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188        For Life Insurance and/or Disability Income Replacement Insurance</h1>
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245    
246    <div id="cph_main_ctl05_control_space">
247			<input name="ctl00$cph_main$ctl05$txtPrimaryLast" type="text" maxlength="50" id="cph_main_ctl05_txtPrimaryLast" aria-label="Personal Information Last Name" />
248		</div>
249    
250</div>
251
252
253<div id="cph_main_ctl06_tr_controlRow" class="form-column">
254    <div id="cph_main_ctl06_LabelLiteral">
255			<span id="cph_main_ctl06_lbl_txtBirthDate" class="formFieldText" style="font-weight:bold;">Date of Birth</span><span id="cph_main_ctl06_lbl_req" class="formFieldRequiredTag"> *</span>
256		</div>
257
258    
259    <div id="cph_main_ctl06_control_space">
260			
261<table style="border-collapse:collapse; border: 0px none;"  role="presentation">
262    <tr>
263        <td style="padding: 0px 5px 0px 0px; border: 0px none;">
264            <select name="ctl00$cph_main$ctl06$txtBirthDate$ddl_wuc_Month" id="cph_main_ctl06_txtBirthDate_ddl_wuc_Month" aria-label="Personal Information Date of Birth Month">
265				<option value="1">January</option>
266				<option value="2">February</option>
267				<option value="3">March</option>
268				<option value="4">April</option>
269				<option value="5">May</option>
270				<option value="6">June</option>
271				<option value="7">July</option>
272				<option value="8">August</option>
273				<option value="9">September</option>
274				<option value="10">October</option>
275				<option value="11">November</option>
276				<option value="12">December</option>
277
278			</select>
279        </td>
280        <td style="padding: 0px; border: 0px none;">/</td>
281        <td style="padding: 0px 5px; border: 0px none;">
282            <select name="ctl00$cph_main$ctl06$txtBirthDate$ddl_wuc_Day" id="cph_main_ctl06_txtBirthDate_ddl_wuc_Day" aria-label="Personal Information Date of Birth Day">
283				<option value="1">1</option>
284				<option value="2">2</option>
285				<option value="3">3</option>
286				<option value="4">4</option>
287				<option value="5">5</option>
288				<option value="6">6</option>
289				<option value="7">7</option>
290				<option value="8">8</option>
291				<option value="9">9</option>
292				<option value="10">10</option>
293				<option value="11">11</option>
294				<option value="12">12</option>
295				<option value="13">13</option>
296				<option value="14">14</option>
297				<option value="15">15</option>
298				<option value="16">16</option>
299				<option value="17">17</option>
300				<option value="18">18</option>
301				<option value="19">19</option>
302				<option value="20">20</option>
303				<option value="21">21</option>
304				<option value="22">22</option>
305				<option value="23">23</option>
306				<option value="24">24</option>
307				<option value="25">25</option>
308				<option value="26">26</option>
309				<option value="27">27</option>
310				<option value="28">28</option>
311				<option value="29">29</option>
312				<option value="30">30</option>
313				<option value="31">31</option>
314
315			</select>
316        </td>
317        <td style="padding: 0px; border: 0px none;">/</td>
318        <td style="padding: 0px 5px; border: 0px none;">
319            <select name="ctl00$cph_main$ctl06$txtBirthDate$ddl_wuc_Year" id="cph_main_ctl06_txtBirthDate_ddl_wuc_Year" aria-label="Personal Information Date of Birth Year">
320				<option value="2036">2036</option>
321				<option value="2035">2035</option>
322				<option value="2034">2034</option>
323				<option value="2033">2033</option>
324				<option value="2032">2032</option>
325				<option value="2031">2031</option>
326				<option value="2030">2030</option>
327				<option value="2029">2029</option>
328				<option value="2028">2028</option>
329				<option value="2027">2027</option>
330				<option selected="selected" value="2026">2026</option>
331				<option value="2025">2025</option>
332				<option value="2024">2024</option>
333				<option value="2023">2023</option>
334				<option value="2022">2022</option>
335				<option value="2021">2021</option>
336				<option value="2020">2020</option>
337				<option value="2019">2019</option>
338				<option value="2018">2018</option>
339				<option value="2017">2017</option>
340				<option value="2016">2016</option>
341				<option value="2015">2015</option>
342				<option value="2014">2014</option>
343				<option value="2013">2013</option>
344				<option value="2012">2012</option>
345				<option value="2011">2011</option>
346				<option value="2010">2010</option>
347				<option value="2009">2009</option>
348				<option value="2008">2008</option>
349				<option value="2007">2007</option>
350				<option value="2006">2006</option>
351				<option value="2005">2005</option>
352				<option value="2004">2004</option>
353				<option value="2003">2003</option>
354				<option value="2002">2002</option>
355				<option value="2001">2001</option>
356				<option value="2000">2000</option>
357				<option value="1999">1999</option>
358				<option value="1998">1998</option>
359				<option value="1997">1997</option>
360				<option value="1996">1996</option>
361				<option value="1995">1995</option>
362				<option value="1994">1994</option>
363				<option value="1993">1993</option>
364				<option value="1992">1992</option>
365				<option value="1991">1991</option>
366				<option value="1990">1990</option>
367				<option value="1989">
3671989</option>
368				<option value="1988">1988</option>
369				<option value="1987">1987</option>
370				<option value="1986">1986</option>
371				<option value="1985">1985</option>
372				<option value="1984">1984</option>
373				<option value="1983">1983</option>
374				<option value="1982">1982</option>
375				<option value="1981">1981</option>
376				<option value="1980">1980</option>
377				<option value="1979">1979</option>
378				<option value="1978">1978</option>
379				<option value="1977">1977</option>
380				<option value="1976">1976</option>
381				<option value="1975">1975</option>
382				<option value="1974">1974</option>
383				<option value="1973">1973</option>
384				<option value="1972">1972</option>
385				<option value="1971">1971</option>
386				<option value="1970">1970</option>
387				<option value="1969">1969</option>
388				<option value="1968">1968</option>
389				<option value="1967">1967</option>
390				<option value="1966">1966</option>
391				<option value="1965">1965</option>
392				<option value="1964">1964</option>
393				<option value="1963">1963</option>
394				<option value="1962">1962</option>
395				<option value="1961">1961</option>
396				<option value="1960">1960</option>
397				<option value="1959">1959</option>
398				<option value="1958">1958</option>
399				<option value="1957">1957</option>
400				<option value="1956">1956</option>
401				<option value="1955">1955</option>
402				<option value="1954">1954</option>
403				<option value="1953">1953</option>
404				<option value="1952">1952</option>
