3' class='gform-field-label gform-field-label--type-sub '>First name(s)<\/label>\n                                                <\/span>\n                            \n                            <span id='input_80_129_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_129.6' id='input_80_129_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_80_129_6' class='gform-field-label gform-field-label--type-sub '>Surname(s)<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_80_130\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_130'>Relationship with the policyholder<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_130' id='input_80_130' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>- Please select<\/option><option value='Me' >Me<\/option><option value='Spouse' >Spouse<\/option><option value='Son' >Son<\/option><option value='Daughter' >Daughter<\/option><option value='Father' >Father<\/option><option value='Mother' >Mother<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><fieldset id=\"field_80_131\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_131'>\n\t\t\t<div class='gchoice gchoice_80_131_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='Hombre'  id='choice_80_131_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_131_0' id='label_80_131_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_131_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_131' type='radio' value='Mujer'  id='choice_80_131_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_131_1' id='label_80_131_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_132\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gcldf-field gcldf-field-date gcldf-date-format-dmy gfield_trigger_change gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_132'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_132' id='input_80_132' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_132_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_80_132_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_132' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_80_133\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nationality<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_country ginput_container_address gform-grid-row' id='input_80_133' >\n                        <input type='hidden' class='gform_hidden' name='input_133.4' id='input_80_133_4' value=''\/><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_80_133_6_container' >\n                                        <select name='input_133.6' id='input_80_133_6'   aria-required='true'    ><option value='' selected='selected'>- Please select<\/option><option value='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antigua y Barbuda' >Antigua y Barbuda<\/option><option value='Ant\u00e1rtida' >Ant\u00e1rtida<\/option><option value='Arabia Saudita' >Arabia Saudita<\/option><option value='Argelia' >Argelia<\/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='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='Belice' >Belice<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos \u00c1rabes Unidos<\/option><option value='Eritrea' >Eritrea<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estados Unidos' >Estados Unidos<\/option><option value='Estonia' >Estonia<\/option><option value='Esuatini' >Esuatini<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Federaci\u00f3n Rusa' >Federaci\u00f3n Rusa<\/option><option value='Fiji' >Fiji<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Granada' >Granada<\/option><option value='Grecia' >Grecia<\/option><option value='Groenlandia' >Groenlandia<\/option><option value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Islas \u00c5land' >Islas \u00c5land<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jord\u00e1n' >Jord\u00e1n<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='LIbia' >LIbia<\/option><option value='Lesoto' >Lesoto<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituania' >Lituania<\/option><option value='Lituania' >Lituania<\/option><option value='Luxemburgo' >Luxemburgo<\/option><option value='L\u00edbano' >L\u00edbano<\/option><option value='Macau' >Macau<\/option><option value='Macedonia del Norte' >Macedonia del Norte<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malawi' >Malawi<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Martinica' >Martinica<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mayotte' >Mayotte<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldavia' >Moldavia<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noruega' >Noruega<\/option><option value='Nueva Caledonia' >Nueva Caledonia<\/option><option value='Nueva Zelanda' >Nueva Zelanda<\/option><option value='N\u00edger' >N\u00edger<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Paises Bajos' >Paises Bajos<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Estado de' >Palestina, Estado de<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Pap\u00faa Nueva Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polinesia Francesa' >Polinesia Francesa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica Centroafricana' >Rep\u00fablica Centroafricana<\/option><option value='Rep\u00fablica Democr\u00e1tica Popular de Laos' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Rep\u00fablica \u00c1rabe de Siria' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='Reuni\u00f3n' >Reuni\u00f3n<\/option><option value='Ruanda' >Ruanda<\/option><option value='Ruman\u00eda' >Ruman\u00eda<\/option><option value='Sahara Occidental' >Sahara Occidental<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='San Bartolom\u00e9' >San Bartolom\u00e9<\/option><option value='San Crist\u00f3bal y Nieves' >San Crist\u00f3bal y Nieves<\/option><option value='San Marino' >San Marino<\/option><option value='San Mart\u00edn' >San Mart\u00edn<\/option><option value='San Pedro y Miquel\u00f3n' >San Pedro y Miquel\u00f3n<\/option><option value='San Vicente y las Granadinas' >San Vicente y las Granadinas<\/option><option value='Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='Santa Luc\u00eda' >Santa Luc\u00eda<\/option><option value='Santa Sede' >Santa Sede<\/option><option value='Santo Tom\u00e9 y Principe' >Santo Tom\u00e9 y Principe<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >Zimbaue<\/option><\/select>\n                                        <label for='input_80_133_6' id='input_80_133_6_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_80_134\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_134'>Profession<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_134' id='input_80_134' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_80_135\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >ID Document<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_135'>\n\t\t\t<div class='gchoice gchoice_80_135_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_135' type='radio' value='Pasaporte'  id='choice_80_135_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_135_0' id='label_80_135_0' class='gform-field-label gform-field-label--type-inline'>Passport<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_135_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_135' type='radio' value='NIE'  id='choice_80_135_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_135_1' id='label_80_135_1' class='gform-field-label gform-field-label--type-inline'>NIE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_135_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_135' type='radio' value='DNI'  id='choice_80_135_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_135_2' id='label_80_135_2' class='gform-field-label gform-field-label--type-inline'>DNI<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_136\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_136'>ID Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_136' id='input_80_136' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_728\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_728'>Please attach your passport or NIE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_80_728'>Please attach a scan or good quality photo of the document\n<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_728' id='input_80_728' type='file' class='large' aria-describedby=\"gfield_upload_rules_80_728 gfield_description_80_728\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_80_728'>Tipos de archivos aceptados: jpg, jpeg, png, pdf, m\u00e1x. tama\u00f1o del archivo: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_80_728'><\/div> <\/div><\/div><div id=\"field_80_137\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_137'>Height (cm)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_137' id='input_80_137' type='number' step='any' min='40'  value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_80_137\" \/><div class='gfield_description instruction ' id='gfield_instruction_80_137'>Por favor, escribe un n\u00famero mayor o igual a <strong>40<\/strong>.<\/div><\/div><\/div><div id=\"field_80_138\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_138'>Weight (kg)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_138' id='input_80_138' type='number' step='any' min='1'  value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_80_138\" \/><div class='gfield_description instruction ' id='gfield_instruction_80_138'>Por favor, escribe un n\u00famero mayor o igual a <strong>1<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_80_139\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you previously been insured by Uni\u00f3n Madrile\u00f1a?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_139'>\n\t\t\t<div class='gchoice gchoice_80_139_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='Yes'  id='choice_80_139_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_139_0' id='label_80_139_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_139_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_139' type='radio' value='No'  id='choice_80_139_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_139_1' id='label_80_139_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_140\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_140'>Previous policy number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_140' id='input_80_140' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_80_141\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you come from another insurance company?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_141'>\n\t\t\t<div class='gchoice gchoice_80_141_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='Yes'  id='choice_80_141_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_141_0' id='label_80_141_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_141_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_141' type='radio' value='No'  id='choice_80_141_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_141_1' id='label_80_141_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_142\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_142'>Which company?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_142' id='input_80_142' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_143\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insured 2 \u2014 Confidential Medical Information<\/h3><\/div><fieldset id=\"field_80_144\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you been hospitalised, admitted to a clinic, or had surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_144'>\n\t\t\t<div class='gchoice gchoice_80_144_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_144' type='radio' value='Yes'  id='choice_80_144_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_144_0' id='label_80_144_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_144_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_144' type='radio' value='No'  id='choice_80_144_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_144_1' id='label_80_144_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_145\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_145'>If yes, please detail (including dates)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_145' id='input_80_145' class='textarea large'   maxlength='280'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_80_146\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have any diagnostic test, medical treatment, or surgery scheduled?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_146'>\n\t\t\t<div class='gchoice gchoice_80_146_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_146' type='radio' value='Yes'  id='choice_80_146_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_146_0' id='label_80_146_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_146_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_146' type='radio' value='No'  id='choice_80_146_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_146_1' id='label_80_146_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_147\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_147'>If yes, please detail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_147' id='input_80_147' class='textarea large'   maxlength='230'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_80_148\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you currently receiving medical treatment or under medical supervision?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_148'>\n\t\t\t<div class='gchoice gchoice_80_148_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_148' type='radio' value='Yes'  id='choice_80_148_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_148_0' id='label_80_148_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_148_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_148' type='radio' value='No'  id='choice_80_148_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_148_1' id='label_80_148_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_149\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_149'>If yes, please detail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_149' id='input_80_149' class='textarea large'   maxlength='300'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_80_150\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If female, are you currently pregnant?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_150'>\n\t\t\t<div class='gchoice gchoice_80_150_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_150' type='radio' value='Yes'  id='choice_80_150_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_150_0' id='label_80_150_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_150_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_150' type='radio' value='No'  id='choice_80_150_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_150_1' id='label_80_150_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_151\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_151'>How many weeks?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_151' id='input_80_151' type='number' step='any' min='0' max='42' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_80_151\" \/><div class='gfield_description instruction ' id='gfield_instruction_80_151'>Por favor, escribe un n\u00famero entre <strong>0<\/strong> y <strong>42<\/strong>.<\/div><\/div><\/div><div id=\"field_80_152\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>Declaration of other illnesses<\/strong><br>Have you suffered, or do you currently suffer, any of the following? Tick all that apply.<\/p><\/div><fieldset id=\"field_80_153\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cancer \/ oncological processes<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_153'><div class='gchoice gchoice_80_153_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_153.1' type='checkbox'  value='Cancer \/ oncological processes'  id='choice_80_153_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_153_1' id='label_80_153_1' class='gform-field-label gform-field-label--type-inline'>Cancer \/ oncological processes<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_154\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Congenital diseases<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_154'><div class='gchoice gchoice_80_154_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_154.1' type='checkbox'  value='Congenital diseases'  id='choice_80_154_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_154_1' id='label_80_154_1' class='gform-field-label gform-field-label--type-inline'>Congenital diseases<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_155\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Demyelinating diseases<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_155'><div class='gchoice gchoice_80_155_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_155.1' type='checkbox'  value='Demyelinating diseases'  id='choice_80_155_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_155_1' id='label_80_155_1' class='gform-field-label gform-field-label--type-inline'>Demyelinating diseases<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_156\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Parkinson&#039;s disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_156'><div class='gchoice gchoice_80_156_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_156.1' type='checkbox'  value='Parkinson&#039;s disease'  id='choice_80_156_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_156_1' id='label_80_156_1' class='gform-field-label gform-field-label--type-inline'>Parkinson's disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_157\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Epilepsy<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_157'><div class='gchoice gchoice_80_157_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_157.1' type='checkbox'  value='Epilepsy'  id='choice_80_157_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_157_1' id='label_80_157_1' class='gform-field-label gform-field-label--type-inline'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_158\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Intramedullary \/ intracranial pathology<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_158'><div class='gchoice gchoice_80_158_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_158.1' type='checkbox'  value='Intramedullary \/ intracranial pathology'  id='choice_80_158_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_158_1' id='label_80_158_1' class='gform-field-label gform-field-label--type-inline'>Intramedullary \/ intracranial pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_159\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Paraplegia \/ hemiplegia \/ tetraplegia<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_159'><div class='gchoice gchoice_80_159_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_159.1' type='checkbox'  value='Paraplegia \/ hemiplegia \/ tetraplegia'  id='choice_80_159_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_159_1' id='label_80_159_1' class='gform-field-label gform-field-label--type-inline'>Paraplegia \/ hemiplegia \/ tetraplegia<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_160\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Arteriosclerosis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_160'><div class='gchoice gchoice_80_160_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_160.1' type='checkbox'  value='Arteriosclerosis'  id='choice_80_160_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_160_1' id='label_80_160_1' class='gform-field-label gform-field-label--type-inline'>Arteriosclerosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_161\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Aortic aneurysm<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_161'><div class='gchoice gchoice_80_161_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_161.1' type='checkbox'  value='Aortic aneurysm'  id='choice_80_161_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_161_1' id='label_80_161_1' class='gform-field-label gform-field-label--type-inline'>Aortic aneurysm<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_162\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ischemic \/ valvular \/ cardiomyopathic heart disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_162'><div class='gchoice gchoice_80_162_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_162.1' type='checkbox'  value='Ischemic \/ valvular \/ cardiomyopathic heart disease'  id='choice_80_162_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_162_1' id='label_80_162_1' class='gform-field-label gform-field-label--type-inline'>Ischemic \/ valvular \/ cardiomyopathic heart disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_163\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Malignant hypertension<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_163'><div class='gchoice gchoice_80_163_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_163.1' type='checkbox'  value='Malignant hypertension'  id='choice_80_163_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_163_1' id='label_80_163_1' class='gform-field-label gform-field-label--type-inline'>Malignant hypertension<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_164\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Pulmonary fibrosis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_164'><div class='gchoice gchoice_80_164_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_164.1' type='checkbox'  value='Pulmonary fibrosis'  id='choice_80_164_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_164_1' id='label_80_164_1' class='gform-field-label gform-field-label--type-inline'>Pulmonary fibrosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_165\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chronic respiratory failure<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_165'><div class='gchoice gchoice_80_165_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_165.1' type='checkbox'  value='Chronic respiratory failure'  id='choice_80_165_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_165_1' id='label_80_165_1' class='gform-field-label gform-field-label--type-inline'>Chronic respiratory failure<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_166\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cerebrovascular disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_166'><div class='gchoice gchoice_80_166_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_166.1' type='checkbox'  value='Cerebrovascular disease'  id='choice_80_166_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_166_1' id='label_80_166_1' class='gform-field-label gform-field-label--type-inline'>Cerebrovascular disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_167\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chronic kidney failure<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_167'><div class='gchoice gchoice_80_167_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_167.1' type='checkbox'  value='Chronic kidney failure'  id='choice_80_167_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_167_1' id='label_80_167_1' class='gform-field-label gform-field-label--type-inline'>Chronic kidney failure<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_168\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chronic hepatopathy or pancreatitis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_168'><div class='gchoice gchoice_80_168_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_168.1' type='checkbox'  value='Chronic hepatopathy or pancreatitis'  id='choice_80_168_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_168_1' id='label_80_168_1' class='gform-field-label gform-field-label--type-inline'>Chronic hepatopathy or pancreatitis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_169\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Endocrine-metabolic pathology<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_169'><div class='gchoice gchoice_80_169_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_169.1' type='checkbox'  value='Endocrine-metabolic pathology'  id='choice_80_169_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_169_1' id='label_80_169_1' class='gform-field-label gform-field-label--type-inline'>Endocrine-metabolic pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_170\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ulcerative colitis \/ Crohn&#039;s disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_170'><div class='gchoice gchoice_80_170_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_170.1' type='checkbox'  value='Ulcerative colitis \/ Crohn&#039;s disease'  id='choice_80_170_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_170_1' id='label_80_170_1' class='gform-field-label gform-field-label--type-inline'>Ulcerative colitis \/ Crohn's disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_171\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Endometriosis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_171'><div class='gchoice gchoice_80_171_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_171.1' type='checkbox'  value='Endometriosis'  id='choice_80_171_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_171_1' id='label_80_171_1' class='gform-field-label gform-field-label--type-inline'>Endometriosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_172\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Rheumatoid or psoriatic arthritis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_172'><div class='gchoice gchoice_80_172_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_172.1' type='checkbox'  value='Rheumatoid or psoriatic arthritis'  id='choice_80_172_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_172_1' id='label_80_172_1' class='gform-field-label gform-field-label--type-inline'>Rheumatoid or psoriatic arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_173\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Muscular dystrophy<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_173'><div class='gchoice gchoice_80_173_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_173.1' type='checkbox'  value='Muscular dystrophy'  id='choice_80_173_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_173_1' id='label_80_173_1' class='gform-field-label gform-field-label--type-inline'>Muscular dystrophy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_174\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Systemic lupus<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_174'><div class='gchoice gchoice_80_174_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_174.1' type='checkbox'  value='Systemic lupus'  id='choice_80_174_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_174_1' id='label_80_174_1' class='gform-field-label gform-field-label--type-inline'>Systemic lupus<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_175\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Dermatomyositis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_175'><div class='gchoice gchoice_80_175_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_175.1' type='checkbox'  value='Dermatomyositis'  id='choice_80_175_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_175_1' id='label_80_175_1' class='gform-field-label gform-field-label--type-inline'>Dermatomyositis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_176\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ankylosing spondylitis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_176'><div class='gchoice gchoice_80_176_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_176.1' type='checkbox'  value='Ankylosing spondylitis'  id='choice_80_176_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_176_1' id='label_80_176_1' class='gform-field-label gform-field-label--type-inline'>Ankylosing spondylitis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_177\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Severe haematological disorders<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_177'><div class='gchoice gchoice_80_177_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_177.1' type='checkbox'  value='Severe haematological disorders'  id='choice_80_177_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_177_1' id='label_80_177_1' class='gform-field-label gform-field-label--type-inline'>Severe haematological disorders<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_178\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Osteoarticular surgery with prosthesis or implants<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_178'><div class='gchoice gchoice_80_178_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_178.1' type='checkbox'  value='Osteoarticular surgery with prosthesis or implants'  id='choice_80_178_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_178_1' id='label_80_178_1' class='gform-field-label gform-field-label--type-inline'>Osteoarticular surgery with prosthesis or implants<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_179\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Degenerative \/ accidental spine, hip, knee, shoulder or foot pathology<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_179'><div class='gchoice gchoice_80_179_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_179.1' type='checkbox'  value='Degenerative \/ accidental spine, hip, knee, shoulder or foot pathology'  id='choice_80_179_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_179_1' id='label_80_179_1' class='gform-field-label gform-field-label--type-inline'>Degenerative \/ accidental spine, hip, knee, shoulder or foot pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_180\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Psychiatric disorders<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_180'><div class='gchoice gchoice_80_180_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_180.1' type='checkbox'  value='Psychiatric disorders'  id='choice_80_180_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_180_1' id='label_80_180_1' class='gform-field-label gform-field-label--type-inline'>Psychiatric disorders<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_181\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Eating disorders<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_181'><div class='gchoice gchoice_80_181_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_181.1' type='checkbox'  value='Eating disorders'  id='choice_80_181_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_181_1' id='label_80_181_1' class='gform-field-label gform-field-label--type-inline'>Eating disorders<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_182\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Transplants<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_182'><div class='gchoice gchoice_80_182_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_182.1' type='checkbox'  value='Transplants'  id='choice_80_182_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_182_1' id='label_80_182_1' class='gform-field-label gform-field-label--type-inline'>Transplants<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_183\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Allergies \/ Intolerances<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_183'><div class='gchoice gchoice_80_183_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_183.1' type='checkbox'  value='Allergies \/ Intolerances'  id='choice_80_183_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_183_1' id='label_80_183_1' class='gform-field-label gform-field-label--type-inline'>Allergies \/ Intolerances<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_80_184' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_80_184' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_80_5' class='gform_page um-cuest-2-page' data-js='page-field-id-184' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_80_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_80_185\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insured 2 \u2014 Additional Confidential Medical Questionnaire<\/h3><div class='gsection_description' id='gfield_description_80_185'>Complete this questionnaire because you have flagged at least one health issue above. Up to 4 separate problems. For paired organs or limbs, indicate the side.