405				<option value="1951">1951</option>
406				<option value="1950">1950</option>
407				<option value="1949">1949</option>
408				<option value="1948">1948</option>
409				<option value="1947">1947</option>
410				<option value="1946">1946</option>
411				<option value="1945">1945</option>
412				<option value="1944">1944</option>
413				<option value="1943">1943</option>
414				<option value="1942">1942</option>
415				<option value="1941">1941</option>
416				<option value="1940">1940</option>
417				<option value="1939">1939</option>
418				<option value="1938">1938</option>
419				<option value="1937">1937</option>
420				<option value="1936">1936</option>
421				<option value="1935">1935</option>
422				<option value="1934">1934</option>
423				<option value="1933">1933</option>
424				<option value="1932">1932</option>
425				<option value="1931">1931</option>
426				<option value="1930">1930</option>
427				<option value="1929">1929</option>
428				<option value="1928">1928</option>
429				<option value="1927">1927</option>
430				<option value="1926">1926</option>
431				<option value="1925">1925</option>
432				<option value="1924">1924</option>
433				<option value="1923">1923</option>
434				<option value="1922">1922</option>
435				<option value="1921">1921</option>
436				<option value="1920">1920</option>
437				<option value="1919">1919</option>
438				<option value="1918">1918</option>
439				<option value="1917">1917</option>
440				<option value="1916">1916</option>
441				<option value="1915">1915</option>
442				<option value="1914">1914</option>
443				<option value="1913">1913</option>
444				<option value="1912">1912</option>
445				<option value="1911">1911</option>
446				<option value="1910">1910</option>
447				<option value="1909">1909</option>
448				<option value="1908">1908</option>
449				<option value="1907">1907</option>
450				<option value="1906">1906</option>
451				<option value="1905">1905</option>
452				<option value="1904">1904</option>
453				<option value="1903">1903</option>
454				<option value="1902">1902</option>
455				<option value="1901">1901</option>
456				<option value="1900">1900</option>
457
458			</select>
459        </td>
460    </tr>
461</table>
462		</div>
463    
464</div>
465
466
467<div id="cph_main_ctl07_tr_controlRow" class="form-column">
468    <div id="cph_main_ctl07_LabelLiteral">
469			<span id="cph_main_ctl07_lbl_TextBox_639258503795948282_7" class="formFieldText" style="font-weight:bold;">Birth Location (US State or Country)</span><span id="cph_main_ctl07_lbl_req" class="formFieldRequiredTag"> *</span>
470		</div>
471
472    
473    <div id="cph_main_ctl07_control_space">
474			<input name="ctl00$cph_main$ctl07$TextBox_639258503795948282_7" type="text" maxlength="50" id="cph_main_ctl07_TextBox_639258503795948282_7" aria-label="Personal Information Birth Location (US State or Country)" />
475		</div>
476    
477</div>
478
479
480<div id="cph_main_ctl08_tr_controlRow" class="form-column">
481    <div id="cph_main_ctl08_LabelLiteral">
482			<span id="cph_main_ctl08_lbl_RadioButtonList_636870445410258785_8" class="formFieldText" style="font-weight:bold;">Gender</span>
482<span id="cph_main_ctl08_lbl_req" class="formFieldRequiredTag"> *</span>
483		</div>
484
485    
486    <div id="cph_main_ctl08_control_space">
487			<span id="cph_main_ctl08_RadioButtonList_636870445410258785_8" class="plainText rblCntrl"><input id="cph_main_ctl08_RadioButtonList_636870445410258785_8_0" type="radio" name="ctl00$cph_main$ctl08$RadioButtonList_636870445410258785_8" value="Male" checked="checked" /><label for="cph_main_ctl08_RadioButtonList_636870445410258785_8_0">Male</label><br /><input id="cph_main_ctl08_RadioButtonList_636870445410258785_8_1" type="radio" name="ctl00$cph_main$ctl08$RadioButtonList_636870445410258785_8" value="Female" /><label for="cph_main_ctl08_RadioButtonList_636870445410258785_8_1">Female</label></span>
488		</div>
489    
490</div>
491
492
493<div id="cph_main_ctl09_tr_controlRow" class="form-column">
494    <div id="cph_main_ctl09_LabelLiteral">
495			<span id="cph_main_ctl09_lbl_txtStreet" class="formFieldText" style="font-weight:bold;">Street</span><span id="cph_main_ctl09_lbl_req" class="formFieldRequiredTag"> *</span>
496		</div>
497
498    
499    <div id="cph_main_ctl09_control_space">
500			<input name="ctl00$cph_main$ctl09$txtStreet" type="text" maxlength="255" id="cph_main_ctl09_txtStreet" aria-label="Personal Information Street" />
501		</div>
502    
503</div>
504
505
506<div id="cph_main_ctl10_tr_controlRow" class="form-column">
507    <div id="cph_main_ctl10_LabelLiteral">
508			<span id="cph_main_ctl10_lbl_txtState" class="formFieldText" style="font-weight:bold;">State</span><span id="cph_main_ctl10_lbl_req" class="formFieldRequiredTag"> *</span>
509		</div>
510
511    
512    <div id="cph_main_ctl10_control_space">
513			<select name="ctl00$cph_main$ctl10$txtState" id="cph_main_ctl10_txtState" aria-label="Personal Information State">
514				<option value="AL">AL</option>
515				<option value="AK">AK</option>
516				<option value="AZ">AZ</option>
517				<option value="AR">AR</option>
518				<option value="CA">CA</option>
519				<option value="CO">CO</option>
520				<option value="CT">CT</option>
521				<option value="DE">DE</option>
522				<option value="FL">FL</option>
523				<option value="GA">GA</option>
524				<option value="HI">HI</option>
525				<option value="ID">ID</option>
526				<option value="IA">IA</option>
527				<option value="IL">IL</option>
528				<option value="IN">IN</option>
529				<option value="KS">KS</option>
530				<option value="KY">KY</option>
531				<option value="LA">LA</option>
532				<option value="ME">ME</option>
533				<option value="MD">MD</option>
534				<option value="MA">MA</option>
535				<option value="MI">MI</option>
536				<option value="MN">MN</option>
537				<option value="MS">MS</option>
538				<option value="MO">MO</option>
539				<option value="MT">MT</option>
540				<option value="NC">NC</option>
541				<option value="ND">ND</option>
542				<option value="NE">NE</option>
543				<option value="NV">NV</option>
544				<option value="NH">NH</option>
545				<option value="NJ">NJ</option>
546				<option value="NM">NM</option>
547				<option value="NY">NY</option>
548				<option value="OH">OH</option>
549				<option value="OK">OK</option>
550				<option value="OR">OR</option>
551				<option value="PA">PA</option>
552				<option value="RI">RI</option>
553				<option value="SC">SC</option>
554				<option value="SD">SD</option>
555				<option value="TN">TN</option>
556				<option value="TX">TX</option>
557				<option value="UT">UT</option>
558				<option value="VT">VT</option>
559				<option value="VA">VA</option>
560				<option value="WA">WA</option>
561				<option value="DC">DC</option>
562				<option value="WV">WV</option>
563				<option value="WI">WI</option>
564				<option value="WY">WY</option>
565
566			</select>
567		</div>
568    
569</div>
570
571
572<div id="cph_main_ctl11_tr_controlRow" class="form-column">
573    <div id="cph_main_ctl11_LabelLiteral">
574			<span id="cph_main_ctl11_lbl_txtZIP" class="formFieldText" style="font-weight:bold;">ZIP / Postal Code</span><span id="cph_main_ctl11_lbl_req" class="formFieldRequiredTag"> *</span>
575		</div>
576
577    
578    <div id="cph_main_ctl11_control_space">
579			<input name="ctl00$cph_main$ctl11$txtZIP" type="text" maxlength="10" id="cph_main_ctl11_txtZIP" aria-label="Personal Information ZIP / Postal Code" />
580		</div>
581    
582</div>
583
584
585<div id="cph_main_ctl12_tr_controlRow" class="form-column">
586    <div id="cph_main_ctl12_LabelLiteral">
587			<span id="cph_main_ctl12_lbl_TextBox_636888745558229927_12" class="formFieldText" style="font-weight:bold;">Marital Status</span>
588		</div>
589
590    
591    <div id="cph_main_ctl12_control_space">
592			<input name="ctl00$cph_main$ctl12$TextBox_636888745558229927_12" type="text" maxlength="50" id="cph_main_ctl12_TextBox_636888745558229927_12" aria-label="Personal Information Marital Status" />
593		</div>
594    
595</div>
596
597
598<div id="cph_main_ctl13_tr_controlRow" class="form-column">
599    <div id="cph_main_ctl13_LabelLiteral">
600			<span id="cph_main_ctl13_lbl_RadioButtonList_636870446211242234_13" class="formFieldText" style="font-weight:bold;">U.S. Citizen?</span>
600<span id="cph_main_ctl13_lbl_req" class="formFieldRequiredTag"> *</span>
601		</div>
602
603    
604    <div id="cph_main_ctl13_control_space">
605			<span id="cph_main_ctl13_RadioButtonList_636870446211242234_13" class="plainText rblCntrl"><input id="cph_main_ctl13_RadioButtonList_636870446211242234_13_0" type="radio" name="ctl00$cph_main$ctl13$RadioButtonList_636870446211242234_13" value="Yes" checked="checked" /><label for="cph_main_ctl13_RadioButtonList_636870446211242234_13_0">Yes</label><br /><input id="cph_main_ctl13_RadioButtonList_636870446211242234_13_1" type="radio" name="ctl00$cph_main$ctl13$RadioButtonList_636870446211242234_13" value="No" /><label for="cph_main_ctl13_RadioButtonList_636870446211242234_13_1">No</label></span>
606		</div>
607    
608</div>
609
610
611<div id="cph_main_ctl14_tr_controlRow" class="form-column">
612    <div id="cph_main_ctl14_LabelLiteral">
613			<span id="cph_main_ctl14_lbl_DropDown_636888744554159858_14" class="formFieldText" style="font-weight:bold;">Do you have a Visa or Green Card?</span><span id="cph_main_ctl14_lbl_req" class="formFieldRequiredTag"> *</span>
614		</div>
615
616    
617    <div id="cph_main_ctl14_control_space">
618			<select name="ctl00$cph_main$ctl14$DropDown_636888744554159858_14" id="cph_main_ctl14_DropDown_636888744554159858_14" aria-label="Personal Information Do you have a Visa or Green Card?">
619				<option value="Not Applicable">Not Applicable</option>
620				<option value="Green Card">Green Card</option>
621				<option value="Visa">Visa</option>
622
623			</select>
624		</div>
625    
626</div>
627
628
629<div id="cph_main_ctl15_tr_controlRow" class="form-column">
630    <div id="cph_main_ctl15_LabelLiteral">
631			<span id="cph_main_ctl15_lbl_TextBox_636888742702761187_15" class="formFieldText" style="font-weight:bold;">If you have a Visa, what type?</span>
632		</div>
633
634    
635    <div id="cph_main_ctl15_control_space">
636			<input name="ctl00$cph_main$ctl15$TextBox_636888742702761187_15" type="text" maxlength="50" id="cph_main_ctl15_TextBox_636888742702761187_15" aria-label="Personal Information If you have a Visa, what type?" />
637		</div>
638    
639</div>
640
641
642<div id="cph_main_ctl16_tr_controlRow" class="form-column">
643    <div id="cph_main_ctl16_LabelLiteral">
644			<span id="cph_main_ctl16_lbl_txtPrimaryNumber" class="formFieldText" style="font-weight:bold;">Primary Phone Number</span><span id="cph_main_ctl16_lbl_req" class="formFieldRequiredTag"> *</span>
645		</div>
646
647    
648    <div id="cph_main_ctl16_control_space">
649			<input name="ctl00$cph_main$ctl16$txtPrimaryNumber" type="text" maxlength="20" id="cph_main_ctl16_txtPrimaryNumber" aria-label="Personal Information Primary Phone Number" />
650		</div>
651    
652</div>
653
654
655<div id="cph_main_ctl17_tr_controlRow" class="form-column">
656    <div id="cph_main_ctl17_LabelLiteral">
657			<span id="cph_main_ctl17_lbl_txtEmail" class="formFieldText" style="font-weight:bold;">E-Mail Address</span><span id="cph_main_ctl17_lbl_req" class="formFieldRequiredTag"> *</span>
658		</div>
659
660    
661    <div id="cph_main_ctl17_control_space">
662			<input name="ctl00$cph_main$ctl17$txtEmail" type="text" maxlength="250" id="cph_main_ctl17_txtEmail" aria-label="Personal Information E-Mail Address" />
663		</div>
664    
665</div>
666
667
668<div id="cph_main_ctl18_tr_controlRow" class="form-column">
669    <div id="cph_main_ctl18_LabelLiteral">
670			<span id="cph_main_ctl18_lbl_TextBox_639261958739673655_18" class="formFieldText" style="font-weight:bold;">Social Security Number (Required to Apply)</span>
671		</div>
672
673    
674    <div id="cph_main_ctl18_control_space">
675			<input name="ctl00$cph_main$ctl18$TextBox_639261958739673655_18" type="text" maxlength="50" id="cph_main_ctl18_TextBox_639261958739673655_18" aria-label="Personal Information Social Security Number (Required to Apply)" />
676		</div>
677    
678</div>
679
680
681<div id="cph_main_ctl19_tr_controlRow" class="form-column">
682    <div id="cph_main_ctl19_LabelLiteral">
683			<span id="cph_main_ctl19_lbl_TextBox_639261959570202217_19" class="formFieldText" style="font-weight:bold;">Driver's License Number (Required to Apply)</span>
684		</div>
685
686    
687    <div id="cph_main_ctl19_control_space">
688			<input name="ctl00$cph_main$ctl19$TextBox_639261959570202217_19" type="text" maxlength="50" id="cph_main_ctl19_TextBox_639261959570202217_19" aria-label="Personal Information Driver&#39;s License Number (Required to Apply)" />
689		</div>
690    
691</div>
692
693<div id="cph_main_ctl20_tr_titleRow" class="form-column form-title">
694    <span id="cph_main_ctl20_lbl_title" class="title" style="font-weight:bold;">
694Policy Information</span>
695
696</div>
697
698
699<div id="cph_main_ctl21_tr_titleRow" class="form-column form-title">
700    <span id="cph_main_ctl21_lbl_title" class="subtitle" style="font-weight:bold;">This Section for Life Insurance Only</span>
701
702</div>
703
704
705
706<div id="cph_main_ctl22_tr_controlRow" class="form-column">
707    <div id="cph_main_ctl22_LabelLiteral">
708			<span id="cph_main_ctl22_lbl_DropDown_636967216044509399_22" class="formFieldText" style="font-weight:bold;">Death Benefit Amount</span>
709		</div>
710
711    
712    <div id="cph_main_ctl22_control_space">
713			<select name="ctl00$cph_main$ctl22$DropDown_636967216044509399_22" id="cph_main_ctl22_DropDown_636967216044509399_22" aria-label="Policy Information Death Benefit Amount">
714				<option value=""></option>
715				<option value="100,000">100,000</option>
716				<option value="150,000">150,000</option>
717				<option value="200,000">200,000</option>
718				<option value="250,000">250,000</option>
719				<option value="300,000">300,000</option>
720				<option value="350,000">350,000</option>