<\/div><\/div><div id=\"field_80_186\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 1<\/h4><\/div><fieldset id=\"field_80_187\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 1: Current or Past?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_187'>\n\t\t\t<div class='gchoice gchoice_80_187_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_187' type='radio' value='Current'  id='choice_80_187_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_187_0' id='label_80_187_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_187_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_187' type='radio' value='Past'  id='choice_80_187_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_187_1' id='label_80_187_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_188\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_188'>Start date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_188' id='input_80_188' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_188_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_80_188_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_188' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_189\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_189'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_189' id='input_80_189' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_189_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_189_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_189' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_190\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_190'>Describe the problem<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_190' id='input_80_190' class='textarea large'   maxlength='40'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_191\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_191'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_191' id='input_80_191' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_192\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_192'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_192' id='input_80_192' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_193\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_193'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_193' id='input_80_193' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_194\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_194'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_194' id='input_80_194' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_195\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_195'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_195' id='input_80_195' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_196\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_196'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_196' id='input_80_196' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_197\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 2<\/h4><\/div><fieldset id=\"field_80_198\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 2: Current or Past?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_198'>\n\t\t\t<div class='gchoice gchoice_80_198_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_198' type='radio' value='Current'  id='choice_80_198_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_198_0' id='label_80_198_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_198_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_198' type='radio' value='Past'  id='choice_80_198_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_198_1' id='label_80_198_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_199\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_199'>Start date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_199' id='input_80_199' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_199_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_199_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_199' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_200\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_200'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_200' id='input_80_200' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_200_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_200_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_200' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_201\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_201'>Describe the problem<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_201' id='input_80_201' class='textarea large'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_202\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_202'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_202' id='input_80_202' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_203\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_203'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_203' id='input_80_203' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_204\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_204'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_204' id='input_80_204' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_205\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_205'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_205' id='input_80_205' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_206\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_206'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_206' id='input_80_206' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_207\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_207'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_207' id='input_80_207' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_208\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 3<\/h4><\/div><fieldset id=\"field_80_209\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 3: Current or Past?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_209'>\n\t\t\t<div class='gchoice gchoice_80_209_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_209' type='radio' value='Current'  id='choice_80_209_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_209_0' id='label_80_209_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_209_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_209' type='radio' value='Past'  id='choice_80_209_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_209_1' id='label_80_209_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_210\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_210'>Start date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_210' id='input_80_210' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_210_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_210_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_210' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_211\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_211'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_211' id='input_80_211' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_211_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_211_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_211' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_212\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_212'>Describe the problem<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_212' id='input_80_212' class='textarea large'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_213\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_213'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_213' id='input_80_213' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_214\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_214'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_214' id='input_80_214' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_215\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_215'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_215' id='input_80_215' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_216\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_216'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_216' id='input_80_216' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_217\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_217'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_217' id='input_80_217' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_218\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_218'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_218' id='input_80_218' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_219\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 4<\/h4><\/div><fieldset id=\"field_80_220\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 4: Current or Past?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_220'>\n\t\t\t<div class='gchoice gchoice_80_220_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_220' type='radio' value='Current'  id='choice_80_220_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_220_0' id='label_80_220_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_220_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_220' type='radio' value='Past'  id='choice_80_220_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_220_1' id='label_80_220_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_221\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_221'>Start date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_221' id='input_80_221' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_221_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_221_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_221' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_222\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_222'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_222' id='input_80_222' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_222_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_222_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_222' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_223\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_223'>Describe the problem<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_223' id='input_80_223' class='textarea large'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_224\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_224'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_224' id='input_80_224' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_225\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_225'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_225' id='input_80_225' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_226\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_226'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_226' id='input_80_226' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_227\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_227'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_227' id='input_80_227' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_228\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_228'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_228' id='input_80_228' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_229\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_229'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_229' id='input_80_229' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_230\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>7th \u2014 Refractive eye defect<\/h4><\/div><div id=\"field_80_231\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_231'>Specify (myopia, hyperopia, astigmatism, etc.)<\/label><div class='ginput_container ginput_container_text'><input name='input_231' id='input_80_231' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_233\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_233'>Dioptres left eye<\/label><div class='ginput_container ginput_container_text'><input name='input_233' id='input_80_233' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_232\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_232'>Dioptres right eye<\/label><div class='ginput_container ginput_container_text'><input name='input_232' id='input_80_232' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_710\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Newborn<\/h3><\/div><div id=\"field_80_718\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_718'>Week of gestation at birth<\/label><div class='ginput_container ginput_container_number'><input name='input_718' id='input_80_718' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_80_713\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_713'>Birth weight (kg)<\/label><div class='ginput_container ginput_container_number'><input name='input_713' id='input_80_713' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_80_237\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Type of assistance received or required<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_237'><div class='gchoice gchoice_80_237_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.1' type='checkbox'  value='Incubator'  id='choice_80_237_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_237_1' id='label_80_237_1' class='gform-field-label gform-field-label--type-inline'>Incubator<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_80_237_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.2' type='checkbox'  value='Intermediate care'  id='choice_80_237_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_237_2' id='label_80_237_2' class='gform-field-label gform-field-label--type-inline'>Intermediate care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_80_237_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.3' type='checkbox'  value='ICU'  id='choice_80_237_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_237_3' id='label_80_237_3' class='gform-field-label gform-field-label--type-inline'>ICU<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_80_237_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_237.4' type='checkbox'  value='Paediatric consultations'  id='choice_80_237_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_237_4' id='label_80_237_4' class='gform-field-label gform-field-label--type-inline'>Paediatric consultations<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_238\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_238'>Paediatric specialty<\/label><div class='ginput_container ginput_container_text'><input name='input_238' id='input_80_238' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_239\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_239'>Specify congenital condition<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_239' id='input_80_239' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_80_240' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_80_240' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_80_6' class='gform_page um-insured-3-page' data-js='page-field-id-240' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_80_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_80_241\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insured 3 \u2014 Details<\/h3><\/div><fieldset id=\"field_80_242\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Insured Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_80_242'>\n                            \n                            <span id='input_80_242_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_242.3' id='input_80_242_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_80_242_3' class='gform-field-label gform-field-label--type-sub '>First name(s)<\/label>\n                                                <\/span>\n                            \n                            <span id='input_80_242_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_242.6' id='input_80_242_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_80_242_6' class='gform-field-label gform-field-label--type-sub '>Surname(s)<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_80_243\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_243'>Relationship with the policyholder<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_243' id='input_80_243' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>- Please select<\/option><option value='Me' >Me<\/option><option value='Spouse' >Spouse<\/option><option value='Son' >Son<\/option><option value='Daughter' >Daughter<\/option><option value='Father' >Father<\/option><option value='Mother' >Mother<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><fieldset id=\"field_80_244\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_244'>\n\t\t\t<div class='gchoice gchoice_80_244_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_244' type='radio' value='Hombre'  id='choice_80_244_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_244_0' id='label_80_244_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_244_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_244' type='radio' value='Mujer'  id='choice_80_244_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_244_1' id='label_80_244_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_245\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gcldf-field gcldf-field-date gcldf-date-format-dmy gfield_trigger_change gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_245'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_245' id='input_80_245' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_245_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_80_245_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_245' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_80_246\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nationality<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_country ginput_container_address gform-grid-row' id='input_80_246' >\n                        <input type='hidden' class='gform_hidden' name='input_246.4' id='input_80_246_4' value=''\/><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_80_246_6_container' >\n                                        <select name='input_246.6' id='input_80_246_6'   aria-required='true'    ><option value='' selected='selected'>- Please select<\/option><option value='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antigua y Barbuda' >Antigua y Barbuda<\/option><option value='Ant\u00e1rtida' >Ant\u00e1rtida<\/option><option value='Arabia Saudita' >Arabia Saudita<\/option><option value='Argelia' >Argelia<\/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='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='Belice' >Belice<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos \u00c1rabes Unidos<\/option><option value='Eritrea' >Eritrea<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estados Unidos' >Estados Unidos<\/option><option value='Estonia' >Estonia<\/option><option value='Esuatini' >Esuatini<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Federaci\u00f3n Rusa' >Federaci\u00f3n Rusa<\/option><option value='Fiji' >Fiji<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Granada' >Granada<\/option><option value='Grecia' >Grecia<\/option><option value='Groenlandia' >Groenlandia<\/option><option value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Islas \u00c5land' >Islas \u00c5land<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jord\u00e1n' >Jord\u00e1n<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='LIbia' >LIbia<\/option><option value='Lesoto' >Lesoto<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituania' >Lituania<\/option><option value='Lituania' >Lituania<\/option><option value='Luxemburgo' >Luxemburgo<\/option><option value='L\u00edbano' >L\u00edbano<\/option><option value='Macau' >Macau<\/option><option value='Macedonia del Norte' >Macedonia del Norte<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malawi' >Malawi<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Martinica' >Martinica<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mayotte' >Mayotte<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldavia' >Moldavia<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noruega' >Noruega<\/option><option value='Nueva Caledonia' >Nueva Caledonia<\/option><option value='Nueva Zelanda' >Nueva Zelanda<\/option><option value='N\u00edger' >N\u00edger<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Paises Bajos' >Paises Bajos<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Estado de' >Palestina, Estado de<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Pap\u00faa Nueva Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polinesia Francesa' >Polinesia Francesa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica Centroafricana' >Rep\u00fablica Centroafricana<\/option><option value='Rep\u00fablica Democr\u00e1tica Popular de Laos' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Rep\u00fablica \u00c1rabe de Siria' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='Reuni\u00f3n' >Reuni\u00f3n<\/option><option value='Ruanda' >Ruanda<\/option><option value='Ruman\u00eda' >Ruman\u00eda<\/option><option value='Sahara Occidental' >Sahara Occidental<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='San Bartolom\u00e9' >San Bartolom\u00e9<\/option><option value='San Crist\u00f3bal y Nieves' >San Crist\u00f3bal y Nieves<\/option><option value='San Marino' >San Marino<\/option><option value='San Mart\u00edn' >San Mart\u00edn<\/option><option value='San Pedro y Miquel\u00f3n' >San Pedro y Miquel\u00f3n<\/option><option value='San Vicente y las Granadinas' >San Vicente y las Granadinas<\/option><option value='Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='Santa Luc\u00eda' >Santa Luc\u00eda<\/option><option value='Santa Sede' >Santa Sede<\/option><option value='Santo Tom\u00e9 y Principe' >Santo Tom\u00e9 y Principe<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >Zimbaue<\/option><\/select>\n                                        <label for='input_80_246_6' id='input_80_246_6_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_80_247\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_247'>Profession<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_247' id='input_80_247' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_80_248\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >ID Document<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_248'>\n\t\t\t<div class='gchoice gchoice_80_248_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_248' type='radio' value='Pasaporte'  id='choice_80_248_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_248_0' id='label_80_248_0' class='gform-field-label gform-field-label--type-inline'>Passport<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_248_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_248' type='radio' value='NIE'  id='choice_80_248_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_248_1' id='label_80_248_1' class='gform-field-label gform-field-label--type-inline'>NIE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_248_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_248' type='radio' value='DNI'  id='choice_80_248_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_248_2' id='label_80_248_2' class='gform-field-label gform-field-label--type-inline'>DNI<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_249\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_249'>ID Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_249' id='input_80_249' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_729\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_729'>Please attach your passport or NIE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_80_729'>Please attach a scan or good quality photo of the document\n<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_729' id='input_80_729' type='file' class='large' aria-describedby=\"gfield_upload_rules_80_729 gfield_description_80_729\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_80_729'>Tipos de archivos aceptados: jpg, jpeg, png, pdf, m\u00e1x. tama\u00f1o del archivo: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_80_729'><\/div> <\/div><\/div><div id=\"field_80_250\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_250'>Height (cm)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_250' id='input_80_250' type='number' step='any' min='40'  value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_80_250\" \/><div class='gfield_description instruction ' id='gfield_instruction_80_250'>Por favor, escribe un n\u00famero mayor o igual a <strong>40<\/strong>.<\/div><\/div><\/div><div id=\"field_80_251\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_251'>Weight (kg)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_251' id='input_80_251' type='number' step='any' min='1'  value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_80_251\" \/><div class='gfield_description instruction ' id='gfield_instruction_80_251'>Por favor, escribe un n\u00famero mayor o igual a <strong>1<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_80_252\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you previously been insured by Uni\u00f3n Madrile\u00f1a?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_252'>\n\t\t\t<div class='gchoice gchoice_80_252_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_252' type='radio' value='Yes'  id='choice_80_252_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_252_0' id='label_80_252_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_252_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_252' type='radio' value='No'  id='choice_80_252_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_252_1' id='label_80_252_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_253\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_253'>Previous policy number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_253' id='input_80_253' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_80_254\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you come from another insurance company?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_254'>\n\t\t\t<div class='gchoice gchoice_80_254_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_254' type='radio' value='Yes'  id='choice_80_254_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_254_0' id='label_80_254_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_254_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_254' type='radio' value='No'  id='choice_80_254_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_254_1' id='label_80_254_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_255\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_255'>Which company?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_255' id='input_80_255' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_256\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insured 3 \u2014 Confidential Medical Information<\/h3><\/div><fieldset id=\"field_80_257\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you been hospitalised, admitted to a clinic, or had surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_257'>\n\t\t\t<div class='gchoice gchoice_80_257_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_257' type='radio' value='Yes'  id='choice_80_257_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_257_0' id='label_80_257_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_257_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_257' type='radio' value='No'  id='choice_80_257_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_257_1' id='label_80_257_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_258\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_258'>If yes, please detail (including dates)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_258' id='input_80_258' class='textarea large'   maxlength='280'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_80_259\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have any diagnostic test, medical treatment, or surgery scheduled?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_259'>\n\t\t\t<div class='gchoice gchoice_80_259_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_259' type='radio' value='Yes'  id='choice_80_259_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_259_0' id='label_80_259_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_259_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_259' type='radio' value='No'  id='choice_80_259_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_259_1' id='label_80_259_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_260\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_260'>If yes, please detail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_260' id='input_80_260' class='textarea large'   maxlength='230'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_80_261\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you currently receiving medical treatment or under medical supervision?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_261'>\n\t\t\t<div class='gchoice gchoice_80_261_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_261' type='radio' value='Yes'  id='choice_80_261_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_261_0' id='label_80_261_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_261_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_261' type='radio' value='No'  id='choice_80_261_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_261_1' id='label_80_261_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_262\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_262'>If yes, please detail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_262' id='input_80_262' class='textarea large'   maxlength='300'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_80_263\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If female, are you currently pregnant?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_263'>\n\t\t\t<div class='gchoice gchoice_80_263_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_263' type='radio' value='Yes'  id='choice_80_263_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_263_0' id='label_80_263_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_263_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_263' type='radio' value='No'  id='choice_80_263_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_263_1' id='label_80_263_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_264\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_264'>How many weeks?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_264' id='input_80_264' type='number' step='any' min='0' max='42' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_80_264\" \/><div class='gfield_description instruction ' id='gfield_instruction_80_264'>Por favor, escribe un n\u00famero entre <strong>0<\/strong> y <strong>42<\/strong>.<\/div><\/div><\/div><div id=\"field_80_265\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>Declaration of other illnesses<\/strong><br>Have you suffered, or do you currently suffer, any of the following? Tick all that apply.<\/p><\/div><fieldset id=\"field_80_266\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cancer \/ oncological processes<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_266'><div class='gchoice gchoice_80_266_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_266.1' type='checkbox'  value='Cancer \/ oncological processes'  id='choice_80_266_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_266_1' id='label_80_266_1' class='gform-field-label gform-field-label--type-inline'>Cancer \/ oncological processes<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_267\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Congenital diseases<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_267'><div class='gchoice gchoice_80_267_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_267.1' type='checkbox'  value='Congenital diseases'  id='choice_80_267_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_267_1' id='label_80_267_1' class='gform-field-label gform-field-label--type-inline'>Congenital diseases<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_268\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Demyelinating diseases<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_268'><div class='gchoice gchoice_80_268_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_268.1' type='checkbox'  value='Demyelinating diseases'  id='choice_80_268_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_268_1' id='label_80_268_1' class='gform-field-label gform-field-label--type-inline'>Demyelinating diseases<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_269\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Parkinson&#039;s disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_269'><div class='gchoice gchoice_80_269_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_269.1' type='checkbox'  value='Parkinson&#039;s disease'  id='choice_80_269_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_269_1' id='label_80_269_1' class='gform-field-label gform-field-label--type-inline'>Parkinson's disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_270\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Epilepsy<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_270'><div class='gchoice gchoice_80_270_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_270.1' type='checkbox'  value='Epilepsy'  id='choice_80_270_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_270_1' id='label_80_270_1' class='gform-field-label gform-field-label--type-inline'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_271\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Intramedullary \/ intracranial pathology<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_271'><div class='gchoice gchoice_80_271_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_271.1' type='checkbox'  value='Intramedullary \/ intracranial pathology'  id='choice_80_271_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_271_1' id='label_80_271_1' class='gform-field-label gform-field-label--type-inline'>Intramedullary \/ intracranial pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_272\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Paraplegia \/ hemiplegia \/ tetraplegia<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_272'><div class='gchoice gchoice_80_272_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_272.1' type='checkbox'  value='Paraplegia \/ hemiplegia \/ tetraplegia'  id='choice_80_272_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_272_1' id='label_80_272_1' class='gform-field-label gform-field-label--type-inline'>Paraplegia \/ hemiplegia \/ tetraplegia<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_273\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Arteriosclerosis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_273'><div class='gchoice gchoice_80_273_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_273.1' type='checkbox'  value='Arteriosclerosis'  id='choice_80_273_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_273_1' id='label_80_273_1' class='gform-field-label gform-field-label--type-inline'>Arteriosclerosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_274\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Aortic aneurysm<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_274'><div class='gchoice gchoice_80_274_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_274.1' type='checkbox'  value='Aortic aneurysm'  id='choice_80_274_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_274_1' id='label_80_274_1' class='gform-field-label gform-field-label--type-inline'>Aortic aneurysm<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_275\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ischemic \/ valvular \/ cardiomyopathic heart disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_275'><div class='gchoice gchoice_80_275_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_275.1' type='checkbox'  value='Ischemic \/ valvular \/ cardiomyopathic heart disease'  id='choice_80_275_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_275_1' id='label_80_275_1' class='gform-field-label gform-field-label--type-inline'>Ischemic \/ valvular \/ cardiomyopathic heart disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_276\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Malignant hypertension<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_276'><div class='gchoice gchoice_80_276_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_276.1' type='checkbox'  value='Malignant hypertension'  id='choice_80_276_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_276_1' id='label_80_276_1' class='gform-field-label gform-field-label--type-inline'>Malignant hypertension<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_277\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Pulmonary fibrosis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_277'><div class='gchoice gchoice_80_277_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_277.1' type='checkbox'  value='Pulmonary fibrosis'  id='choice_80_277_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_277_1' id='label_80_277_1' class='gform-field-label gform-field-label--type-inline'>Pulmonary fibrosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_278\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chronic respiratory failure<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_278'><div class='gchoice gchoice_80_278_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_278.1' type='checkbox'  value='Chronic respiratory failure'  id='choice_80_278_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_278_1' id='label_80_278_1' class='gform-field-label gform-field-label--type-inline'>Chronic respiratory failure<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_279\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cerebrovascular disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_279'><div class='gchoice gchoice_80_279_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_279.1' type='checkbox'  value='Cerebrovascular disease'  id='choice_80_279_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_279_1' id='label_80_279_1' class='gform-field-label gform-field-label--type-inline'>Cerebrovascular disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_280\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chronic kidney failure<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_280'><div class='gchoice gchoice_80_280_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_280.1' type='checkbox'  value='Chronic kidney failure'  id='choice_80_280_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_280_1' id='label_80_280_1' class='gform-field-label gform-field-label--type-inline'>Chronic kidney failure<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_281\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chronic hepatopathy or pancreatitis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_281'><div class='gchoice gchoice_80_281_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_281.1' type='checkbox'  value='Chronic hepatopathy or pancreatitis'  id='choice_80_281_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_281_1' id='label_80_281_1' class='gform-field-label gform-field-label--type-inline'>Chronic hepatopathy or pancreatitis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_282\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Endocrine-metabolic pathology<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_282'><div class='gchoice gchoice_80_282_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_282.1' type='checkbox'  value='Endocrine-metabolic pathology'  id='choice_80_282_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_282_1' id='label_80_282_1' class='gform-field-label gform-field-label--type-inline'>Endocrine-metabolic pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_283\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ulcerative colitis \/ Crohn&#039;s disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_283'><div class='gchoice gchoice_80_283_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_283.1' type='checkbox'  value='Ulcerative colitis \/ Crohn&#039;s disease'  id='choice_80_283_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_283_1' id='label_80_283_1' class='gform-field-label gform-field-label--type-inline'>Ulcerative colitis \/ Crohn's disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_284\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Endometriosis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_284'><div class='gchoice gchoice_80_284_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_284.1' type='checkbox'  value='Endometriosis'  id='choice_80_284_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_284_1' id='label_80_284_1' class='gform-field-label gform-field-label--type-inline'>Endometriosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_285\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Rheumatoid or psoriatic arthritis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_285'><div class='gchoice gchoice_80_285_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_285.1' type='checkbox'  value='Rheumatoid or psoriatic arthritis'  id='choice_80_285_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_285_1' id='label_80_285_1' class='gform-field-label gform-field-label--type-inline'>Rheumatoid or psoriatic arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_286\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Muscular dystrophy<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_286'><div class='gchoice gchoice_80_286_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_286.1' type='checkbox'  value='Muscular dystrophy'  id='choice_80_286_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_286_1' id='label_80_286_1' class='gform-field-label gform-field-label--type-inline'>Muscular dystrophy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_287\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Systemic lupus<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_287'><div class='gchoice gchoice_80_287_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_287.1' type='checkbox'  value='Systemic lupus'  id='choice_80_287_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_287_1' id='label_80_287_1' class='gform-field-label gform-field-label--type-inline'>Systemic lupus<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_288\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Dermatomyositis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_288'><div class='gchoice gchoice_80_288_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_288.1' type='checkbox'  value='Dermatomyositis'  id='choice_80_288_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_288_1' id='label_80_288_1' class='gform-field-label gform-field-label--type-inline'>Dermatomyositis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_289\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ankylosing spondylitis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_289'><div class='gchoice gchoice_80_289_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_289.1' type='checkbox'  value='Ankylosing spondylitis'  id='choice_80_289_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_289_1' id='label_80_289_1' class='gform-field-label gform-field-label--type-inline'>Ankylosing spondylitis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_290\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Severe haematological disorders<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_290'><div class='gchoice gchoice_80_290_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_290.1' type='checkbox'  value='Severe haematological disorders'  id='choice_80_290_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_290_1' id='label_80_290_1' class='gform-field-label gform-field-label--type-inline'>Severe haematological disorders<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_291\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Osteoarticular surgery with prosthesis or implants<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_291'><div class='gchoice gchoice_80_291_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_291.1' type='checkbox'  value='Osteoarticular surgery with prosthesis or implants'  id='choice_80_291_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_291_1' id='label_80_291_1' class='gform-field-label gform-field-label--type-inline'>Osteoarticular surgery with prosthesis or implants<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_292\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Degenerative \/ accidental spine, hip, knee, shoulder or foot pathology<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_292'><div class='gchoice gchoice_80_292_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_292.1' type='checkbox'  value='Degenerative \/ accidental spine, hip, knee, shoulder or foot pathology'  id='choice_80_292_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_292_1' id='label_80_292_1' class='gform-field-label gform-field-label--type-inline'>Degenerative \/ accidental spine, hip, knee, shoulder or foot pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_293\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Psychiatric disorders<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_293'><div class='gchoice gchoice_80_293_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_293.1' type='checkbox'  value='Psychiatric disorders'  id='choice_80_293_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_293_1' id='label_80_293_1' class='gform-field-label gform-field-label--type-inline'>Psychiatric disorders<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_294\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Eating disorders<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_294'><div class='gchoice gchoice_80_294_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_294.1' type='checkbox'  value='Eating disorders'  id='choice_80_294_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_294_1' id='label_80_294_1' class='gform-field-label gform-field-label--type-inline'>Eating disorders<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_295\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Transplants<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_295'><div class='gchoice gchoice_80_295_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_295.1' type='checkbox'  value='Transplants'  id='choice_80_295_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_295_1' id='label_80_295_1' class='gform-field-label gform-field-label--type-inline'>Transplants<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_296\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Allergies \/ Intolerances<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_296'><div class='gchoice gchoice_80_296_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_296.1' type='checkbox'  value='Allergies \/ Intolerances'  id='choice_80_296_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_296_1' id='label_80_296_1' class='gform-field-label gform-field-label--type-inline'>Allergies \/ Intolerances<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_80_297' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_80_297' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_80_7' class='gform_page um-cuest-3-page' data-js='page-field-id-297' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_80_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_80_298\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insured 3 \u2014 Additional Confidential Medical Questionnaire<\/h3><div class='gsection_description' id='gfield_description_80_298'>Complete this questionnaire because you have flagged at least one health issue above. Up to 4 separate problems. For paired organs or limbs, indicate the side.<\/div><\/div><div id=\"field_80_299\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 1<\/h4><\/div><fieldset id=\"field_80_300\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 1: Current or Past?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_300'>\n\t\t\t<div class='gchoice gchoice_80_300_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_300' type='radio' value='Current'  id='choice_80_300_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_300_0' id='label_80_300_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_300_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_300' type='radio' value='Past'  id='choice_80_300_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_300_1' id='label_80_300_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_301\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_301'>Start date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_301' id='input_80_301' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_301_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_80_301_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_301' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_302\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_302'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_302' id='input_80_302' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_302_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_302_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_302' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_303\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_303'>Describe the problem<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_303' id='input_80_303' class='textarea large'   maxlength='40'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_304\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_304'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_304' id='input_80_304' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_305\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_305'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_305' id='input_80_305' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_306\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_306'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_306' id='input_80_306' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_307\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_307'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_307' id='input_80_307' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_308\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_308'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_308' id='input_80_308' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_309\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_309'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_309' id='input_80_309' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_310\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 2<\/h4><\/div><fieldset id=\"field_80_311\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 2: Current or Past?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_311'>\n\t\t\t<div class='gchoice gchoice_80_311_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_311' type='radio' value='Current'  id='choice_80_311_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_311_0' id='label_80_311_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_311_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_311' type='radio' value='Past'  id='choice_80_311_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_311_1' id='label_80_311_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_312\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_312'>Start date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_312' id='input_80_312' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_312_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_312_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_312' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_313\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_313'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_313' id='input_80_313' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_313_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_313_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_313' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_314\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_314'>Describe the problem<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_314' id='input_80_314' class='textarea large'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_315\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_315'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_315' id='input_80_315' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_316\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_316'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_316' id='input_80_316' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_317\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_317'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_317' id='input_80_317' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_318\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_318'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_318' id='input_80_318' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_319\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_319'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_319' id='input_80_319' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_320\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_320'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_320' id='input_80_320' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_321\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 3<\/h4><\/div><fieldset id=\"field_80_322\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 3: Current or Past?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_322'>\n\t\t\t<div class='gchoice gchoice_80_322_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_322' type='radio' value='Current'  id='choice_80_322_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_322_0' id='label_80_322_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_322_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_322' type='radio' value='Past'  id='choice_80_322_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_322_1' id='label_80_322_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_323\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_323'>Start date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_323' id='input_80_323' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_323_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_323_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_323' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_324\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_324'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_324' id='input_80_324' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_324_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_324_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_324' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_325\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_325'>Describe the problem<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_325' id='input_80_325' class='textarea large'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_326\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_326'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_326' id='input_80_326' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_327\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_327'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_327' id='input_80_327' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_328\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_328'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_328' id='input_80_328' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_329\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_329'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_329' id='input_80_329' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_330\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_330'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_330' id='input_80_330' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_331\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_331'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_331' id='input_80_331' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_332\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 4<\/h4><\/div><fieldset id=\"field_80_333\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 4: Current or Past?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_333'>\n\t\t\t<div class='gchoice gchoice_80_333_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_333' type='radio' value='Current'  id='choice_80_333_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_333_0' id='label_80_333_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_333_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_333' type='radio' value='Past'  id='choice_80_333_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_333_1' id='label_80_333_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_334\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_334'>Start date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_334' id='input_80_334' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_334_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_334_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_334' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_335\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_335'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_335' id='input_80_335' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_335_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_335_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_335' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_336\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_336'>Describe the problem<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_336' id='input_80_336' class='textarea large'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_337\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_337'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_337' id='input_80_337' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_338\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_338'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_338' id='input_80_338' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_339\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_339'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_339' id='input_80_339' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_340\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_340'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_340' id='input_80_340' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_341\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_341'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_341' id='input_80_341' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_342\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_342'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_342' id='input_80_342' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_343\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>7th \u2014 Refractive eye defect<\/h4><\/div><div id=\"field_80_344\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_344'>Specify (myopia, hyperopia, astigmatism, etc.)