721				<option value="400,000">400,000</option>
722				<option value="450,000">450,000</option>
723				<option value="500,000">500,000</option>
724				<option value="550,000">550,000</option>
725				<option value="600,000">600,000</option>
726				<option value="650,000">650,000</option>
727				<option value="700,000">700,000</option>
728				<option value="750,000">750,000</option>
729				<option value="800,000">800,000</option>
730				<option value="850,000">850,000</option>
731				<option value="900,000">900,000</option>
732				<option value="950,000">950,000</option>
733				<option value="1,000,000">1,000,000</option>
734				<option value="1,500,000">1,500,000</option>
735				<option value="1,750,000">1,750,000</option>
736				<option value="2,000,000">2,000,000</option>
737				<option value="2,500,000">2,500,000</option>
738				<option value="3,000,000">3,000,000</option>
739				<option value="3,500,000">3,500,000</option>
740				<option value="4,000,000">4,000,000</option>
741				<option value="4,500,000">4,500,000</option>
742				<option value="5,000,000">5,000,000</option>
743
744			</select>
745		</div>
746    
747</div>
748
749
750<div id="cph_main_ctl23_tr_controlRow" class="form-column">
751    <div id="cph_main_ctl23_LabelLiteral">
752			<span id="cph_main_ctl23_lbl_DropDown_636967216280606366_23" class="formFieldText" style="font-weight:bold;">Term Period</span>
753		</div>
754
755    
756    <div id="cph_main_ctl23_control_space">
757			<select name="ctl00$cph_main$ctl23$DropDown_636967216280606366_23" id="cph_main_ctl23_DropDown_636967216280606366_23" aria-label="Policy Information Term Period">
758				<option value=""></option>
759				<option value="10">10</option>
760				<option value="15">15</option>
761				<option value="20">20</option>
762				<option value="25">25</option>
763				<option value="30">30</option>
764				<option value="35">35</option>
765				<option value="40">40</option>
766
767			</select>
768		</div>
769    
770</div>
771
772<div id="cph_main_ctl24_tr_titleRow" class="form-column form-title">
773    <span id="cph_main_ctl24_lbl_title" class="title" style="font-weight:bold;">Beneficiary Information</span>
774
775</div>
776
777
778<div id="cph_main_ctl25_tr_titleRow" class="form-column form-title">
779    <span id="cph_main_ctl25_lbl_title" class="subtitle" style="font-weight:bold;">This Section for Life Insurance Only</span>
780
781</div>
782
783
784
785<div id="cph_main_ctl26_tr_controlRow" class="form-column">
786    <div id="cph_main_ctl26_LabelLiteral">
787			<span id="cph_main_ctl26_lbl_TextBox_639077011021731457_26" class="formFieldText" style="font-weight:bold;">Primary Beneficiary Name (First, Middle, Last)</span><span id="cph_main_ctl26_lbl_req" class="formFieldRequiredTag"> *</span>
788		</div>
789
790    
791    <div id="cph_main_ctl26_control_space">
792			<input name="ctl00$cph_main$ctl26$TextBox_639077011021731457_26" type="text" maxlength="50" id="cph_main_ctl26_TextBox_639077011021731457_26" aria-label="Beneficiary Information Primary Beneficiary Name (First, Middle, Last)" />
793		</div>
794    
795</div>
796
797
798<div id="cph_main_ctl27_tr_controlRow" class="form-column">
799    <div id="cph_main_ctl27_LabelLiteral">
800			<span id="cph_main_ctl27_lbl_TextBox_636967217741555134_27" class="formFieldText" style="font-weight:bold;">
800% of Benefit</span>
801		</div>
802
803    
804    <div id="cph_main_ctl27_control_space">
805			<input name="ctl00$cph_main$ctl27$TextBox_636967217741555134_27" type="text" maxlength="50" id="cph_main_ctl27_TextBox_636967217741555134_27" aria-label="Beneficiary Information % of Benefit" />
806		</div>
807    
808</div>
809
810
811<div id="cph_main_ctl28_tr_controlRow" class="form-column">
812    <div id="cph_main_ctl28_LabelLiteral">
813			<span id="cph_main_ctl28_lbl_TextBox_639077011465545143_28" class="formFieldText" style="font-weight:bold;">Relationship</span><span id="cph_main_ctl28_lbl_req" class="formFieldRequiredTag"> *</span>
814		</div>
815
816    
817    <div id="cph_main_ctl28_control_space">
818			<input name="ctl00$cph_main$ctl28$TextBox_639077011465545143_28" type="text" maxlength="50" id="cph_main_ctl28_TextBox_639077011465545143_28" aria-label="Beneficiary Information Relationship" />
819		</div>
820    
821</div>
822
823
824<div id="cph_main_ctl29_tr_controlRow" class="form-column">
825    <div id="cph_main_ctl29_LabelLiteral">
826			<span id="cph_main_ctl29_lbl_DropDownCalendar_639077012064021686_29" class="formFieldText" style="font-weight:bold;">Date of Birth</span><span id="cph_main_ctl29_lbl_req" class="formFieldRequiredTag"> *</span>
827		</div>
828
829    
830    <div id="cph_main_ctl29_control_space">
831			
832<table style="border-collapse:collapse; border: 0px none;"  role="presentation">
833    <tr>
834        <td style="padding: 0px 5px 0px 0px; border: 0px none;">
835            <select name="ctl00$cph_main$ctl29$DropDownCalendar_639077012064021686_29$ddl_wuc_Month" id="cph_main_ctl29_DropDownCalendar_639077012064021686_29_ddl_wuc_Month" aria-label="Beneficiary Information Date of Birth Month">
836				<option value="1">January</option>
837				<option value="2">February</option>
838				<option value="3">March</option>
839				<option value="4">April</option>
840				<option value="5">May</option>
841				<option value="6">June</option>
842				<option value="7">July</option>
843				<option value="8">August</option>
844				<option value="9">September</option>
845				<option value="10">October</option>
846				<option value="11">November</option>
847				<option value="12">December</option>
848
849			</select>
850        </td>
851        <td style="padding: 0px; border: 0px none;">/</td>
852        <td style="padding: 0px 5px; border: 0px none;">
853            <select name="ctl00$cph_main$ctl29$DropDownCalendar_639077012064021686_29$ddl_wuc_Day" id="cph_main_ctl29_DropDownCalendar_639077012064021686_29_ddl_wuc_Day" aria-label="Beneficiary Information Date of Birth Day">
854				<option value="1">1</option>
855				<option value="2">2</option>
856				<option value="3">3</option>
857				<option value="4">4</option>
858				<option value="5">5</option>
859				<option value="6">6</option>
860				<option value="7">7</option>
861				<option value="8">8</option>
862				<option value="9">9</option>
863				<option value="10">10</option>
864				<option value="11">11</option>
865				<option value="12">12</option>
866				<option value="13">13</option>
867				<option value="14">14</option>
868				<option value="15">15</option>
869				<option value="16">16</option>
870				<option value="17">17</option>
871				<option value="18">18</option>
872				<option value="19">19</option>
873				<option value="20">20</option>
874				<option value="21">21</option>
875				<option value="22">22</option>
876				<option value="23">23</option>
877				<option value="24">24</option>
878				<option value="25">25</option>
879				<option value="26">26</option>
880				<option value="27">27</option>
881				<option value="28">28</option>
882				<option value="29">29</option>
883				<option value="30">30</option>