<\/label><div class='ginput_container ginput_container_text'><input name='input_344' id='input_80_344' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_346\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_346'>Dioptres left eye<\/label><div class='ginput_container ginput_container_text'><input name='input_346' id='input_80_346' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_345\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_345'>Dioptres right eye<\/label><div class='ginput_container ginput_container_text'><input name='input_345' id='input_80_345' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_709\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Newborn<\/h3><\/div><div id=\"field_80_719\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_719'>Week of gestation at birth<\/label><div class='ginput_container ginput_container_number'><input name='input_719' id='input_80_719' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_80_714\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_714'>Birth weight (kg)<\/label><div class='ginput_container ginput_container_number'><input name='input_714' id='input_80_714' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_80_350\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Type of assistance received or required<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_350'><div class='gchoice gchoice_80_350_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_350.1' type='checkbox'  value='Incubator'  id='choice_80_350_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_350_1' id='label_80_350_1' class='gform-field-label gform-field-label--type-inline'>Incubator<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_80_350_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_350.2' type='checkbox'  value='Intermediate care'  id='choice_80_350_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_350_2' id='label_80_350_2' class='gform-field-label gform-field-label--type-inline'>Intermediate care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_80_350_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_350.3' type='checkbox'  value='ICU'  id='choice_80_350_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_350_3' id='label_80_350_3' class='gform-field-label gform-field-label--type-inline'>ICU<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_80_350_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_350.4' type='checkbox'  value='Paediatric consultations'  id='choice_80_350_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_350_4' id='label_80_350_4' class='gform-field-label gform-field-label--type-inline'>Paediatric consultations<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_351\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_351'>Paediatric specialty<\/label><div class='ginput_container ginput_container_text'><input name='input_351' id='input_80_351' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_352\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_352'>Specify congenital condition<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_352' id='input_80_352' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_80_353' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_80_353' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_80_8' class='gform_page um-insured-4-page' data-js='page-field-id-353' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_80_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_80_354\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insured 4 \u2014 Details<\/h3><\/div><fieldset id=\"field_80_355\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Insured Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_80_355'>\n                            \n                            <span id='input_80_355_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_355.3' id='input_80_355_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_80_355_3' class='gform-field-label gform-field-label--type-sub '>First name(s)<\/label>\n                                                <\/span>\n                            \n                            <span id='input_80_355_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_355.6' id='input_80_355_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_80_355_6' class='gform-field-label gform-field-label--type-sub '>Surname(s)<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_80_356\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_356'>Relationship with the policyholder<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_356' id='input_80_356' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>- Please select<\/option><option value='Me' >Me<\/option><option value='Spouse' >Spouse<\/option><option value='Son' >Son<\/option><option value='Daughter' >Daughter<\/option><option value='Father' >Father<\/option><option value='Mother' >Mother<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><fieldset id=\"field_80_357\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_357'>\n\t\t\t<div class='gchoice gchoice_80_357_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_357' type='radio' value='Hombre'  id='choice_80_357_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_357_0' id='label_80_357_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_357_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_357' type='radio' value='Mujer'  id='choice_80_357_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_357_1' id='label_80_357_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_358\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gcldf-field gcldf-field-date gcldf-date-format-dmy gfield_trigger_change gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_358'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_358' id='input_80_358' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_358_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_80_358_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_358' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_80_359\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nationality<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_country ginput_container_address gform-grid-row' id='input_80_359' >\n                        <input type='hidden' class='gform_hidden' name='input_359.4' id='input_80_359_4' value=''\/><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_80_359_6_container' >\n                                        <select name='input_359.6' id='input_80_359_6'   aria-required='true'    ><option value='' selected='selected'>- Please select<\/option><option value='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antigua y Barbuda' >Antigua y Barbuda<\/option><option value='Ant\u00e1rtida' >Ant\u00e1rtida<\/option><option value='Arabia Saudita' >Arabia Saudita<\/option><option value='Argelia' >Argelia<\/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='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='Belice' >Belice<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos \u00c1rabes Unidos<\/option><option value='Eritrea' >Eritrea<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estados Unidos' >Estados Unidos<\/option><option value='Estonia' >Estonia<\/option><option value='Esuatini' >Esuatini<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Federaci\u00f3n Rusa' >Federaci\u00f3n Rusa<\/option><option value='Fiji' >Fiji<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Granada' >Granada<\/option><option value='Grecia' >Grecia<\/option><option value='Groenlandia' >Groenlandia<\/option><option value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Islas \u00c5land' >Islas \u00c5land<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jord\u00e1n' >Jord\u00e1n<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='LIbia' >LIbia<\/option><option value='Lesoto' >Lesoto<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituania' >Lituania<\/option><option value='Lituania' >Lituania<\/option><option value='Luxemburgo' >Luxemburgo<\/option><option value='L\u00edbano' >L\u00edbano<\/option><option value='Macau' >Macau<\/option><option value='Macedonia del Norte' >Macedonia del Norte<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malawi' >Malawi<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Martinica' >Martinica<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mayotte' >Mayotte<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldavia' >Moldavia<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noruega' >Noruega<\/option><option value='Nueva Caledonia' >Nueva Caledonia<\/option><option value='Nueva Zelanda' >Nueva Zelanda<\/option><option value='N\u00edger' >N\u00edger<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Paises Bajos' >Paises Bajos<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Estado de' >Palestina, Estado de<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Pap\u00faa Nueva Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polinesia Francesa' >Polinesia Francesa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica Centroafricana' >Rep\u00fablica Centroafricana<\/option><option value='Rep\u00fablica Democr\u00e1tica Popular de Laos' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Rep\u00fablica \u00c1rabe de Siria' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='Reuni\u00f3n' >Reuni\u00f3n<\/option><option value='Ruanda' >Ruanda<\/option><option value='Ruman\u00eda' >Ruman\u00eda<\/option><option value='Sahara Occidental' >Sahara Occidental<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='San Bartolom\u00e9' >San Bartolom\u00e9<\/option><option value='San Crist\u00f3bal y Nieves' >San Crist\u00f3bal y Nieves<\/option><option value='San Marino' >San Marino<\/option><option value='San Mart\u00edn' >San Mart\u00edn<\/option><option value='San Pedro y Miquel\u00f3n' >San Pedro y Miquel\u00f3n<\/option><option value='San Vicente y las Granadinas' >San Vicente y las Granadinas<\/option><option value='Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='Santa Luc\u00eda' >Santa Luc\u00eda<\/option><option value='Santa Sede' >Santa Sede<\/option><option value='Santo Tom\u00e9 y Principe' >Santo Tom\u00e9 y Principe<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >Zimbaue<\/option><\/select>\n                                        <label for='input_80_359_6' id='input_80_359_6_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_80_360\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_360'>Profession<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_360' id='input_80_360' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_80_361\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >ID Document<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_361'>\n\t\t\t<div class='gchoice gchoice_80_361_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_361' type='radio' value='Pasaporte'  id='choice_80_361_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_361_0' id='label_80_361_0' class='gform-field-label gform-field-label--type-inline'>Passport<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_361_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_361' type='radio' value='NIE'  id='choice_80_361_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_361_1' id='label_80_361_1' class='gform-field-label gform-field-label--type-inline'>NIE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_361_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_361' type='radio' value='DNI'  id='choice_80_361_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_361_2' id='label_80_361_2' class='gform-field-label gform-field-label--type-inline'>DNI<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_362\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_362'>ID Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_362' id='input_80_362' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_730\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_730'>Please attach your passport or NIE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_80_730'>Please attach a scan or good quality photo of the document\n<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_730' id='input_80_730' type='file' class='large' aria-describedby=\"gfield_upload_rules_80_730 gfield_description_80_730\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_80_730'>Tipos de archivos aceptados: jpg, jpeg, png, pdf, m\u00e1x. tama\u00f1o del archivo: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_80_730'><\/div> <\/div><\/div><div id=\"field_80_363\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_363'>Height (cm)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_363' id='input_80_363' type='number' step='any' min='40'  value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_80_363\" \/><div class='gfield_description instruction ' id='gfield_instruction_80_363'>Por favor, escribe un n\u00famero mayor o igual a <strong>40<\/strong>.<\/div><\/div><\/div><div id=\"field_80_364\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_364'>Weight (kg)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_364' id='input_80_364' type='number' step='any' min='1'  value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_80_364\" \/><div class='gfield_description instruction ' id='gfield_instruction_80_364'>Por favor, escribe un n\u00famero mayor o igual a <strong>1<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_80_365\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you previously been insured by Uni\u00f3n Madrile\u00f1a?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_365'>\n\t\t\t<div class='gchoice gchoice_80_365_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_365' type='radio' value='Yes'  id='choice_80_365_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_365_0' id='label_80_365_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_365_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_365' type='radio' value='No'  id='choice_80_365_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_365_1' id='label_80_365_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_366\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_366'>Previous policy number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_366' id='input_80_366' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_80_367\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you come from another insurance company?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_367'>\n\t\t\t<div class='gchoice gchoice_80_367_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_367' type='radio' value='Yes'  id='choice_80_367_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_367_0' id='label_80_367_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_367_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_367' type='radio' value='No'  id='choice_80_367_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_367_1' id='label_80_367_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_368\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_368'>Which company?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_368' id='input_80_368' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_369\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insured 4 \u2014 Confidential Medical Information<\/h3><\/div><fieldset id=\"field_80_370\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you been hospitalised, admitted to a clinic, or had surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_370'>\n\t\t\t<div class='gchoice gchoice_80_370_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_370' type='radio' value='Yes'  id='choice_80_370_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_370_0' id='label_80_370_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_370_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_370' type='radio' value='No'  id='choice_80_370_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_370_1' id='label_80_370_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_371\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_371'>If yes, please detail (including dates)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_371' id='input_80_371' class='textarea large'   maxlength='280'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_80_372\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have any diagnostic test, medical treatment, or surgery scheduled?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_372'>\n\t\t\t<div class='gchoice gchoice_80_372_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_372' type='radio' value='Yes'  id='choice_80_372_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_372_0' id='label_80_372_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_372_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_372' type='radio' value='No'  id='choice_80_372_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_372_1' id='label_80_372_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_373\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_373'>If yes, please detail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_373' id='input_80_373' class='textarea large'   maxlength='230'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_80_374\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you currently receiving medical treatment or under medical supervision?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_374'>\n\t\t\t<div class='gchoice gchoice_80_374_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_374' type='radio' value='Yes'  id='choice_80_374_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_374_0' id='label_80_374_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_374_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_374' type='radio' value='No'  id='choice_80_374_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_374_1' id='label_80_374_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_375\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_375'>If yes, please detail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_375' id='input_80_375' class='textarea large'   maxlength='300'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_80_376\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If female, are you currently pregnant?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_376'>\n\t\t\t<div class='gchoice gchoice_80_376_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_376' type='radio' value='Yes'  id='choice_80_376_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_376_0' id='label_80_376_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_376_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_376' type='radio' value='No'  id='choice_80_376_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_376_1' id='label_80_376_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_377\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_377'>How many weeks?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_377' id='input_80_377' type='number' step='any' min='0' max='42' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_80_377\" \/><div class='gfield_description instruction ' id='gfield_instruction_80_377'>Por favor, escribe un n\u00famero entre <strong>0<\/strong> y <strong>42<\/strong>.<\/div><\/div><\/div><div id=\"field_80_378\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>Declaration of other illnesses<\/strong><br>Have you suffered, or do you currently suffer, any of the following? Tick all that apply.<\/p><\/div><fieldset id=\"field_80_379\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cancer \/ oncological processes<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_379'><div class='gchoice gchoice_80_379_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_379.1' type='checkbox'  value='Cancer \/ oncological processes'  id='choice_80_379_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_379_1' id='label_80_379_1' class='gform-field-label gform-field-label--type-inline'>Cancer \/ oncological processes<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_380\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Congenital diseases<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_380'><div class='gchoice gchoice_80_380_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_380.1' type='checkbox'  value='Congenital diseases'  id='choice_80_380_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_380_1' id='label_80_380_1' class='gform-field-label gform-field-label--type-inline'>Congenital diseases<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_381\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Demyelinating diseases<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_381'><div class='gchoice gchoice_80_381_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_381.1' type='checkbox'  value='Demyelinating diseases'  id='choice_80_381_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_381_1' id='label_80_381_1' class='gform-field-label gform-field-label--type-inline'>Demyelinating diseases<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_382\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Parkinson&#039;s disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_382'><div class='gchoice gchoice_80_382_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_382.1' type='checkbox'  value='Parkinson&#039;s disease'  id='choice_80_382_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_382_1' id='label_80_382_1' class='gform-field-label gform-field-label--type-inline'>Parkinson's disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_383\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Epilepsy<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_383'><div class='gchoice gchoice_80_383_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_383.1' type='checkbox'  value='Epilepsy'  id='choice_80_383_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_383_1' id='label_80_383_1' class='gform-field-label gform-field-label--type-inline'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_384\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Intramedullary \/ intracranial pathology<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_384'><div class='gchoice gchoice_80_384_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_384.1' type='checkbox'  value='Intramedullary \/ intracranial pathology'  id='choice_80_384_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_384_1' id='label_80_384_1' class='gform-field-label gform-field-label--type-inline'>Intramedullary \/ intracranial pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_385\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Paraplegia \/ hemiplegia \/ tetraplegia<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_385'><div class='gchoice gchoice_80_385_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_385.1' type='checkbox'  value='Paraplegia \/ hemiplegia \/ tetraplegia'  id='choice_80_385_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_385_1' id='label_80_385_1' class='gform-field-label gform-field-label--type-inline'>Paraplegia \/ hemiplegia \/ tetraplegia<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_386\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Arteriosclerosis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_386'><div class='gchoice gchoice_80_386_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_386.1' type='checkbox'  value='Arteriosclerosis'  id='choice_80_386_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_386_1' id='label_80_386_1' class='gform-field-label gform-field-label--type-inline'>Arteriosclerosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_387\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Aortic aneurysm<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_387'><div class='gchoice gchoice_80_387_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_387.1' type='checkbox'  value='Aortic aneurysm'  id='choice_80_387_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_387_1' id='label_80_387_1' class='gform-field-label gform-field-label--type-inline'>Aortic aneurysm<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_388\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ischemic \/ valvular \/ cardiomyopathic heart disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_388'><div class='gchoice gchoice_80_388_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_388.1' type='checkbox'  value='Ischemic \/ valvular \/ cardiomyopathic heart disease'  id='choice_80_388_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_388_1' id='label_80_388_1' class='gform-field-label gform-field-label--type-inline'>Ischemic \/ valvular \/ cardiomyopathic heart disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_389\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Malignant hypertension<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_389'><div class='gchoice gchoice_80_389_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_389.1' type='checkbox'  value='Malignant hypertension'  id='choice_80_389_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_389_1' id='label_80_389_1' class='gform-field-label gform-field-label--type-inline'>Malignant hypertension<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_390\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Pulmonary fibrosis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_390'><div class='gchoice gchoice_80_390_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_390.1' type='checkbox'  value='Pulmonary fibrosis'  id='choice_80_390_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_390_1' id='label_80_390_1' class='gform-field-label gform-field-label--type-inline'>Pulmonary fibrosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_391\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chronic respiratory failure<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_391'><div class='gchoice gchoice_80_391_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_391.1' type='checkbox'  value='Chronic respiratory failure'  id='choice_80_391_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_391_1' id='label_80_391_1' class='gform-field-label gform-field-label--type-inline'>Chronic respiratory failure<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_392\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cerebrovascular disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_392'><div class='gchoice gchoice_80_392_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_392.1' type='checkbox'  value='Cerebrovascular disease'  id='choice_80_392_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_392_1' id='label_80_392_1' class='gform-field-label gform-field-label--type-inline'>Cerebrovascular disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_393\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chronic kidney failure<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_393'><div class='gchoice gchoice_80_393_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_393.1' type='checkbox'  value='Chronic kidney failure'  id='choice_80_393_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_393_1' id='label_80_393_1' class='gform-field-label gform-field-label--type-inline'>Chronic kidney failure<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_394\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chronic hepatopathy or pancreatitis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_394'><div class='gchoice gchoice_80_394_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_394.1' type='checkbox'  value='Chronic hepatopathy or pancreatitis'  id='choice_80_394_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_394_1' id='label_80_394_1' class='gform-field-label gform-field-label--type-inline'>Chronic hepatopathy or pancreatitis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_395\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Endocrine-metabolic pathology<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_395'><div class='gchoice gchoice_80_395_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_395.1' type='checkbox'  value='Endocrine-metabolic pathology'  id='choice_80_395_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_395_1' id='label_80_395_1' class='gform-field-label gform-field-label--type-inline'>Endocrine-metabolic pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_396\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ulcerative colitis \/ Crohn&#039;s disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_396'><div class='gchoice gchoice_80_396_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_396.1' type='checkbox'  value='Ulcerative colitis \/ Crohn&#039;s disease'  id='choice_80_396_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_396_1' id='label_80_396_1' class='gform-field-label gform-field-label--type-inline'>Ulcerative colitis \/ Crohn's disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_397\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Endometriosis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_397'><div class='gchoice gchoice_80_397_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_397.1' type='checkbox'  value='Endometriosis'  id='choice_80_397_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_397_1' id='label_80_397_1' class='gform-field-label gform-field-label--type-inline'>Endometriosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_398\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Rheumatoid or psoriatic arthritis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_398'><div class='gchoice gchoice_80_398_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_398.1' type='checkbox'  value='Rheumatoid or psoriatic arthritis'  id='choice_80_398_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_398_1' id='label_80_398_1' class='gform-field-label gform-field-label--type-inline'>Rheumatoid or psoriatic arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_399\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Muscular dystrophy<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_399'><div class='gchoice gchoice_80_399_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_399.1' type='checkbox'  value='Muscular dystrophy'  id='choice_80_399_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_399_1' id='label_80_399_1' class='gform-field-label gform-field-label--type-inline'>Muscular dystrophy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_400\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Systemic lupus<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_400'><div class='gchoice gchoice_80_400_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_400.1' type='checkbox'  value='Systemic lupus'  id='choice_80_400_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_400_1' id='label_80_400_1' class='gform-field-label gform-field-label--type-inline'>Systemic lupus<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_401\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Dermatomyositis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_401'><div class='gchoice gchoice_80_401_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_401.1' type='checkbox'  value='Dermatomyositis'  id='choice_80_401_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_401_1' id='label_80_401_1' class='gform-field-label gform-field-label--type-inline'>Dermatomyositis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_402\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ankylosing spondylitis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_402'><div class='gchoice gchoice_80_402_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_402.1' type='checkbox'  value='Ankylosing spondylitis'  id='choice_80_402_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_402_1' id='label_80_402_1' class='gform-field-label gform-field-label--type-inline'>Ankylosing spondylitis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_403\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Severe haematological disorders<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_403'><div class='gchoice gchoice_80_403_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_403.1' type='checkbox'  value='Severe haematological disorders'  id='choice_80_403_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_403_1' id='label_80_403_1' class='gform-field-label gform-field-label--type-inline'>Severe haematological disorders<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_404\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Osteoarticular surgery with prosthesis or implants<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_404'><div class='gchoice gchoice_80_404_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_404.1' type='checkbox'  value='Osteoarticular surgery with prosthesis or implants'  id='choice_80_404_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_404_1' id='label_80_404_1' class='gform-field-label gform-field-label--type-inline'>Osteoarticular surgery with prosthesis or implants<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_405\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Degenerative \/ accidental spine, hip, knee, shoulder or foot pathology<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_405'><div class='gchoice gchoice_80_405_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_405.1' type='checkbox'  value='Degenerative \/ accidental spine, hip, knee, shoulder or foot pathology'  id='choice_80_405_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_405_1' id='label_80_405_1' class='gform-field-label gform-field-label--type-inline'>Degenerative \/ accidental spine, hip, knee, shoulder or foot pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_406\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Psychiatric disorders<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_406'><div class='gchoice gchoice_80_406_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_406.1' type='checkbox'  value='Psychiatric disorders'  id='choice_80_406_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_406_1' id='label_80_406_1' class='gform-field-label gform-field-label--type-inline'>Psychiatric disorders<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_407\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Eating disorders<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_407'><div class='gchoice gchoice_80_407_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_407.1' type='checkbox'  value='Eating disorders'  id='choice_80_407_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_407_1' id='label_80_407_1' class='gform-field-label gform-field-label--type-inline'>Eating disorders<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_408\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Transplants<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_408'><div class='gchoice gchoice_80_408_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_408.1' type='checkbox'  value='Transplants'  id='choice_80_408_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_408_1' id='label_80_408_1' class='gform-field-label gform-field-label--type-inline'>Transplants<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_409\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Allergies \/ Intolerances<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_409'><div class='gchoice gchoice_80_409_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_409.1' type='checkbox'  value='Allergies \/ Intolerances'  id='choice_80_409_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_409_1' id='label_80_409_1' class='gform-field-label gform-field-label--type-inline'>Allergies \/ Intolerances<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_80_410' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_80_410' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_80_9' class='gform_page um-cuest-4-page' data-js='page-field-id-410' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_80_9' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_80_411\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insured 4 \u2014 Additional Confidential Medical Questionnaire<\/h3><div class='gsection_description' id='gfield_description_80_411'>Complete this questionnaire because you have flagged at least one health issue above. Up to 4 separate problems. For paired organs or limbs, indicate the side.