884				<option value="31">31</option>
885
886			</select>
887        </td>
888        <td style="padding: 0px; border: 0px none;">/</td>
889        <td style="padding: 0px 5px; border: 0px none;">
890            <select name="ctl00$cph_main$ctl29$DropDownCalendar_639077012064021686_29$ddl_wuc_Year" id="cph_main_ctl29_DropDownCalendar_639077012064021686_29_ddl_wuc_Year" aria-label="Beneficiary Information Date of Birth Year">
891				<option value="2036">2036</option>
892				<option value="2035">2035</option>
893				<option value="2034">2034</option>
894				<option value="2033">2033</option>
895				<option value="2032">2032</option>
896				<option value="2031">2031</option>
897				<option value="2030">2030</option>
898				<option value="2029">2029</option>
899				<option value="2028">2028</option>
900				<option value="2027">2027</option>
901				<option selected="selected" value="2026">2026</option>
902				<option value="2025">2025</option>
903				<option value="2024">2024</option>
904				<option value="2023">2023</option>
905				<option value="2022">2022</option>
906				<option value="2021">2021</option>
907				<option value="2020">2020</option>
908				<option value="2019">2019</option>
909				<option value="2018">2018</option>
910				<option value="2017">2017</option>
911				<option value="2016">2016</option>
912				<option value="2015">2015</option>
913				<option value="2014">2014</option>
914				<option value="2013">2013</option>
915				<option value="2012">2012</option>
916				<option value="2011">2011</option>
917				<option value="2010">2010</option>
918				<option value="2009">2009</option>
919				<option value="2008">2008</option>
920				<option value="2007">2007</option>
921				<option value="2006">2006</option>
922				<option value="2005">2005</option>
923				<option value="2004">2004</option>
924				<option value="2003">2003</option>
925				<option value="2002">2002</option>
926				<option value="2001">2001</option>
927				<option value="2000">2000</option>
928				<option value="1999">1999</option>
929				<option value="1998">1998</option>
930				<option value="1997">1997</option>
931				<option value="1996">1996</option>
932				<option value="1995">1995</option>
933				<option value="1994">1994</option>
934				<option value="1993">1993</option>
935				<option value="1992">1992</option>
936				<option value="1991">1991</option>
937				<option value="1990">1990</option>
938				<option value="1989">
9381989</option>
939				<option value="1988">1988</option>
940				<option value="1987">1987</option>
941				<option value="1986">1986</option>
942				<option value="1985">1985</option>
943				<option value="1984">1984</option>
944				<option value="1983">1983</option>
945				<option value="1982">1982</option>
946				<option value="1981">1981</option>
947				<option value="1980">1980</option>
948				<option value="1979">1979</option>
949				<option value="1978">1978</option>
950				<option value="1977">1977</option>
951				<option value="1976">1976</option>
952				<option value="1975">1975</option>
953				<option value="1974">1974</option>
954				<option value="1973">1973</option>
955				<option value="1972">1972</option>
956				<option value="1971">1971</option>
957				<option value="1970">1970</option>
958				<option value="1969">1969</option>
959				<option value="1968">1968</option>
960				<option value="1967">1967</option>
961				<option value="1966">1966</option>
962				<option value="1965">1965</option>
963				<option value="1964">1964</option>
964				<option value="1963">1963</option>
965				<option value="1962">1962</option>
966				<option value="1961">1961</option>
967				<option value="1960">1960</option>
968				<option value="1959">1959</option>
969				<option value="1958">1958</option>
970				<option value="1957">1957</option>
971				<option value="1956">1956</option>
972				<option value="1955">1955</option>
973				<option value="1954">1954</option>
974				<option value="1953">1953</option>
975				<option value="1952">1952</option>
976				<option value="1951">1951</option>
977				<option value="1950">1950</option>
978				<option value="1949">1949</option>
979				<option value="1948">1948</option>
980				<option value="1947">1947</option>
981				<option value="1946">1946</option>
982				<option value="1945">1945</option>
983				<option value="1944">1944</option>
984				<option value="1943">1943</option>
985				<option value="1942">1942</option>
986				<option value="1941">1941</option>
987				<option value="1940">1940</option>
988				<option value="1939">1939</option>
989				<option value="1938">1938</option>
990				<option value="1937">1937</option>
991				<option value="1936">1936</option>
992				<option value="1935">1935</option>
993				<option value="1934">1934</option>
994				<option value="1933">1933</option>
995				<option value="1932">1932</option>
996				<option value="1931">1931</option>
997				<option value="1930">1930</option>
998				<option value="1929">1929</option>
999				<option value="1928">1928</option>
1000				<option value="1927">1927</option>
1001				<option value="1926">1926</option>
1002				<option value="1925">1925</option>
1003				<option value="1924">1924</option>
1004				<option value="1923">1923</option>
1005				<option value="1922">1922</option>
1006				<option value="1921">1921</option>
1007				<option value="1920">1920</option>
1008				<option value="1919">1919</option>
1009				<option value="1918">1918</option>
1010				<option value="1917">1917</option>
1011				<option value="1916">1916</option>
1012				<option value="1915">1915</option>
1013				<option value="1914">1914</option>
1014				<option value="1913">1913</option>
1015				<option value="1912">1912</option>
1016				<option value="1911">1911</option>
1017				<option value="1910">1910</option>
1018				<option value="1909">1909</option>
1019				<option value="1908">1908</option>
1020				<option value="1907">1907</option>
1021				<option value="1906">1906</option>
1022				<option value="1905">1905</option>
1023				<option value="1904">1904</option>
1024				<option value="1903">1903</option>
1025				<option value="1902">1902</option>
1026				<option value="1901">1901</option>
1027				<option value="1900">1900</option>
1028
1029			</select>
1030        </td>
1031    </tr>
1032</table>
1033		</div>
1034    
1035</div>
1036
1037
1038<div id="cph_main_ctl30_tr_controlRow" class="form-column">
1039    <div id="cph_main_ctl30_LabelLiteral">
1040			<span id="cph_main_ctl30_lbl_TextBox_639258502093180362_30" class="formFieldText" style="font-weight:bold;">If Naming a Trust as the Contingent Beneficiary, provide the Name &amp; Date of Trust</span>
1041		</div>
1042
1043    
1044    <div id="cph_main_ctl30_control_space">
1045			<input name="ctl00$cph_main$ctl30$TextBox_639258502093180362_30" type="text" maxlength="50" id="cph_main_ctl30_TextBox_639258502093180362_30" aria-label="Beneficiary Information If Naming a Trust as the Contingent Beneficiary, provide the Name &amp; Date of Trust" />
1046		</div>
1047    
1048</div>
1049
1050
1051<div id="cph_main_ctl31_tr_controlRow" class="form-column">
1052    <div id="cph_main_ctl31_LabelLiteral">
1053			<span id="cph_main_ctl31_lbl_RadioButtonList_636870470841985403_31" class="formFieldText" style="font-weight:bold;">Beneficiary 2</span>
1054		</div>
1055
1056    
1057    <div id="cph_main_ctl31_control_space">
1058			<span id="cph_main_ctl31_RadioButtonList_636870470841985403_31" class="plainText rblCntrl"><input id="cph_main_ctl31_RadioButtonList_636870470841985403_31_0" type="radio" name="ctl00$cph_main$ctl31$RadioButtonList_636870470841985403_31" value="Primary" /><label for="cph_main_ctl31_RadioButtonList_636870470841985403_31_0">Primary</label><br /><input id="cph_main_ctl31_RadioButtonList_636870470841985403_31_1" type="radio" name="ctl00$cph_main$ctl31$RadioButtonList_636870470841985403_31" value="Contingent" /><label for="cph_main_ctl31_RadioButtonList_636870470841985403_31_1">Contingent</label></span>
1059		</div>
1060    
1061</div>
1062
1063
1064<div id="cph_main_ctl32_tr_controlRow" class="form-column">
1065    <div id="cph_main_ctl32_LabelLiteral">
1066			<span id="cph_main_ctl32_lbl_TextBox_636870469989686568_32" class="formFieldText" style="font-weight:bold;">
1066Beneficiary Name 2</span>
1067		</div>
1068
1069    
1070    <div id="cph_main_ctl32_control_space">
1071			<input name="ctl00$cph_main$ctl32$TextBox_636870469989686568_32" type="text" maxlength="50" id="cph_main_ctl32_TextBox_636870469989686568_32" aria-label="Beneficiary Information Beneficiary Name 2" />
1072		</div>
1073    
1074</div>
1075
1076
1077<div id="cph_main_ctl33_tr_controlRow" class="form-column">
1078    <div id="cph_main_ctl33_LabelLiteral">
1079			<span id="cph_main_ctl33_lbl_TextBox_636870470066875016_33" class="formFieldText" style="font-weight:bold;">% of Benefit</span>
1080		</div>
1081
1082    
1083    <div id="cph_main_ctl33_control_space">
1084			<input name="ctl00$cph_main$ctl33$TextBox_636870470066875016_33" type="text" maxlength="50" id="cph_main_ctl33_TextBox_636870470066875016_33" aria-label="Beneficiary Information % of Benefit" />
1085		</div>
1086    
1087</div>
1088
1089
1090<div id="cph_main_ctl34_tr_controlRow" class="form-column">
1091    <div id="cph_main_ctl34_LabelLiteral">
1092			<span id="cph_main_ctl34_lbl_TextBox_636870470132652089_34" class="formFieldText" style="font-weight:bold;">Relationship</span>
1093		</div>
1094
1095    
1096    <div id="cph_main_ctl34_control_space">
1097			<input name="ctl00$cph_main$ctl34$TextBox_636870470132652089_34" type="text" maxlength="50" id="cph_main_ctl34_TextBox_636870470132652089_34" aria-label="Beneficiary Information Relationship" />
1098		</div>
1099    
1100</div>
1101
1102
1103<div id="cph_main_ctl35_tr_controlRow" class="form-column">
1104    <div id="cph_main_ctl35_LabelLiteral">
1105			<span id="cph_main_ctl35_lbl_TextBox_636870470192647860_35" class="formFieldText" style="font-weight:bold;">Date of Birth</span>
1106		</div>
1107
1108    
1109    <div id="cph_main_ctl35_control_space">
1110			<input name="ctl00$cph_main$ctl35$TextBox_636870470192647860_35" type="text" maxlength="50" id="cph_main_ctl35_TextBox_636870470192647860_35" aria-label="Beneficiary Information Date of Birth" />
1111		</div>
1112    
1113</div>
1114
1115
1116<div id="cph_main_ctl36_tr_controlRow" class="form-column">
1117    <div id="cph_main_ctl36_LabelLiteral">
1118			<span id="cph_main_ctl36_lbl_RadioButtonList_636870470523252692_36" class="formFieldText" style="font-weight:bold;">Beneficiary 3</span>
1119		</div>
1120
1121    
1122    <div id="cph_main_ctl36_control_space">
1123			<span id="cph_main_ctl36_RadioButtonList_636870470523252692_36" class="plainText rblCntrl"><input id="cph_main_ctl36_RadioButtonList_636870470523252692_36_0" type="radio" name="ctl00$cph_main$ctl36$RadioButtonList_636870470523252692_36" value="Primary" /><label for="cph_main_ctl36_RadioButtonList_636870470523252692_36_0">Primary</label><br /><input id="cph_main_ctl36_RadioButtonList_636870470523252692_36_1" type="radio" name="ctl00$cph_main$ctl36$RadioButtonList_636870470523252692_36" value="Contingent" /><label for="cph_main_ctl36_RadioButtonList_636870470523252692_36_1">Contingent</label></span>
1124		</div>
1125    
1126</div>
1127
1128
1129<div id="cph_main_ctl37_tr_controlRow" class="form-column">
1130    <div id="cph_main_ctl37_LabelLiteral">
1131			<span id="cph_main_ctl37_lbl_TextBox_636870471086661881_37" class="formFieldText" style="font-weight:bold;">Beneficiary Name 3</span>
1132		</div>
1133
1134    
1135    <div id="cph_main_ctl37_control_space">
1136			<input name="ctl00$cph_main$ctl37$TextBox_636870471086661881_37" type="text" maxlength="50" id="cph_main_ctl37_TextBox_636870471086661881_37" aria-label="Beneficiary Information Beneficiary Name 3" />
1137		</div>
1138    
1139</div>
1140
1141
1142<div id="cph_main_ctl38_tr_controlRow" class="form-column">
1143    <div id="cph_main_ctl38_LabelLiteral">
1144			<span id="cph_main_ctl38_lbl_TextBox_636870471154314337_38" class="formFieldText" style="font-weight:bold;">% of Benefit</span>
1145		</div>
1146
1147    
1148    <div id="cph_main_ctl38_control_space">
1149			<input name="ctl00$cph_main$ctl38$TextBox_636870471154314337_38" type="text" maxlength="50" id="cph_main_ctl38_TextBox_636870471154314337_38" aria-label="Beneficiary Information % of Benefit" />
1150		</div>
1151    
1152</div>
1153
1154
1155<div id="cph_main_ctl39_tr_controlRow" class="form-column">
1156    <div id="cph_main_ctl39_LabelLiteral">
1157			<span id="cph_main_ctl39_lbl_TextBox_636870471239780564_39" class="formFieldText" style="font-weight:bold;">Relationship</span>
1158		</div>
1159
1160    
1161    <div id="cph_main_ctl39_control_space">
1162			<input name="ctl00$cph_main$ctl39$TextBox_636870471239780564_39" type="text" maxlength="50" id="cph_main_ctl39_TextBox_636870471239780564_39" aria-label="Beneficiary Information Relationship" />
1163		</div>
1164    
1165</div>
1166
1167
1168<div id="cph_main_ctl40_tr_controlRow" class="form-column">
1169    <div id="cph_main_ctl40_LabelLiteral">
1170			<span id="cph_main_ctl40_lbl_TextBox_636870471309464312_40" class="formFieldText" style="font-weight:bold;">Date of Birth</span>
1171		</div>
1172
1173    
1174    <div id="cph_main_ctl40_control_space">
1175			<input name="ctl00$cph_main$ctl40$TextBox_636870471309464312_40" type="text" maxlength="50" id="cph_main_ctl40_TextBox_636870471309464312_40" aria-label="Beneficiary Information Date of Birth" />
1176		</div>
1177    
1178</div>
1179
1180<div id="cph_main_ctl41_tr_titleRow" class="form-column form-title">
1181    <span id="cph_main_ctl41_lbl_title" class="title" style="font-weight:bold;">Financial Information</span>
1182
1183</div>
1184
1185
1186
1187<div id="cph_main_ctl42_tr_controlRow" class="form-column">
1188    <div id="cph_main_ctl42_LabelLiteral">
1189			<span id="cph_main_ctl42_lbl_TextBox_636888612327266947_42" class="formFieldText" style="font-weight:bold;">Occupation/Job Title</span>
1189<span id="cph_main_ctl42_lbl_req" class="formFieldRequiredTag"> *</span>
1190		</div>
1191
1192    
1193    <div id="cph_main_ctl42_control_space">