<\/div><\/div><div id=\"field_80_412\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 1<\/h4><\/div><fieldset id=\"field_80_413\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 1: Current or Past?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_413'>\n\t\t\t<div class='gchoice gchoice_80_413_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_413' type='radio' value='Current'  id='choice_80_413_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_413_0' id='label_80_413_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_413_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_413' type='radio' value='Past'  id='choice_80_413_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_413_1' id='label_80_413_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_414\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_414'>Start date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_414' id='input_80_414' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_414_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_80_414_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_414' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_415\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_415'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_415' id='input_80_415' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_415_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_415_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_415' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_416\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_416'>Describe the problem<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_416' id='input_80_416' class='textarea large'   maxlength='40'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_417\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_417'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_417' id='input_80_417' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_418\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_418'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_418' id='input_80_418' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_419\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_419'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_419' id='input_80_419' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_420\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_420'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_420' id='input_80_420' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_421\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_421'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_421' id='input_80_421' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_422\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_422'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_422' id='input_80_422' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_423\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 2<\/h4><\/div><fieldset id=\"field_80_424\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 2: Current or Past?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_424'>\n\t\t\t<div class='gchoice gchoice_80_424_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_424' type='radio' value='Current'  id='choice_80_424_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_424_0' id='label_80_424_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_424_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_424' type='radio' value='Past'  id='choice_80_424_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_424_1' id='label_80_424_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_425\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_425'>Start date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_425' id='input_80_425' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_425_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_425_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_425' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_426\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_426'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_426' id='input_80_426' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_426_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_426_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_426' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_427\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_427'>Describe the problem<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_427' id='input_80_427' class='textarea large'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_428\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_428'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_428' id='input_80_428' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_429\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_429'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_429' id='input_80_429' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_430\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_430'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_430' id='input_80_430' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_431\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_431'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_431' id='input_80_431' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_432\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_432'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_432' id='input_80_432' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_433\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_433'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_433' id='input_80_433' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_434\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 3<\/h4><\/div><fieldset id=\"field_80_435\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 3: Current or Past?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_435'>\n\t\t\t<div class='gchoice gchoice_80_435_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_435' type='radio' value='Current'  id='choice_80_435_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_435_0' id='label_80_435_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_435_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_435' type='radio' value='Past'  id='choice_80_435_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_435_1' id='label_80_435_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_436\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_436'>Start date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_436' id='input_80_436' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_436_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_436_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_436' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_437\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_437'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_437' id='input_80_437' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_437_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_437_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_437' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_438\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_438'>Describe the problem<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_438' id='input_80_438' class='textarea large'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_439\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_439'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_439' id='input_80_439' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_440\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_440'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_440' id='input_80_440' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_441\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_441'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_441' id='input_80_441' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_442\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_442'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_442' id='input_80_442' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_443\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_443'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_443' id='input_80_443' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_444\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_444'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_444' id='input_80_444' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_445\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 4<\/h4><\/div><fieldset id=\"field_80_446\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 4: Current or Past?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_446'>\n\t\t\t<div class='gchoice gchoice_80_446_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_446' type='radio' value='Current'  id='choice_80_446_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_446_0' id='label_80_446_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_446_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_446' type='radio' value='Past'  id='choice_80_446_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_446_1' id='label_80_446_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_447\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_447'>Start date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_447' id='input_80_447' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_447_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_447_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_447' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_448\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_448'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_448' id='input_80_448' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_448_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_448_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_448' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_449\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_449'>Describe the problem<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_449' id='input_80_449' class='textarea large'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_450\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_450'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_450' id='input_80_450' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_451\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_451'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_451' id='input_80_451' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_452\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_452'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_452' id='input_80_452' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_453\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_453'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_453' id='input_80_453' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_454\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_454'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_454' id='input_80_454' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_455\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_455'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_455' id='input_80_455' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_456\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>7th \u2014 Refractive eye defect<\/h4><\/div><div id=\"field_80_457\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_457'>Specify (myopia, hyperopia, astigmatism, etc.)<\/label><div class='ginput_container ginput_container_text'><input name='input_457' id='input_80_457' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_459\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_459'>Dioptres left eye<\/label><div class='ginput_container ginput_container_text'><input name='input_459' id='input_80_459' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_458\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_458'>Dioptres right eye<\/label><div class='ginput_container ginput_container_text'><input name='input_458' id='input_80_458' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_708\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Newborn<\/h3><\/div><div id=\"field_80_720\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_720'>Week of gestation at birth<\/label><div class='ginput_container ginput_container_number'><input name='input_720' id='input_80_720' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_80_715\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_715'>Birth weight (kg)<\/label><div class='ginput_container ginput_container_number'><input name='input_715' id='input_80_715' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_80_463\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Type of assistance received or required<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_463'><div class='gchoice gchoice_80_463_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_463.1' type='checkbox'  value='Incubator'  id='choice_80_463_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_463_1' id='label_80_463_1' class='gform-field-label gform-field-label--type-inline'>Incubator<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_80_463_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_463.2' type='checkbox'  value='Intermediate care'  id='choice_80_463_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_463_2' id='label_80_463_2' class='gform-field-label gform-field-label--type-inline'>Intermediate care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_80_463_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_463.3' type='checkbox'  value='ICU'  id='choice_80_463_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_463_3' id='label_80_463_3' class='gform-field-label gform-field-label--type-inline'>ICU<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_80_463_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_463.4' type='checkbox'  value='Paediatric consultations'  id='choice_80_463_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_463_4' id='label_80_463_4' class='gform-field-label gform-field-label--type-inline'>Paediatric consultations<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_464\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_464'>Paediatric specialty<\/label><div class='ginput_container ginput_container_text'><input name='input_464' id='input_80_464' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_465\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_465'>Specify congenital condition<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_465' id='input_80_465' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_80_466' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_80_466' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_80_10' class='gform_page um-insured-5-page' data-js='page-field-id-466' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_80_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_80_467\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insured 5 \u2014 Details<\/h3><\/div><fieldset id=\"field_80_468\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Insured Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_80_468'>\n                            \n                            <span id='input_80_468_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_468.3' id='input_80_468_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_80_468_3' class='gform-field-label gform-field-label--type-sub '>First name(s)<\/label>\n                                                <\/span>\n                            \n                            <span id='input_80_468_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_468.6' id='input_80_468_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_80_468_6' class='gform-field-label gform-field-label--type-sub '>Surname(s)<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_80_469\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_469'>Relationship with the policyholder<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_469' id='input_80_469' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>- Please select<\/option><option value='Me' >Me<\/option><option value='Spouse' >Spouse<\/option><option value='Son' >Son<\/option><option value='Daughter' >Daughter<\/option><option value='Father' >Father<\/option><option value='Mother' >Mother<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><fieldset id=\"field_80_470\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_470'>\n\t\t\t<div class='gchoice gchoice_80_470_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_470' type='radio' value='Hombre'  id='choice_80_470_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_470_0' id='label_80_470_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_470_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_470' type='radio' value='Mujer'  id='choice_80_470_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_470_1' id='label_80_470_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_471\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gcldf-field gcldf-field-date gcldf-date-format-dmy gfield_trigger_change gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_471'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_471' id='input_80_471' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_471_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_80_471_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_471' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_80_472\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nationality<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_country ginput_container_address gform-grid-row' id='input_80_472' >\n                        <input type='hidden' class='gform_hidden' name='input_472.4' id='input_80_472_4' value=''\/><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_80_472_6_container' >\n                                        <select name='input_472.6' id='input_80_472_6'   aria-required='true'    ><option value='' selected='selected'>- Please select<\/option><option value='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antigua y Barbuda' >Antigua y Barbuda<\/option><option value='Ant\u00e1rtida' >Ant\u00e1rtida<\/option><option value='Arabia Saudita' >Arabia Saudita<\/option><option value='Argelia' >Argelia<\/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='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='Belice' >Belice<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos \u00c1rabes Unidos<\/option><option value='Eritrea' >Eritrea<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estados Unidos' >Estados Unidos<\/option><option value='Estonia' >Estonia<\/option><option value='Esuatini' >Esuatini<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Federaci\u00f3n Rusa' >Federaci\u00f3n Rusa<\/option><option value='Fiji' >Fiji<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Granada' >Granada<\/option><option value='Grecia' >Grecia<\/option><option value='Groenlandia' >Groenlandia<\/option><option value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Islas \u00c5land' >Islas \u00c5land<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jord\u00e1n' >Jord\u00e1n<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='LIbia' >LIbia<\/option><option value='Lesoto' >Lesoto<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituania' >Lituania<\/option><option value='Lituania' >Lituania<\/option><option value='Luxemburgo' >Luxemburgo<\/option><option value='L\u00edbano' >L\u00edbano<\/option><option value='Macau' >Macau<\/option><option value='Macedonia del Norte' >Macedonia del Norte<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malawi' >Malawi<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Martinica' >Martinica<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mayotte' >Mayotte<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldavia' >Moldavia<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noruega' >Noruega<\/option><option value='Nueva Caledonia' >Nueva Caledonia<\/option><option value='Nueva Zelanda' >Nueva Zelanda<\/option><option value='N\u00edger' >N\u00edger<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Paises Bajos' >Paises Bajos<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Estado de' >Palestina, Estado de<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Pap\u00faa Nueva Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polinesia Francesa' >Polinesia Francesa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica Centroafricana' >Rep\u00fablica Centroafricana<\/option><option value='Rep\u00fablica Democr\u00e1tica Popular de Laos' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Rep\u00fablica \u00c1rabe de Siria' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='Reuni\u00f3n' >Reuni\u00f3n<\/option><option value='Ruanda' >Ruanda<\/option><option value='Ruman\u00eda' >Ruman\u00eda<\/option><option value='Sahara Occidental' >Sahara Occidental<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='San Bartolom\u00e9' >San Bartolom\u00e9<\/option><option value='San Crist\u00f3bal y Nieves' >San Crist\u00f3bal y Nieves<\/option><option value='San Marino' >San Marino<\/option><option value='San Mart\u00edn' >San Mart\u00edn<\/option><option value='San Pedro y Miquel\u00f3n' >San Pedro y Miquel\u00f3n<\/option><option value='San Vicente y las Granadinas' >San Vicente y las Granadinas<\/option><option value='Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='Santa Luc\u00eda' >Santa Luc\u00eda<\/option><option value='Santa Sede' >Santa Sede<\/option><option value='Santo Tom\u00e9 y Principe' >Santo Tom\u00e9 y Principe<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >Zimbaue<\/option><\/select>\n                                        <label for='input_80_472_6' id='input_80_472_6_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_80_473\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_473'>Profession<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_473' id='input_80_473' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_80_474\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >ID Document<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_474'>\n\t\t\t<div class='gchoice gchoice_80_474_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_474' type='radio' value='Pasaporte'  id='choice_80_474_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_474_0' id='label_80_474_0' class='gform-field-label gform-field-label--type-inline'>Passport<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_474_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_474' type='radio' value='NIE'  id='choice_80_474_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_474_1' id='label_80_474_1' class='gform-field-label gform-field-label--type-inline'>NIE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_474_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_474' type='radio' value='DNI'  id='choice_80_474_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_474_2' id='label_80_474_2' class='gform-field-label gform-field-label--type-inline'>DNI<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_475\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_475'>ID Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_475' id='input_80_475' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_731\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_731'>Please attach your passport or NIE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_80_731'>Please attach a scan or good quality photo of the document\n<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_731' id='input_80_731' type='file' class='large' aria-describedby=\"gfield_upload_rules_80_731 gfield_description_80_731\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_80_731'>Tipos de archivos aceptados: jpg, jpeg, png, pdf, m\u00e1x. tama\u00f1o del archivo: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_80_731'><\/div> <\/div><\/div><div id=\"field_80_476\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_476'>Height (cm)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_476' id='input_80_476' type='number' step='any' min='40'  value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_80_476\" \/><div class='gfield_description instruction ' id='gfield_instruction_80_476'>Por favor, escribe un n\u00famero mayor o igual a <strong>40<\/strong>.<\/div><\/div><\/div><div id=\"field_80_477\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_477'>Weight (kg)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_477' id='input_80_477' type='number' step='any' min='1'  value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_80_477\" \/><div class='gfield_description instruction ' id='gfield_instruction_80_477'>Por favor, escribe un n\u00famero mayor o igual a <strong>1<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_80_478\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you previously been insured by Uni\u00f3n Madrile\u00f1a?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_478'>\n\t\t\t<div class='gchoice gchoice_80_478_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_478' type='radio' value='Yes'  id='choice_80_478_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_478_0' id='label_80_478_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_478_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_478' type='radio' value='No'  id='choice_80_478_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_478_1' id='label_80_478_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_479\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_479'>Previous policy number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_479' id='input_80_479' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_80_480\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you come from another insurance company?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_480'>\n\t\t\t<div class='gchoice gchoice_80_480_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_480' type='radio' value='Yes'  id='choice_80_480_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_480_0' id='label_80_480_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_480_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_480' type='radio' value='No'  id='choice_80_480_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_480_1' id='label_80_480_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_481\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_481'>Which company?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_481' id='input_80_481' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_482\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insured 5 \u2014 Confidential Medical Information<\/h3><\/div><fieldset id=\"field_80_483\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you been hospitalised, admitted to a clinic, or had surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_483'>\n\t\t\t<div class='gchoice gchoice_80_483_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_483' type='radio' value='Yes'  id='choice_80_483_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_483_0' id='label_80_483_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_483_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_483' type='radio' value='No'  id='choice_80_483_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_483_1' id='label_80_483_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_484\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_484'>If yes, please detail (including dates)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_484' id='input_80_484' class='textarea large'   maxlength='280'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_80_485\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have any diagnostic test, medical treatment, or surgery scheduled?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_485'>\n\t\t\t<div class='gchoice gchoice_80_485_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_485' type='radio' value='Yes'  id='choice_80_485_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_485_0' id='label_80_485_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_485_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_485' type='radio' value='No'  id='choice_80_485_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_485_1' id='label_80_485_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_486\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_486'>If yes, please detail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_486' id='input_80_486' class='textarea large'   maxlength='230'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_80_487\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you currently receiving medical treatment or under medical supervision?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_487'>\n\t\t\t<div class='gchoice gchoice_80_487_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_487' type='radio' value='Yes'  id='choice_80_487_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_487_0' id='label_80_487_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_487_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_487' type='radio' value='No'  id='choice_80_487_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_487_1' id='label_80_487_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_488\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_488'>If yes, please detail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_488' id='input_80_488' class='textarea large'   maxlength='300'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_80_489\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If female, are you currently pregnant?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_489'>\n\t\t\t<div class='gchoice gchoice_80_489_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_489' type='radio' value='Yes'  id='choice_80_489_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_489_0' id='label_80_489_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_489_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_489' type='radio' value='No'  id='choice_80_489_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_489_1' id='label_80_489_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_490\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_490'>How many weeks?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_490' id='input_80_490' type='number' step='any' min='0' max='42' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_80_490\" \/><div class='gfield_description instruction ' id='gfield_instruction_80_490'>Por favor, escribe un n\u00famero entre <strong>0<\/strong> y <strong>42<\/strong>.<\/div><\/div><\/div><div id=\"field_80_491\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>Declaration of other illnesses<\/strong><br>Have you suffered, or do you currently suffer, any of the following? Tick all that apply.