1194			<input name="ctl00$cph_main$ctl42$TextBox_636888612327266947_42" type="text" maxlength="50" id="cph_main_ctl42_TextBox_636888612327266947_42" aria-label="Financial Information Occupation/Job Title" />
1195		</div>
1196    
1197</div>
1198
1199
1200<div id="cph_main_ctl43_tr_controlRow" class="form-column">
1201    <div id="cph_main_ctl43_LabelLiteral">
1202			<span id="cph_main_ctl43_lbl_TextBox_636874594885462686_43" class="formFieldText" style="font-weight:bold;">Employer</span><span id="cph_main_ctl43_lbl_req" class="formFieldRequiredTag"> *</span>
1203		</div>
1204
1205    
1206    <div id="cph_main_ctl43_control_space">
1207			<input name="ctl00$cph_main$ctl43$TextBox_636874594885462686_43" type="text" maxlength="50" id="cph_main_ctl43_TextBox_636874594885462686_43" aria-label="Financial Information Employer" />
1208		</div>
1209    
1210</div>
1211
1212
1213<div id="cph_main_ctl44_tr_controlRow" class="form-column">
1214    <div id="cph_main_ctl44_LabelLiteral">
1215			<span id="cph_main_ctl44_lbl_TextBox_637140997543436958_44" class="formFieldText" style="font-weight:bold;">Base Annual Income</span><span id="cph_main_ctl44_lbl_req" class="formFieldRequiredTag"> *</span>
1216		</div>
1217
1218    
1219    <div id="cph_main_ctl44_control_space">
1220			<input name="ctl00$cph_main$ctl44$TextBox_637140997543436958_44" type="text" maxlength="50" id="cph_main_ctl44_TextBox_637140997543436958_44" aria-label="Financial Information Base Annual Income" />
1221		</div>
1222    
1223</div>
1224
1225
1226<div id="cph_main_ctl45_tr_controlRow" class="form-column">
1227    <div id="cph_main_ctl45_LabelLiteral">
1228			<span id="cph_main_ctl45_lbl_TextBox_639258505934444558_45" class="formFieldText" style="font-weight:bold;">Bonus and Stock / RSU Income (please specify)</span>
1229		</div>
1230
1231    
1232    <div id="cph_main_ctl45_control_space">
1233			<input name="ctl00$cph_main$ctl45$TextBox_639258505934444558_45" type="text" maxlength="50" id="cph_main_ctl45_TextBox_639258505934444558_45" aria-label="Financial Information Bonus and Stock / RSU Income (please specify)" />
1234		</div>
1235    
1236</div>
1237
1238
1239<div id="cph_main_ctl46_tr_controlRow" class="form-column">
1240    <div id="cph_main_ctl46_LabelLiteral">
1241			<span id="cph_main_ctl46_lbl_TextBox_639077021158473549_46" class="formFieldText" style="font-weight:bold;">Total Net Worth (Approx)</span>
1242		</div>
1243
1244    
1245    <div id="cph_main_ctl46_control_space">
1246			<input name="ctl00$cph_main$ctl46$TextBox_639077021158473549_46" type="text" maxlength="50" id="cph_main_ctl46_TextBox_639077021158473549_46" aria-label="Financial Information Total Net Worth (Approx)" />
1247		</div>
1248    
1249</div>
1250
1251
1252<div id="cph_main_ctl47_tr_controlRow" class="form-column">
1253    <div id="cph_main_ctl47_LabelLiteral">
1254			<span id="cph_main_ctl47_lbl_RadioButtonList_636894564579823484_47" class="formFieldText" style="font-weight:bold;">Ever filed for Bankruptcy?</span><span id="cph_main_ctl47_lbl_req" class="formFieldRequiredTag"> *</span>
1255		</div>
1256
1257    
1258    <div id="cph_main_ctl47_control_space">
1259			<span id="cph_main_ctl47_RadioButtonList_636894564579823484_47" class="plainText rblCntrl"><input id="cph_main_ctl47_RadioButtonList_636894564579823484_47_0" type="radio" name="ctl00$cph_main$ctl47$RadioButtonList_636894564579823484_47" value="No" checked="checked" /><label for="cph_main_ctl47_RadioButtonList_636894564579823484_47_0">No</label><br /><input id="cph_main_ctl47_RadioButtonList_636894564579823484_47_1" type="radio" name="ctl00$cph_main$ctl47$RadioButtonList_636894564579823484_47" value="Yes" /><label for="cph_main_ctl47_RadioButtonList_636894564579823484_47_1">Yes</label></span>
1260		</div>
1261    
1262</div>
1263
1264
1265<div id="cph_main_ctl48_tr_controlRow" class="form-column">
1266    <div id="cph_main_ctl48_LabelLiteral">
1267			<span id="cph_main_ctl48_lbl_TextBox_636870476663712072_48" class="formFieldText" style="font-weight:bold;">Type of Bankruptcy? (if applicable)</span>
1268		</div>
1269
1270    
1271    <div id="cph_main_ctl48_control_space">
1272			<input name="ctl00$cph_main$ctl48$TextBox_636870476663712072_48" type="text" maxlength="50" id="cph_main_ctl48_TextBox_636870476663712072_48" aria-label="Financial Information Type of Bankruptcy? (if applicable)" />
1273		</div>
1274    
1275</div>
1276
1277
1278<div id="cph_main_ctl49_tr_controlRow" class="form-column">
1279    <div id="cph_main_ctl49_LabelLiteral">
1280			<span id="cph_main_ctl49_lbl_TextBox_636870476724649327_49" class="formFieldText" style="font-weight:bold;">Date Discharged: (if applicable)</span>
1281		</div>
1282
1283    
1284    <div id="cph_main_ctl49_control_space">
1285			<input name="ctl00$cph_main$ctl49$TextBox_636870476724649327_49" t
1285ype="text" maxlength="50" id="cph_main_ctl49_TextBox_636870476724649327_49" aria-label="Financial Information Date Discharged: (if applicable)" />
1286		</div>
1287    
1288</div>
1289
1290<div id="cph_main_ctl50_tr_titleRow" class="form-column form-title">
1291    <span id="cph_main_ctl50_lbl_title" class="title" style="font-weight:bold;">Health Information</span>
1292
1293</div>
1294
1295
1296
1297<div id="cph_main_ctl51_tr_controlRow" class="form-column">
1298    <div id="cph_main_ctl51_LabelLiteral">
1299			<span id="cph_main_ctl51_lbl_TextBox_636888613789309777_51" class="formFieldText" style="font-weight:bold;">Height (ft/in)</span><span id="cph_main_ctl51_lbl_req" class="formFieldRequiredTag"> *</span>
1300		</div>
1301
1302    
1303    <div id="cph_main_ctl51_control_space">
1304			<input name="ctl00$cph_main$ctl51$TextBox_636888613789309777_51" type="text" maxlength="50" id="cph_main_ctl51_TextBox_636888613789309777_51" aria-label="Health Information Height (ft/in)" />
1305		</div>
1306    
1307</div>
1308
1309
1310<div id="cph_main_ctl52_tr_controlRow" class="form-column">
1311    <div id="cph_main_ctl52_LabelLiteral">
1312			<span id="cph_main_ctl52_lbl_TextBox_636888613953215351_52" class="formFieldText" style="font-weight:bold;">Weight (lbs)</span><span id="cph_main_ctl52_lbl_req" class="formFieldRequiredTag"> *</span>
1313		</div>
1314
1315    
1316    <div id="cph_main_ctl52_control_space">
1317			<input name="ctl00$cph_main$ctl52$TextBox_636888613953215351_52" type="text" maxlength="50" id="cph_main_ctl52_TextBox_636888613953215351_52" aria-label="Health Information Weight (lbs)" />
1318		</div>
1319    
1320</div>
1321
1322
1323<div id="cph_main_ctl53_tr_controlRow" class="form-column">
1324    <div id="cph_main_ctl53_LabelLiteral">
1325			<span id="cph_main_ctl53_lbl_RadioButtonList_639258517021890225_53" class="formFieldText" style="font-weight:bold;">Medical Part 1: Do you have currently, or in the past, any of the following health conditions: Elevated blood pressure/cholesterol/A1C, pre-diabetes, diabetes, sleep apnea, mental health conditions (anxiety, depression, ADHD, bipolar, PTSD)</span>
1325<span id="cph_main_ctl53_lbl_req" class="formFieldRequiredTag"> *</span>
1326		</div>
1327
1328    
1329    <div id="cph_main_ctl53_control_space">