<\/p><\/div><fieldset id=\"field_80_492\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cancer \/ oncological processes<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_492'><div class='gchoice gchoice_80_492_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_492.1' type='checkbox'  value='Cancer \/ oncological processes'  id='choice_80_492_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_492_1' id='label_80_492_1' class='gform-field-label gform-field-label--type-inline'>Cancer \/ oncological processes<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_493\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Congenital diseases<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_493'><div class='gchoice gchoice_80_493_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_493.1' type='checkbox'  value='Congenital diseases'  id='choice_80_493_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_493_1' id='label_80_493_1' class='gform-field-label gform-field-label--type-inline'>Congenital diseases<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_494\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Demyelinating diseases<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_494'><div class='gchoice gchoice_80_494_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_494.1' type='checkbox'  value='Demyelinating diseases'  id='choice_80_494_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_494_1' id='label_80_494_1' class='gform-field-label gform-field-label--type-inline'>Demyelinating diseases<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_495\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Parkinson&#039;s disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_495'><div class='gchoice gchoice_80_495_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_495.1' type='checkbox'  value='Parkinson&#039;s disease'  id='choice_80_495_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_495_1' id='label_80_495_1' class='gform-field-label gform-field-label--type-inline'>Parkinson's disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_496\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Epilepsy<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_496'><div class='gchoice gchoice_80_496_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_496.1' type='checkbox'  value='Epilepsy'  id='choice_80_496_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_496_1' id='label_80_496_1' class='gform-field-label gform-field-label--type-inline'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_497\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Intramedullary \/ intracranial pathology<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_497'><div class='gchoice gchoice_80_497_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_497.1' type='checkbox'  value='Intramedullary \/ intracranial pathology'  id='choice_80_497_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_497_1' id='label_80_497_1' class='gform-field-label gform-field-label--type-inline'>Intramedullary \/ intracranial pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_498\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Paraplegia \/ hemiplegia \/ tetraplegia<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_498'><div class='gchoice gchoice_80_498_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_498.1' type='checkbox'  value='Paraplegia \/ hemiplegia \/ tetraplegia'  id='choice_80_498_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_498_1' id='label_80_498_1' class='gform-field-label gform-field-label--type-inline'>Paraplegia \/ hemiplegia \/ tetraplegia<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_499\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Arteriosclerosis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_499'><div class='gchoice gchoice_80_499_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_499.1' type='checkbox'  value='Arteriosclerosis'  id='choice_80_499_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_499_1' id='label_80_499_1' class='gform-field-label gform-field-label--type-inline'>Arteriosclerosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_500\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Aortic aneurysm<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_500'><div class='gchoice gchoice_80_500_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_500.1' type='checkbox'  value='Aortic aneurysm'  id='choice_80_500_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_500_1' id='label_80_500_1' class='gform-field-label gform-field-label--type-inline'>Aortic aneurysm<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_501\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ischemic \/ valvular \/ cardiomyopathic heart disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_501'><div class='gchoice gchoice_80_501_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_501.1' type='checkbox'  value='Ischemic \/ valvular \/ cardiomyopathic heart disease'  id='choice_80_501_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_501_1' id='label_80_501_1' class='gform-field-label gform-field-label--type-inline'>Ischemic \/ valvular \/ cardiomyopathic heart disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_502\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Malignant hypertension<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_502'><div class='gchoice gchoice_80_502_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_502.1' type='checkbox'  value='Malignant hypertension'  id='choice_80_502_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_502_1' id='label_80_502_1' class='gform-field-label gform-field-label--type-inline'>Malignant hypertension<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_503\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Pulmonary fibrosis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_503'><div class='gchoice gchoice_80_503_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_503.1' type='checkbox'  value='Pulmonary fibrosis'  id='choice_80_503_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_503_1' id='label_80_503_1' class='gform-field-label gform-field-label--type-inline'>Pulmonary fibrosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_504\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chronic respiratory failure<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_504'><div class='gchoice gchoice_80_504_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_504.1' type='checkbox'  value='Chronic respiratory failure'  id='choice_80_504_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_504_1' id='label_80_504_1' class='gform-field-label gform-field-label--type-inline'>Chronic respiratory failure<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_505\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cerebrovascular disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_505'><div class='gchoice gchoice_80_505_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_505.1' type='checkbox'  value='Cerebrovascular disease'  id='choice_80_505_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_505_1' id='label_80_505_1' class='gform-field-label gform-field-label--type-inline'>Cerebrovascular disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_506\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chronic kidney failure<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_506'><div class='gchoice gchoice_80_506_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_506.1' type='checkbox'  value='Chronic kidney failure'  id='choice_80_506_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_506_1' id='label_80_506_1' class='gform-field-label gform-field-label--type-inline'>Chronic kidney failure<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_507\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chronic hepatopathy or pancreatitis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_507'><div class='gchoice gchoice_80_507_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_507.1' type='checkbox'  value='Chronic hepatopathy or pancreatitis'  id='choice_80_507_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_507_1' id='label_80_507_1' class='gform-field-label gform-field-label--type-inline'>Chronic hepatopathy or pancreatitis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_508\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Endocrine-metabolic pathology<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_508'><div class='gchoice gchoice_80_508_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_508.1' type='checkbox'  value='Endocrine-metabolic pathology'  id='choice_80_508_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_508_1' id='label_80_508_1' class='gform-field-label gform-field-label--type-inline'>Endocrine-metabolic pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_509\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ulcerative colitis \/ Crohn&#039;s disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_509'><div class='gchoice gchoice_80_509_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_509.1' type='checkbox'  value='Ulcerative colitis \/ Crohn&#039;s disease'  id='choice_80_509_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_509_1' id='label_80_509_1' class='gform-field-label gform-field-label--type-inline'>Ulcerative colitis \/ Crohn's disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_510\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Endometriosis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_510'><div class='gchoice gchoice_80_510_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_510.1' type='checkbox'  value='Endometriosis'  id='choice_80_510_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_510_1' id='label_80_510_1' class='gform-field-label gform-field-label--type-inline'>Endometriosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_511\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Rheumatoid or psoriatic arthritis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_511'><div class='gchoice gchoice_80_511_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_511.1' type='checkbox'  value='Rheumatoid or psoriatic arthritis'  id='choice_80_511_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_511_1' id='label_80_511_1' class='gform-field-label gform-field-label--type-inline'>Rheumatoid or psoriatic arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_512\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Muscular dystrophy<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_512'><div class='gchoice gchoice_80_512_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_512.1' type='checkbox'  value='Muscular dystrophy'  id='choice_80_512_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_512_1' id='label_80_512_1' class='gform-field-label gform-field-label--type-inline'>Muscular dystrophy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_513\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Systemic lupus<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_513'><div class='gchoice gchoice_80_513_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_513.1' type='checkbox'  value='Systemic lupus'  id='choice_80_513_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_513_1' id='label_80_513_1' class='gform-field-label gform-field-label--type-inline'>Systemic lupus<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_514\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Dermatomyositis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_514'><div class='gchoice gchoice_80_514_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_514.1' type='checkbox'  value='Dermatomyositis'  id='choice_80_514_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_514_1' id='label_80_514_1' class='gform-field-label gform-field-label--type-inline'>Dermatomyositis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_515\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ankylosing spondylitis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_515'><div class='gchoice gchoice_80_515_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_515.1' type='checkbox'  value='Ankylosing spondylitis'  id='choice_80_515_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_515_1' id='label_80_515_1' class='gform-field-label gform-field-label--type-inline'>Ankylosing spondylitis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_516\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Severe haematological disorders<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_516'><div class='gchoice gchoice_80_516_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_516.1' type='checkbox'  value='Severe haematological disorders'  id='choice_80_516_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_516_1' id='label_80_516_1' class='gform-field-label gform-field-label--type-inline'>Severe haematological disorders<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_517\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Osteoarticular surgery with prosthesis or implants<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_517'><div class='gchoice gchoice_80_517_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_517.1' type='checkbox'  value='Osteoarticular surgery with prosthesis or implants'  id='choice_80_517_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_517_1' id='label_80_517_1' class='gform-field-label gform-field-label--type-inline'>Osteoarticular surgery with prosthesis or implants<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_518\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Degenerative \/ accidental spine, hip, knee, shoulder or foot pathology<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_518'><div class='gchoice gchoice_80_518_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_518.1' type='checkbox'  value='Degenerative \/ accidental spine, hip, knee, shoulder or foot pathology'  id='choice_80_518_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_518_1' id='label_80_518_1' class='gform-field-label gform-field-label--type-inline'>Degenerative \/ accidental spine, hip, knee, shoulder or foot pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_519\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Psychiatric disorders<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_519'><div class='gchoice gchoice_80_519_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_519.1' type='checkbox'  value='Psychiatric disorders'  id='choice_80_519_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_519_1' id='label_80_519_1' class='gform-field-label gform-field-label--type-inline'>Psychiatric disorders<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_520\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Eating disorders<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_520'><div class='gchoice gchoice_80_520_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_520.1' type='checkbox'  value='Eating disorders'  id='choice_80_520_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_520_1' id='label_80_520_1' class='gform-field-label gform-field-label--type-inline'>Eating disorders<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_521\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Transplants<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_521'><div class='gchoice gchoice_80_521_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_521.1' type='checkbox'  value='Transplants'  id='choice_80_521_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_521_1' id='label_80_521_1' class='gform-field-label gform-field-label--type-inline'>Transplants<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_522\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Allergies \/ Intolerances<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_522'><div class='gchoice gchoice_80_522_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_522.1' type='checkbox'  value='Allergies \/ Intolerances'  id='choice_80_522_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_522_1' id='label_80_522_1' class='gform-field-label gform-field-label--type-inline'>Allergies \/ Intolerances<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_80_523' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_80_523' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_80_11' class='gform_page um-cuest-5-page' data-js='page-field-id-523' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_80_11' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_80_524\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insured 5 \u2014 Additional Confidential Medical Questionnaire<\/h3><div class='gsection_description' id='gfield_description_80_524'>Complete this questionnaire because you have flagged at least one health issue above. Up to 4 separate problems. For paired organs or limbs, indicate the side.<\/div><\/div><div id=\"field_80_525\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 1<\/h4><\/div><fieldset id=\"field_80_526\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 1: Current or Past?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_526'>\n\t\t\t<div class='gchoice gchoice_80_526_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_526' type='radio' value='Current'  id='choice_80_526_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_526_0' id='label_80_526_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_526_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_526' type='radio' value='Past'  id='choice_80_526_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_526_1' id='label_80_526_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_527\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_527'>Start date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_527' id='input_80_527' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_527_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_80_527_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_527' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_528\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_528'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_528' id='input_80_528' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_528_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_528_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_528' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_529\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_529'>Describe the problem<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_529' id='input_80_529' class='textarea large'   maxlength='40'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_530\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_530'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_530' id='input_80_530' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_531\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_531'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_531' id='input_80_531' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_532\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_532'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_532' id='input_80_532' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_533\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_533'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_533' id='input_80_533' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_534\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_534'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_534' id='input_80_534' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_535\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_535'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_535' id='input_80_535' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_536\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 2<\/h4><\/div><fieldset id=\"field_80_537\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 2: Current or Past?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_537'>\n\t\t\t<div class='gchoice gchoice_80_537_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_537' type='radio' value='Current'  id='choice_80_537_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_537_0' id='label_80_537_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_537_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_537' type='radio' value='Past'  id='choice_80_537_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_537_1' id='label_80_537_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_538\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_538'>Start date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_538' id='input_80_538' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_538_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_538_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_538' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_539\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_539'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_539' id='input_80_539' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_539_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_539_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_539' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_540\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_540'>Describe the problem<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_540' id='input_80_540' class='textarea large'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_541\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_541'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_541' id='input_80_541' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_542\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_542'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_542' id='input_80_542' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_543\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_543'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_543' id='input_80_543' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_544\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_544'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_544' id='input_80_544' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_545\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_545'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_545' id='input_80_545' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_546\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_546'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_546' id='input_80_546' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_547\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 3<\/h4><\/div><fieldset id=\"field_80_548\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 3: Current or Past?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_548'>\n\t\t\t<div class='gchoice gchoice_80_548_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_548' type='radio' value='Current'  id='choice_80_548_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_548_0' id='label_80_548_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_548_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_548' type='radio' value='Past'  id='choice_80_548_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_548_1' id='label_80_548_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_549\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_549'>Start date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_549' id='input_80_549' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_549_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_549_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_549' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_550\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_550'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_550' id='input_80_550' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_550_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_550_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_550' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_551\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_551'>Describe the problem<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_551' id='input_80_551' class='textarea large'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_552\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_552'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_552' id='input_80_552' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_553\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_553'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_553' id='input_80_553' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_554\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_554'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_554' id='input_80_554' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_555\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_555'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_555' id='input_80_555' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_556\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_556'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_556' id='input_80_556' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_557\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_557'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_557' id='input_80_557' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_558\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 4<\/h4><\/div><fieldset id=\"field_80_559\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 4: Current or Past?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_559'>\n\t\t\t<div class='gchoice gchoice_80_559_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_559' type='radio' value='Current'  id='choice_80_559_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_559_0' id='label_80_559_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_559_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_559' type='radio' value='Past'  id='choice_80_559_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_559_1' id='label_80_559_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_560\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_560'>Start date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_560' id='input_80_560' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_560_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_560_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_560' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_561\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_561'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_561' id='input_80_561' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_561_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_561_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_561' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_562\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_562'>Describe the problem<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_562' id='input_80_562' class='textarea large'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_563\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_563'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_563' id='input_80_563' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_564\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_564'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_564' id='input_80_564' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_565\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_565'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_565' id='input_80_565' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_566\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_566'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_566' id='input_80_566' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_567\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_567'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_567' id='input_80_567' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_568\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_568'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_568' id='input_80_568' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_569\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>7th \u2014 Refractive eye defect<\/h4><\/div><div id=\"field_80_570\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_570'>Specify (myopia, hyperopia, astigmatism, etc.)<\/label><div class='ginput_container ginput_container_text'><input name='input_570' id='input_80_570' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_572\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_572'>Dioptres left eye<\/label><div class='ginput_container ginput_container_text'><input name='input_572' id='input_80_572' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_571\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_571'>Dioptres right eye<\/label><div class='ginput_container ginput_container_text'><input name='input_571' id='input_80_571' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_707\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Newborn<\/h3><\/div><div id=\"field_80_722\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_722'>Week of gestation at birth<\/label><div class='ginput_container ginput_container_number'><input name='input_722' id='input_80_722' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_80_716\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_716'>Birth weight (kg)<\/label><div class='ginput_container ginput_container_number'><input name='input_716' id='input_80_716' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_80_576\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Type of assistance received or required<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_576'><div class='gchoice gchoice_80_576_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_576.1' type='checkbox'  value='Incubator'  id='choice_80_576_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_576_1' id='label_80_576_1' class='gform-field-label gform-field-label--type-inline'>Incubator<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_80_576_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_576.2' type='checkbox'  value='Intermediate care'  id='choice_80_576_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_576_2' id='label_80_576_2' class='gform-field-label gform-field-label--type-inline'>Intermediate care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_80_576_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_576.3' type='checkbox'  value='ICU'  id='choice_80_576_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_576_3' id='label_80_576_3' class='gform-field-label gform-field-label--type-inline'>ICU<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_80_576_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_576.4' type='checkbox'  value='Paediatric consultations'  id='choice_80_576_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_576_4' id='label_80_576_4' class='gform-field-label gform-field-label--type-inline'>Paediatric consultations<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_577\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_577'>Paediatric specialty<\/label><div class='ginput_container ginput_container_text'><input name='input_577' id='input_80_577' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_578\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_578'>Specify congenital condition<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_578' id='input_80_578' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_80_579' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_80_579' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_80_12' class='gform_page um-insured-6-page' data-js='page-field-id-579' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_80_12' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_80_580\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insured 6 \u2014 Details<\/h3><\/div><fieldset id=\"field_80_581\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Insured Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_80_581'>\n                            \n                            <span id='input_80_581_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_581.3' id='input_80_581_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_80_581_3' class='gform-field-label gform-field-label--type-sub '>First name(s)<\/label>\n                                                <\/span>\n                            \n                            <span id='input_80_581_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_581.6' id='input_80_581_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_80_581_6' class='gform-field-label gform-field-label--type-sub '>Surname(s)<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_80_582\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_582'>Relationship with the policyholder<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_582' id='input_80_582' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Me' >Me<\/option><option value='Spouse' >Spouse<\/option><option value='Son' >Son<\/option><option value='Daughter' >Daughter<\/option><option value='Father' >Father<\/option><option value='Mother' >Mother<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><fieldset id=\"field_80_583\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sex<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_583'>\n\t\t\t<div class='gchoice gchoice_80_583_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_583' type='radio' value='Hombre'  id='choice_80_583_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_583_0' id='label_80_583_0' class='gform-field-label gform-field-label--type-inline'>Male<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_583_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_583' type='radio' value='Mujer'  id='choice_80_583_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_583_1' id='label_80_583_1' class='gform-field-label gform-field-label--type-inline'>Female<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_584\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gcldf-field gcldf-field-date gcldf-date-format-dmy gfield_trigger_change gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_584'>Date of Birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_584' id='input_80_584' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_584_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_80_584_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_584' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_80_585\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nationality<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_country ginput_container_address gform-grid-row' id='input_80_585' >\n                        <input type='hidden' class='gform_hidden' name='input_585.4' id='input_80_585_4' value=''\/><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_80_585_6_container' >\n                                        <select name='input_585.6' id='input_80_585_6'   aria-required='true'    ><option value='' selected='selected'>- Please select<\/option><option value='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antigua y Barbuda' >Antigua y Barbuda<\/option><option value='Ant\u00e1rtida' >Ant\u00e1rtida<\/option><option value='Arabia Saudita' >Arabia Saudita<\/option><option value='Argelia' >Argelia<\/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='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='Belice' >Belice<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos \u00c1rabes Unidos<\/option><option value='Eritrea' >Eritrea<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estados Unidos' >Estados Unidos<\/option><option value='Estonia' >Estonia<\/option><option value='Esuatini' >Esuatini<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Federaci\u00f3n Rusa' >Federaci\u00f3n Rusa<\/option><option value='Fiji' >Fiji<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Granada' >Granada<\/option><option value='Grecia' >Grecia<\/option><option value='Groenlandia' >Groenlandia<\/option><option value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Islas \u00c5land' >Islas \u00c5land<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jord\u00e1n' >Jord\u00e1n<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='LIbia' >LIbia<\/option><option value='Lesoto' >Lesoto<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituania' >Lituania<\/option><option value='Lituania' >Lituania<\/option><option value='Luxemburgo' >Luxemburgo<\/option><option value='L\u00edbano' >L\u00edbano<\/option><option value='Macau' >Macau<\/option><option value='Macedonia del Norte' >Macedonia del Norte<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malawi' >Malawi<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Martinica' >Martinica<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mayotte' >Mayotte<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldavia' >Moldavia<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noruega' >Noruega<\/option><option value='Nueva Caledonia' >Nueva Caledonia<\/option><option value='Nueva Zelanda' >Nueva Zelanda<\/option><option value='N\u00edger' >N\u00edger<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Paises Bajos' >Paises Bajos<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Estado de' >Palestina, Estado de<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Pap\u00faa Nueva Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polinesia Francesa' >Polinesia Francesa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica Centroafricana' >Rep\u00fablica Centroafricana<\/option><option value='Rep\u00fablica Democr\u00e1tica Popular de Laos' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Rep\u00fablica \u00c1rabe de Siria' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='Reuni\u00f3n' >Reuni\u00f3n<\/option><option value='Ruanda' >Ruanda<\/option><option value='Ruman\u00eda' >Ruman\u00eda<\/option><option value='Sahara Occidental' >Sahara Occidental<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='San Bartolom\u00e9' >San Bartolom\u00e9<\/option><option value='San Crist\u00f3bal y Nieves' >San Crist\u00f3bal y Nieves<\/option><option value='San Marino' >San Marino<\/option><option value='San Mart\u00edn' >San Mart\u00edn<\/option><option value='San Pedro y Miquel\u00f3n' >San Pedro y Miquel\u00f3n<\/option><option value='San Vicente y las Granadinas' >San Vicente y las Granadinas<\/option><option value='Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='Santa Luc\u00eda' >Santa Luc\u00eda<\/option><option value='Santa Sede' >Santa Sede<\/option><option value='Santo Tom\u00e9 y Principe' >Santo Tom\u00e9 y Principe<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >Zimbaue<\/option><\/select>\n                                        <label for='input_80_585_6' id='input_80_585_6_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_80_586\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_586'>Profession<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_586' id='input_80_586' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_80_587\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >ID Document<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_587'>\n\t\t\t<div class='gchoice gchoice_80_587_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_587' type='radio' value='Pasaporte'  id='choice_80_587_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_587_0' id='label_80_587_0' class='gform-field-label gform-field-label--type-inline'>Passport<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_587_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_587' type='radio' value='NIE'  id='choice_80_587_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_587_1' id='label_80_587_1' class='gform-field-label gform-field-label--type-inline'>NIE<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_587_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_587' type='radio' value='DNI'  id='choice_80_587_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_587_2' id='label_80_587_2' class='gform-field-label gform-field-label--type-inline'>DNI<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_588\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_588'>ID Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_588' id='input_80_588' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_732\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_732'>Please attach your passport or NIE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_80_732'>Please attach a scan or good quality photo of the document\n<\/div><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_732' id='input_80_732' type='file' class='large' aria-describedby=\"gfield_upload_rules_80_732 gfield_description_80_732\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_80_732'>Tipos de archivos aceptados: jpg, jpeg, png, pdf, m\u00e1x. tama\u00f1o del archivo: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_80_732'><\/div> <\/div><\/div><div id=\"field_80_589\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_589'>Height (cm)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_589' id='input_80_589' type='number' step='any' min='40'  value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_80_589\" \/><div class='gfield_description instruction ' id='gfield_instruction_80_589'>Por favor, escribe un n\u00famero mayor o igual a <strong>40<\/strong>.<\/div><\/div><\/div><div id=\"field_80_590\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_590'>Weight (kg)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_590' id='input_80_590' type='number' step='any' min='1'  value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_80_590\" \/><div class='gfield_description instruction ' id='gfield_instruction_80_590'>Por favor, escribe un n\u00famero mayor o igual a <strong>1<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_80_591\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you previously been insured by Uni\u00f3n Madrile\u00f1a?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_591'>\n\t\t\t<div class='gchoice gchoice_80_591_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_591' type='radio' value='Yes'  id='choice_80_591_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_591_0' id='label_80_591_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_591_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_591' type='radio' value='No'  id='choice_80_591_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_591_1' id='label_80_591_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_592\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_592'>Previous policy number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_592' id='input_80_592' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_80_593\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you come from another insurance company?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_593'>\n\t\t\t<div class='gchoice gchoice_80_593_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_593' type='radio' value='Yes'  id='choice_80_593_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_593_0' id='label_80_593_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_593_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_593' type='radio' value='No'  id='choice_80_593_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_593_1' id='label_80_593_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_594\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_594'>Which company?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_594' id='input_80_594' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_595\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insured 6 \u2014 Confidential Medical Information<\/h3><\/div><fieldset id=\"field_80_596\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Have you been hospitalised, admitted to a clinic, or had surgery?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_596'>\n\t\t\t<div class='gchoice gchoice_80_596_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_596' type='radio' value='Yes'  id='choice_80_596_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_596_0' id='label_80_596_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_596_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_596' type='radio' value='No'  id='choice_80_596_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_596_1' id='label_80_596_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_597\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_597'>If yes, please detail (including dates)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_597' id='input_80_597' class='textarea large'   maxlength='280'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_80_598\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Do you have any diagnostic test, medical treatment, or surgery scheduled?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_598'>\n\t\t\t<div class='gchoice gchoice_80_598_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_598' type='radio' value='Yes'  id='choice_80_598_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_598_0' id='label_80_598_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_598_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_598' type='radio' value='No'  id='choice_80_598_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_598_1' id='label_80_598_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_599\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_599'>If yes, please detail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_599' id='input_80_599' class='textarea large'   maxlength='230'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_80_600\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Are you currently receiving medical treatment or under medical supervision?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_600'>\n\t\t\t<div class='gchoice gchoice_80_600_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_600' type='radio' value='Yes'  id='choice_80_600_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_600_0' id='label_80_600_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_600_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_600' type='radio' value='No'  id='choice_80_600_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_600_1' id='label_80_600_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_601\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_601'>If yes, please detail<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_601' id='input_80_601' class='textarea large'   maxlength='300'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_80_602\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >If female, are you currently pregnant?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_602'>\n\t\t\t<div class='gchoice gchoice_80_602_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_602' type='radio' value='Yes'  id='choice_80_602_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_602_0' id='label_80_602_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_602_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_602' type='radio' value='No'  id='choice_80_602_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_602_1' id='label_80_602_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_603\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_603'>How many weeks?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_603' id='input_80_603' type='number' step='any' min='0' max='42' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_80_603\" \/><div class='gfield_description instruction ' id='gfield_instruction_80_603'>Por favor, escribe un n\u00famero entre <strong>0<\/strong> y <strong>42<\/strong>.<\/div><\/div><\/div><div id=\"field_80_604\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p><strong>Declaration of other illnesses<\/strong><br>Have you suffered, or do you currently suffer, any of the following? Tick all that apply.<\/p><\/div><fieldset id=\"field_80_605\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cancer \/ oncological processes<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_605'><div class='gchoice gchoice_80_605_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_605.1' type='checkbox'  value='Cancer \/ oncological processes'  id='choice_80_605_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_605_1' id='label_80_605_1' class='gform-field-label gform-field-label--type-inline'>Cancer \/ oncological processes<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_606\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Congenital diseases<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_606'><div class='gchoice gchoice_80_606_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_606.1' type='checkbox'  value='Congenital diseases'  id='choice_80_606_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_606_1' id='label_80_606_1' class='gform-field-label gform-field-label--type-inline'>Congenital diseases<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_607\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Demyelinating diseases<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_607'><div class='gchoice gchoice_80_607_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_607.1' type='checkbox'  value='Demyelinating diseases'  id='choice_80_607_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_607_1' id='label_80_607_1' class='gform-field-label gform-field-label--type-inline'>Demyelinating diseases<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_608\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Parkinson&#039;s disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_608'><div class='gchoice gchoice_80_608_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_608.1' type='checkbox'  value='Parkinson&#039;s disease'  id='choice_80_608_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_608_1' id='label_80_608_1' class='gform-field-label gform-field-label--type-inline'>Parkinson's disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_609\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Epilepsy<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_609'><div class='gchoice gchoice_80_609_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_609.1' type='checkbox'  value='Epilepsy'  id='choice_80_609_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_609_1' id='label_80_609_1' class='gform-field-label gform-field-label--type-inline'>Epilepsy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_610\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Intramedullary \/ intracranial pathology<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_610'><div class='gchoice gchoice_80_610_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_610.1' type='checkbox'  value='Intramedullary \/ intracranial pathology'  id='choice_80_610_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_610_1' id='label_80_610_1' class='gform-field-label gform-field-label--type-inline'>Intramedullary \/ intracranial pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_611\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Paraplegia \/ hemiplegia \/ tetraplegia<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_611'><div class='gchoice gchoice_80_611_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_611.1' type='checkbox'  value='Paraplegia \/ hemiplegia \/ tetraplegia'  id='choice_80_611_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_611_1' id='label_80_611_1' class='gform-field-label gform-field-label--type-inline'>Paraplegia \/ hemiplegia \/ tetraplegia<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_612\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Arteriosclerosis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_612'><div class='gchoice gchoice_80_612_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_612.1' type='checkbox'  value='Arteriosclerosis'  id='choice_80_612_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_612_1' id='label_80_612_1' class='gform-field-label gform-field-label--type-inline'>Arteriosclerosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_613\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Aortic aneurysm<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_613'><div class='gchoice gchoice_80_613_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_613.1' type='checkbox'  value='Aortic aneurysm'  id='choice_80_613_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_613_1' id='label_80_613_1' class='gform-field-label gform-field-label--type-inline'>Aortic aneurysm<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_614\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ischemic \/ valvular \/ cardiomyopathic heart disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_614'><div class='gchoice gchoice_80_614_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_614.1' type='checkbox'  value='Ischemic \/ valvular \/ cardiomyopathic heart disease'  id='choice_80_614_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_614_1' id='label_80_614_1' class='gform-field-label gform-field-label--type-inline'>Ischemic \/ valvular \/ cardiomyopathic heart disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_615\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Malignant hypertension<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_615'><div class='gchoice gchoice_80_615_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_615.1' type='checkbox'  value='Malignant hypertension'  id='choice_80_615_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_615_1' id='label_80_615_1' class='gform-field-label gform-field-label--type-inline'>Malignant hypertension<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_616\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Pulmonary fibrosis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_616'><div class='gchoice gchoice_80_616_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_616.1' type='checkbox'  value='Pulmonary fibrosis'  id='choice_80_616_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_616_1' id='label_80_616_1' class='gform-field-label gform-field-label--type-inline'>Pulmonary fibrosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_617\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chronic respiratory failure<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_617'><div class='gchoice gchoice_80_617_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_617.1' type='checkbox'  value='Chronic respiratory failure'  id='choice_80_617_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_617_1' id='label_80_617_1' class='gform-field-label gform-field-label--type-inline'>Chronic respiratory failure<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_618\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Cerebrovascular disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_618'><div class='gchoice gchoice_80_618_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_618.1' type='checkbox'  value='Cerebrovascular disease'  id='choice_80_618_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_618_1' id='label_80_618_1' class='gform-field-label gform-field-label--type-inline'>Cerebrovascular disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_619\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chronic kidney failure<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_619'><div class='gchoice gchoice_80_619_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_619.1' type='checkbox'  value='Chronic kidney failure'  id='choice_80_619_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_619_1' id='label_80_619_1' class='gform-field-label gform-field-label--type-inline'>Chronic kidney failure<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_620\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Chronic hepatopathy or pancreatitis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_620'><div class='gchoice gchoice_80_620_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_620.1' type='checkbox'  value='Chronic hepatopathy or pancreatitis'  id='choice_80_620_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_620_1' id='label_80_620_1' class='gform-field-label gform-field-label--type-inline'>Chronic hepatopathy or pancreatitis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_621\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Endocrine-metabolic pathology<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_621'><div class='gchoice gchoice_80_621_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_621.1' type='checkbox'  value='Endocrine-metabolic pathology'  id='choice_80_621_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_621_1' id='label_80_621_1' class='gform-field-label gform-field-label--type-inline'>Endocrine-metabolic pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_622\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ulcerative colitis \/ Crohn&#039;s disease<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_622'><div class='gchoice gchoice_80_622_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_622.1' type='checkbox'  value='Ulcerative colitis \/ Crohn&#039;s disease'  id='choice_80_622_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_622_1' id='label_80_622_1' class='gform-field-label gform-field-label--type-inline'>Ulcerative colitis \/ Crohn's disease<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_623\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Endometriosis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_623'><div class='gchoice gchoice_80_623_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_623.1' type='checkbox'  value='Endometriosis'  id='choice_80_623_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_623_1' id='label_80_623_1' class='gform-field-label gform-field-label--type-inline'>Endometriosis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_624\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Rheumatoid or psoriatic arthritis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_624'><div class='gchoice gchoice_80_624_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_624.1' type='checkbox'  value='Rheumatoid or psoriatic arthritis'  id='choice_80_624_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_624_1' id='label_80_624_1' class='gform-field-label gform-field-label--type-inline'>Rheumatoid or psoriatic arthritis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_625\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Muscular dystrophy<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_625'><div class='gchoice gchoice_80_625_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_625.1' type='checkbox'  value='Muscular dystrophy'  id='choice_80_625_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_625_1' id='label_80_625_1' class='gform-field-label gform-field-label--type-inline'>Muscular dystrophy<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_626\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Systemic lupus<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_626'><div class='gchoice gchoice_80_626_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_626.1' type='checkbox'  value='Systemic lupus'  id='choice_80_626_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_626_1' id='label_80_626_1' class='gform-field-label gform-field-label--type-inline'>Systemic lupus<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_627\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Dermatomyositis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_627'><div class='gchoice gchoice_80_627_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_627.1' type='checkbox'  value='Dermatomyositis'  id='choice_80_627_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_627_1' id='label_80_627_1' class='gform-field-label gform-field-label--type-inline'>Dermatomyositis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_628\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Ankylosing spondylitis<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_628'><div class='gchoice gchoice_80_628_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_628.1' type='checkbox'  value='Ankylosing spondylitis'  id='choice_80_628_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_628_1' id='label_80_628_1' class='gform-field-label gform-field-label--type-inline'>Ankylosing spondylitis<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_629\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Severe haematological disorders<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_629'><div class='gchoice gchoice_80_629_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_629.1' type='checkbox'  value='Severe haematological disorders'  id='choice_80_629_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_629_1' id='label_80_629_1' class='gform-field-label gform-field-label--type-inline'>Severe haematological disorders<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_630\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Osteoarticular surgery with prosthesis or implants<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_630'><div class='gchoice gchoice_80_630_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_630.1' type='checkbox'  value='Osteoarticular surgery with prosthesis or implants'  id='choice_80_630_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_630_1' id='label_80_630_1' class='gform-field-label gform-field-label--type-inline'>Osteoarticular surgery with prosthesis or implants<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_631\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Degenerative \/ accidental spine, hip, knee, shoulder or foot pathology<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_631'><div class='gchoice gchoice_80_631_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_631.1' type='checkbox'  value='Degenerative \/ accidental spine, hip, knee, shoulder or foot pathology'  id='choice_80_631_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_631_1' id='label_80_631_1' class='gform-field-label gform-field-label--type-inline'>Degenerative \/ accidental spine, hip, knee, shoulder or foot pathology<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_632\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Psychiatric disorders<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_632'><div class='gchoice gchoice_80_632_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_632.1' type='checkbox'  value='Psychiatric disorders'  id='choice_80_632_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_632_1' id='label_80_632_1' class='gform-field-label gform-field-label--type-inline'>Psychiatric disorders<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_633\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Eating disorders<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_633'><div class='gchoice gchoice_80_633_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_633.1' type='checkbox'  value='Eating disorders'  id='choice_80_633_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_633_1' id='label_80_633_1' class='gform-field-label gform-field-label--type-inline'>Eating disorders<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_634\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Transplants<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_634'><div class='gchoice gchoice_80_634_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_634.1' type='checkbox'  value='Transplants'  id='choice_80_634_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_634_1' id='label_80_634_1' class='gform-field-label gform-field-label--type-inline'>Transplants<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_635\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Allergies \/ Intolerances<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_635'><div class='gchoice gchoice_80_635_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_635.1' type='checkbox'  value='Allergies \/ Intolerances'  id='choice_80_635_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_635_1' id='label_80_635_1' class='gform-field-label gform-field-label--type-inline'>Allergies \/ Intolerances<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_80_636' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_80_636' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_80_13' class='gform_page um-cuest-6-page' data-js='page-field-id-636' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_80_13' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_80_637\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Insured 6 \u2014 Additional Confidential Medical Questionnaire<\/h3><div class='gsection_description' id='gfield_description_80_637'>Complete this questionnaire because you have flagged at least one health issue above. Up to 4 separate problems. For paired organs or limbs, indicate the side.<\/div><\/div><div id=\"field_80_638\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 1<\/h4><\/div><fieldset id=\"field_80_639\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 1: Current or Past?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_639'>\n\t\t\t<div class='gchoice gchoice_80_639_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_639' type='radio' value='Current'  id='choice_80_639_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_639_0' id='label_80_639_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_639_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_639' type='radio' value='Past'  id='choice_80_639_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_639_1' id='label_80_639_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_640\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_640'>Start date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_640' id='input_80_640' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_640_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_80_640_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_640' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_641\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_641'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_641' id='input_80_641' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_641_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_641_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_641' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_642\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_642'>Describe the problem<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_642' id='input_80_642' class='textarea large'   maxlength='40'  aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_643\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_643'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_643' id='input_80_643' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_644\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_644'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_644' id='input_80_644' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_645\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_645'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_645' id='input_80_645' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_646\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_646'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_646' id='input_80_646' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_647\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_647'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_647' id='input_80_647' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_648\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_648'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_648' id='input_80_648' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_649\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 2<\/h4><\/div><fieldset id=\"field_80_650\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 2: Current or Past?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_650'>\n\t\t\t<div class='gchoice gchoice_80_650_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_650' type='radio' value='Current'  id='choice_80_650_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_650_0' id='label_80_650_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_650_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_650' type='radio' value='Past'  id='choice_80_650_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_650_1' id='label_80_650_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_651\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_651'>Start date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_651' id='input_80_651' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_651_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_651_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_651' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_652\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_652'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_652' id='input_80_652' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_652_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_652_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_652' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_653\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_653'>Describe the problem<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_653' id='input_80_653' class='textarea large'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_654\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_654'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_654' id='input_80_654' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_655\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_655'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_655' id='input_80_655' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_656\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_656'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_656' id='input_80_656' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_657\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_657'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_657' id='input_80_657' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_658\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_658'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_658' id='input_80_658' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_659\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_659'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_659' id='input_80_659' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_660\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 3<\/h4><\/div><fieldset id=\"field_80_661\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 3: Current or Past?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_661'>\n\t\t\t<div class='gchoice gchoice_80_661_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_661' type='radio' value='Current'  id='choice_80_661_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_661_0' id='label_80_661_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_661_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_661' type='radio' value='Past'  id='choice_80_661_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_661_1' id='label_80_661_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_662\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_662'>Start date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_662' id='input_80_662' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_662_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_662_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_662' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_663\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_663'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_663' id='input_80_663' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_663_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_663_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_663' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_664\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_664'>Describe the problem<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_664' id='input_80_664' class='textarea large'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_665\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_665'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_665' id='input_80_665' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_666\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_666'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_666' id='input_80_666' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_667\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_667'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_667' id='input_80_667' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_668\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_668'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_668' id='input_80_668' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_669\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_669'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_669' id='input_80_669' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_670\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_670'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_670' id='input_80_670' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_671\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>Problem 4<\/h4><\/div><fieldset id=\"field_80_672\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Problem 4: Current or Past?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_80_672'>\n\t\t\t<div class='gchoice gchoice_80_672_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_672' type='radio' value='Current'  id='choice_80_672_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_672_0' id='label_80_672_0' class='gform-field-label gform-field-label--type-inline'>Current<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_80_672_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_672' type='radio' value='Past'  id='choice_80_672_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_80_672_1' id='label_80_672_1' class='gform-field-label gform-field-label--type-inline'>Past<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_673\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_673'>Start date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_673' id='input_80_673' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_673_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_673_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_673' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_674\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_674'>End date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_674' id='input_80_674' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_674_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_80_674_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_674' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_675\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_675'>Describe the problem<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_675' id='input_80_675' class='textarea large'   maxlength='40'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_676\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_676'>1st \u2014 Cause (e.g. illness, accident, congenital, pregnancy, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_676' id='input_80_676' class='textarea large'   maxlength='60'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_677\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_677'>2nd \u2014 Exact location (e.g. left leg, right arm, ears, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_677' id='input_80_677' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_678\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_678'>3rd \u2014 Treatment (medical, surgical, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_678' id='input_80_678' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_679\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_679'>4th \u2014 Prostheses or surgical material implanted (e.g. osteosynthesis: pins, screws, mesh, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_679' id='input_80_679' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_680\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_680'>5th \u2014 Future planned diagnostic tests or treatments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_680' id='input_80_680' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_681\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_681'>6th \u2014 Current status and possible sequelae (e.g. cured, minor discomfort, limp, etc.)<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_681' id='input_80_681' class='textarea large'   maxlength='100'   aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_80_682\" class=\"gfield gfield--type-html gfield--input-type-html gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h4 style='margin:1em 0 .25em'>7th \u2014 Refractive eye defect<\/h4><\/div><div id=\"field_80_683\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_683'>Specify (myopia, hyperopia, astigmatism, etc.)<\/label><div class='ginput_container ginput_container_text'><input name='input_683' id='input_80_683' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_685\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_685'>Dioptres left eye<\/label><div class='ginput_container ginput_container_text'><input name='input_685' id='input_80_685' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_684\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_684'>Dioptres right eye<\/label><div class='ginput_container ginput_container_text'><input name='input_684' id='input_80_684' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_706\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Newborn<\/h3><\/div><div id=\"field_80_723\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_723'>Week of gestation at birth<\/label><div class='ginput_container ginput_container_number'><input name='input_723' id='input_80_723' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_80_717\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_717'>Birth weight (kg)<\/label><div class='ginput_container ginput_container_number'><input name='input_717' id='input_80_717' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_80_689\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Type of assistance received or required<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_689'><div class='gchoice gchoice_80_689_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_689.1' type='checkbox'  value='Incubator'  id='choice_80_689_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_689_1' id='label_80_689_1' class='gform-field-label gform-field-label--type-inline'>Incubator<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_80_689_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_689.2' type='checkbox'  value='Intermediate care'  id='choice_80_689_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_689_2' id='label_80_689_2' class='gform-field-label gform-field-label--type-inline'>Intermediate care<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_80_689_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_689.3' type='checkbox'  value='ICU'  id='choice_80_689_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_689_3' id='label_80_689_3' class='gform-field-label gform-field-label--type-inline'>ICU<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_80_689_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_689.4' type='checkbox'  value='Paediatric consultations'  id='choice_80_689_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_689_4' id='label_80_689_4' class='gform-field-label gform-field-label--type-inline'>Paediatric consultations<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_80_690\" class=\"gfield gfield--type-text gfield--input-type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_690'>Paediatric specialty<\/label><div class='ginput_container ginput_container_text'><input name='input_690' id='input_80_690' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_691\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_691'>Specify congenital condition<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_691' id='input_80_691' class='textarea large'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_80_692' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_80_692' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_80_14' class='gform_page um-complements-page' data-js='page-field-id-692' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_80_14' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_80_726\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_noborder field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_726'>Monthly Health Insurance price<\/label><div class='ginput_container ginput_container_number'><input readonly='readonly' name='input_726' id='input_80_726' type='text' step='any'   value='' class='small'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_80_693\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Optional supplements<\/h3><div class='gsection_description' id='gfield_description_80_693'>Do you want to add any of the following supplements?<\/div><\/div><fieldset id=\"field_80_694\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Supplements<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_694'><div class='gchoice gchoice_80_694_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_694.1' type='checkbox'  value='Dental'  id='choice_80_694_1'   aria-describedby=\"gfield_description_80_694\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_80_694_1' id='label_80_694_1' class='gform-field-label gform-field-label--type-inline'>Dental<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_80_694'>4,5\u20ac \/ month per applicant<\/div><\/fieldset><div id=\"field_80_739\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_noborder gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_739'>Dental Insurance Price<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_739' id='input_80_739' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"   aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_80_737\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-full gf_noborder gfield_contains_required gfield_calculation field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_737'>Monthly price<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_737' id='input_80_737' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_80_737\" \/><\/div><div class='gfield_description' id='gfield_description_80_737'>Total price for all applicants<\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_80_696' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Previous'  \/> <input type='button' id='gform_next_button_80_696' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Next'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_80_15' class='gform_page um-signature-page' data-js='page-field-id-696' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_80_15' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_80_724\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_80_724'>Date of effect of the policy<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='gfield_description' id='gfield_description_80_724'>Please select the 1st day of the month as the start date for your policy. Policies can only commence on the first day of any given month.<\/div><div class='ginput_container ginput_container_date'>\n                            <div style=\"display:none;\"><input name='input_724' id='input_80_724' type='text' value='' class='has-inline-datepicker gform-has-inline-datepicker dmy has-inline-datepicker_with_icon ghas-inline-datepicker_with_icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_80_724_date_format gfield_description_80_724\" aria-invalid=\"false\" aria-required=\"true\"\/><\/div><div id=\"datepicker_80_724\" class=\"datepicker gform-datepicker gpld-inline-datepicker dmy\"><\/div><style type=\"text\/css\">#datepicker_80_724 .ui-datepicker-inline { margin: 0 0 20px; }<\/style>\n                            <span id='input_80_724_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_80_724' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_80_697\" class=\"gfield gfield--type-section gfield--input-type-section gsection um-section field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Declaration and signature<\/h3><div class='gsection_description' id='gfield_description_80_697'>I declare that I have answered truthfully everything stated in this application and acknowledge having received the information prior to signing the insurance. I consent to the processing of personal data.<\/div><\/div><div id=\"field_80_743\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><\/div><fieldset id=\"field_80_744\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Terms of Use of the Medical Network &amp; Reimbursement Commitment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_80_744' tabindex='0'>STATEMENT OF ACKNOWLEDGMENT AND ACCEPTANCE OF THE TERMS OF USE OF THE MEDICAL NETWORK CONTRACTED BY THE COMPANY AND REIMBURSEMENT COMMITMENT (v1.2)<br \/>\n<br \/>\nBetween LA UNI\u00d3N MADRILE\u00d1A DE SEGUROS, S.A. (registered office: Calle Viriato, n\u00ba 2, 28010 Madrid; C.I.F. A-28081818; DGSFP register no. C0368) \u2014 the \"Insurer\" \u2014 and the Applicant (future Policyholder).<br \/>\n<br \/>\nEXPLANATORY STATEMENTS<br \/>\n<br \/>\n1. The Applicant, as a foreigner, is contracting Health Assistance Insurance with the Insurer in order to meet the legal residence requirements in Spain under Organic Law 4\/2000 (Immigration Law) and Royal Decree 240\/2007, regarding accreditation of health coverage equivalent to that of the National Health System.<br \/>\n<br \/>\n2. The coverage operates under a Closed Network: medical services are provided exclusively through professionals and medical or hospital centres contracted by the Insurer. The Applicant acknowledges having been informed of the composition of this network and agrees with it and with the scope of the coverage provided.<br \/>\n<br \/>\n3. The Applicant declares having been clearly and precisely informed about the composition of the agreed network, accepting it as an essential condition for the Insurer's risk assessment.<br \/>\n<br \/>\n4. This agreement regulates the legal and economic consequences should the Applicant or any beneficiary voluntarily seek medical assistance at centres not included in the Insurer's medical directory.<br \/>\n<br \/>\nCLAUSES<br \/>\n<br \/>\nFIRST \u2014 Delimitation of risk and commitment to use the agreed network.<br \/>\nHealthcare is guaranteed only through the Insurer's medical facilities or affiliated hospitals. Any assistance received at centres outside the contracted network (public or private) is considered not covered \u2014 except in cases of vital emergency under Clause Four \u2014 and exempts the Insurer from any obligation of payment, advance or reimbursement.<br \/>\n<br \/>\nSECOND \u2014 Obligation to inform beneficiaries.<br \/>\nThe Applicant undertakes to forward the contents of this document to all beneficiaries and, as future Policyholder, will be personally liable to the Insurer for any expenses arising from the beneficiaries' failure to comply.<br \/>\n<br \/>\nTHIRD \u2014 Means of consulting the medical staff.<br \/>\nThe Insurer provides the full network list through: the digital platform and mobile app (www.unionmadrilena.es, real-time updates); 24-hour telephone support (free number 900 799 148, 365 days a year); and PDF\/physical format provided with the Special Conditions. The Applicant must consult these resources before receiving any benefit; ignorance of the network does not exempt the Applicant from assuming the costs of care obtained through the public system or a non-affiliated private entity.<br \/>\n<br \/>\nFOURTH \u2014 Exception for imminent life-threatening emergency.<br \/>\nThe obligation to use the agreed network does not apply in cases of imminent life emergency (an unforeseen clinical situation posing an immediate and irreversible risk to life or physical integrity, where distance or severity prevents transfer to a contracted facility). Coverage is limited to the care necessary until clinical stabilisation and possible transfer to the contracted network. The Insurer is not responsible for the quality, outcome or incidents of such care.<br \/>\n<br \/>\nFIFTH \u2014 Assumption of costs and right of recovery.<br \/>\nExcept in life-threatening emergencies, if the Applicant or beneficiaries voluntarily attend the public health network or external private centres and these bill the Insurer, the Applicant must reimburse the Insurer 100% of the full invoiced amount within a maximum of 15 calendar days from notification of the charge.<br \/>\n<br \/>\nSIXTH \u2014 Duty of confidentiality.<br \/>\nThe Applicant will maintain strict discretion regarding the existence of the policy with respect to third parties and manage healthcare requests on a strictly personal basis. Should policy details be disclosed to the public healthcare network \u2014 and any resulting claim be made against the Insurer \u2014 the Applicant assumes sole financial responsibility for the resulting invoices, which will be sent for reimbursement.<br \/>\n<br \/>\nSEVENTH \u2014 Resolutory condition for non-compliance.<br \/>\nThe validity of the insurance contract is subject to compliance with the reimbursement obligations herein. Refusal to pay the medical costs incurred, or the return of the corresponding bank receipts, entitles the Insurer to immediate termination of the contract for breach of essential conditions. As this insurance is a requirement for legal residency, the Insurer will notify the termination to the competent Immigration Authorities for the appropriate legal purposes and consequences.<br \/>\n<br \/>\nEIGHTH \u2014 Specific acceptance of limitative clauses.<br \/>\nThe Applicant declares having read and understood this document and expressly acknowledges that the clauses establishing (i) exclusion of coverage outside the medical network, (ii) the obligation to reimburse expenses billed by third parties, and (iii) the right to terminate the contract, constitute clauses limiting their rights, which are specifically and separately accepted by signing, as required by Article 3 of Law 50\/1980 on Insurance Contracts.<\/div><div class='ginput_container ginput_container_consent'><input name='input_744.1' id='input_80_744_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_80_744\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_80_744_1' >I have read, understood and expressly accept the Terms of Use of the Contracted Medical Network and the Reimbursement Commitment   set out below (v1.2). I specifically and separately accept the limitative clauses they contain, as required by Article 3 of Law   50\/1980 on Insurance Contracts.<\/label><input type='hidden' name='input_744.2' value='I have read, understood and expressly accept the Terms of Use of the Contracted Medical Network and the Reimbursement Commitment   set out below (v1.2). I specifically and separately accept the limitative clauses they contain, as required by Article 3 of Law   50\/1980 on Insurance Contracts.' class='gform_hidden' \/><input type='hidden' name='input_744.3' value='6' class='gform_hidden' \/><\/div><\/fieldset><fieldset id=\"field_80_699\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Data protection consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_699'><div class='gchoice gchoice_80_699_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_699.1' type='checkbox'  value='I have read and accepted the &lt;a href=&quot;https:\/\/insbrok.com\/personal-data-protection-policy\/&quot; target=&quot;_blank&quot;&gt;data protection policy&lt;\/a&gt;'  id='choice_80_699_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_699_1' id='label_80_699_1' class='gform-field-label gform-field-label--type-inline'>I have read and accepted the <a href=\"https:\/\/insbrok.com\/personal-data-protection-policy\/\" target=\"_blank\">data protection policy<\/a><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_736\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Renewals and Refunds<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_80_736'><div class='gchoice gchoice_80_736_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_736.1' type='checkbox'  value='I understand that, as required by Spanish law, the insurance contract will be automatically renewed annually unless I inform otherwise in writing at least 30 days prior to the renewal date. I also acknowledge that refunds are only available in case of visa denial, upon presentation of a legal denial letter, and will be based on the months of coverage.'  id='choice_80_736_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_80_736_1' id='label_80_736_1' class='gform-field-label gform-field-label--type-inline'>I understand that, as required by Spanish law, the insurance contract will be automatically renewed annually unless I inform otherwise in writing at least 30 days prior to the renewal date. I also acknowledge that refunds are only available in case of visa denial, upon presentation of a legal denial letter, and will be based on the months of coverage.<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_80_698\" class=\"gfield gfield--type-signature gfield--input-type-signature gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Signature<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class=\"ginput_container ginput_container_signature\"><input type='hidden' value='' name='input_698' id='input_80_698_signature_filename'\/><div class='gfield_signature_ui_container gform-theme__no-reset--children' ><div id='input_80_698_Container' class='gfield_signature_container' style='height:180px; width:450px; ' ><canvas id=\"input_80_698\" width=\"450\" height=\"180\" style=\"border-style: Dashed; border-width: 2px; border-color: #DDDDDD; background-color:#FFFFFF; cursor: url(https:\/\/insbrok.com\/wp-content\/plugins\/formecho-signature-add-on\/assets\/img\/pen.cur), pointer;\" tabindex=\"0\" aria-label=\"Signature pad\" ><\/canvas><\/div><div id='input_80_698_toolbar' style='margin:5px 0;position:relative;height:20px;width:450px;max-width:100%;'><img id='input_80_698_resetbutton' src='data:image\/png;base64,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' style='cursor:pointer;float:right;height:24px;width:24px;border:0px solid transparent' alt='Clear Signature' role='button' tabindex='0' aria-label='Clear Signature' \/><\/div><input type='hidden' id='input_80_698_data' name='input_80_698_data' value=''><\/div><\/div><\/fieldset><div id=\"field_80_701\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class='ginput_container ginput_container_text'><input name='input_701' id='input_80_701' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='UNION MADRILE\u00d1A' \/><\/div><\/div><div id=\"field_80_703\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class='ginput_container ginput_container_text'><input name='input_703' id='input_80_703' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='' \/><\/div><\/div><div id=\"field_80_733\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_80_733'>Exclude workflow<\/label><div class='ginput_container ginput_container_text'><input name='input_733' id='input_80_733' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_734\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_80_734'>affwp_ref<\/label><div class='ginput_container ginput_container_text'><input name='input_734' id='input_80_734' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_735\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_80_735'>Language<\/label><div class='ginput_container ginput_container_text'><input name='input_735' id='input_80_735' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_80_702\" class=\"gfield gfield--type-uid gfield--input-type-uid field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><label class='gfield_label gform-field-label' for='input_80_702'>Order nr<\/label><div class='ginput_container ginput_container_hidden'><input name='input_702' id='input_80_702' type='hidden' value=''  \/><\/div><\/div><div id=\"field_80_740\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below 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