1330			<span id="cph_main_ctl53_RadioButtonList_639258517021890225_53" class="plainText rblCntrl"><input id="cph_main_ctl53_RadioButtonList_639258517021890225_53_0" type="radio" name="ctl00$cph_main$ctl53$RadioButtonList_639258517021890225_53" value="Yes" checked="checked" /><label for="cph_main_ctl53_RadioButtonList_639258517021890225_53_0">Yes</label><br /><input id="cph_main_ctl53_RadioButtonList_639258517021890225_53_1" type="radio" name="ctl00$cph_main$ctl53$RadioButtonList_639258517021890225_53" value="No" /><label for="cph_main_ctl53_RadioButtonList_639258517021890225_53_1">No</label></span>
1331		</div>
1332    
1333</div>
1334
1335
1336<div id="cph_main_ctl54_tr_controlRow" class="form-column">
1337    <div id="cph_main_ctl54_LabelLiteral">
1338			<span id="cph_main_ctl54_lbl_RadioButtonList_639258518264193550_54" class="formFieldText" style="font-weight:bold;">Medical Part 2: Do you currently, or in the past, any of the following health conditions: Thyroid issues, autoimmune issues, fatty liver/elevated liver readings, asthma, cancer, heart attack, stroke, cardiac conditions, or any other diagnosed condition?</span><span id="cph_main_ctl54_lbl_req" class="formFieldRequiredTag"> *</span>
1339		</div>
1340
1341    
1342    <div id="cph_main_ctl54_control_space">
1343			<span id="cph_main_ctl54_RadioButtonList_639258518264193550_54" class="plainText rblCntrl"><input id="cph_main_ctl54_RadioButtonList_639258518264193550_54_0" type="radio" name="ctl00$cph_main$ctl54$RadioButtonList_639258518264193550_54" value="Yes" checked="checked" /><label for="cph_main_ctl54_RadioButtonList_639258518264193550_54_0">Yes</label><br /><input id="cph_main_ctl54_RadioButtonList_639258518264193550_54_1" type="radio" name="ctl00$cph_main$ctl54$RadioButtonList_639258518264193550_54" value="No" /><label for="cph_main_ctl54_RadioButtonList_639258518264193550_54_1">No</label></span>
1344		</div>
1345    
1346</div>
1347
1348
1349<div id="cph_main_ctl55_tr_controlRow" class="form-column">
1350    <div id="cph_main_ctl55_LabelLiteral">
1351			<span id="cph_main_ctl55_lbl_TextBoxMulti_639258518958720553_55" class="formFieldText" style="font-weight:bold;">If you answered "Yes" to any of the above conditions, or have medical conditions not listed, please provide a complete history of your past &amp; current conditions &amp; associated medications. Do not omit any medical history.</span>
1352		</div>
1353
1354    
1355    <div id="cph_main_ctl55_control_space">
1356			<textarea name="ctl00$cph_main$ctl55$TextBoxMulti_639258518958720553_55" rows="2" cols="20" id="cph_main_ctl55_TextBoxMulti_639258518958720553_55" aria-label="Health Information If you answered &quot;Yes&quot; to any of the above conditions, or have medical conditions not listed, please provide a complete history of your past &amp; current conditions &amp; associated medications. Do not omit any medical history.">
1357</textarea>
1358		</div>
1359    
1360</div>
1361
1362
1363<div id="cph_main_ctl56_tr_controlRow" class="form-column">
1364    <div id="cph_main_ctl56_LabelLiteral">
1365			<span id="cph_main_ctl56_lbl_TextBoxMulti_636870479213401587_56" class="formFieldText" style="font-weight:bold;">Any other current or past personal health information that may be applicable</span>
1366		</div>
1367
1368    
1369    <div id="cph_main_ctl56_control_space">
1370			<textarea name="ctl00$cph_main$ctl56$TextBoxMulti_636870479213401587_56" rows="2" cols="20" id="cph_main_ctl56_TextBoxMulti_636870479213401587_56" aria-label="Health Information Any other current or past personal health information that may be applicable">
1371</textarea>
1372		</div>
1373    
1374</div>
1375
1376
1377<div id="cph_main_ctl57_tr_controlRow" class="form-column">
1378    <div id="cph_main_ctl57_LabelLiteral">
1379			<span id="cph_main_ctl57_lbl_RadioButtonList_639168675500485678_57" class="formFieldText" style="font-weight:bold;">Do you now or have you ever used tobacco or nicotine?</span><span id="cph_main_ctl57_lbl_req" class="formFieldRequiredTag"> *</span>
1380		</div>
1381
1382    
1383    <div id="cph_main_ctl57_control_space">
1384			<span id="cph_main_ctl57_RadioButtonList_639168675500485678_57" class="plainText rblCntrl"><input id="cph_main_ctl57_RadioButtonList_639168675500485678_57_0" type="radio" name="ctl00$cph_main$ctl57$RadioButtonList_639168675500485678_57" value="No" checked="checked" /><label for="cph_main_ctl57_RadioButtonList_639168675500485678_57_0">No</label><br /><input id="cph_main_ctl57_RadioButtonList_639168675500485678_57_1" type="radio" name="ctl00$cph_main$ctl57$RadioButtonList_639168675500485678_57" value="Yes" /><label for="cph_main_ctl57_RadioButtonList_639168675500485678_57_1">Yes</label></span>
1385		</div>
1386    
1387</div>
1388
1389
1390<div id="cph_main_ctl58_tr_controlRow" class="form-column">
1391    <div id="cph_main_ctl58_LabelLiteral">
1392			<span id="cph_main_ctl58_lbl_CheckBoxList_639168624546847125_58" class="formFieldText" style="font-weight:bold;">If yes, what kind?</span>
1393		</div>
1394
1395    
1396    <div id="cph_main_ctl58_control_space">
1397			<span id="cph_main_ctl58_CheckBoxList_639168624546847125_58" class="plainText cblCntrl" style="display:inline-block;width:100%;"><input id="cph_main_ctl58_CheckBoxList_639168624546847125_58_0" type="checkbox" name="ctl00$cph_main$ctl58$CheckBoxList_639168624546847125_58$0" value="Cigarettes" /><label for="cph_main_ctl58_CheckBoxList_639168624546847125_58_0">Cigarettes</label><br /><input id="cph_main_ctl58_CheckBoxList_639168624546847125_58_1" type="checkbox" name="ctl00$cph_main$ctl58$CheckBoxList_639168624546847125_58$1" value="Cigars" /><label for="cph_main_ctl58_CheckBoxList_639168624546847125_58_1">Cigars</label><br /><input id="cph_main_ctl58_CheckBoxList_639168624546847125_58_2" type="checkbox" name="ctl00$cph_main$ctl58$CheckBoxList_639168624546847125_58$2" value="Vapes / e-Cigarettes" /><label for="cph_main_ctl58_CheckBoxList_639168624546847125_58_2">Vapes / e-Cigarettes</label><br /><input id="cph_main_ctl58_CheckBoxList_639168624546847125_58_3" type="checkbox" name="ctl00$cph_main$ctl58$CheckBoxList_639168624546847125_58$3" value="Nicotine Pouches (i.e. Zyn)" /><label for="cph_main_ctl58_CheckBoxList_639168624546847125_58_3">Nicotine Pouches (i.e. Zyn)</label><br /><input id="cph_main_ctl58_CheckBoxList_639168624546847125_58_4" type="checkbox" name="ctl00$cph_main$ctl58$CheckBoxList_639168624546847125_58$4" value="Nicotine Patches or Gum" /><label for="cph_main_ctl58_CheckBoxList_639168624546847125_58_4">Nicotine Patches or Gum</label><br /><input id="cph_main_ctl58_CheckBoxList_639168624546847125_58_5" type="checkbox" name="ctl00$cph_main$ctl58$CheckBoxList_639168624546847125_58$5" value="Chewing Tobacco" /><label for="cph_main_ctl58_CheckBoxList_639168624546847125_58_5">Chewing Tobacco</label><br /><input id="cph_main_ctl58_CheckBoxList_639168624546847125_58_6" type="checkbox" name="ctl00$cph_main$ctl58$CheckBoxList_639168624546847125_58$6" value="Pipe" /><label for="cph_main_ctl58_CheckBoxList_639168624546847125_58_6">Pipe</label></span>
1398		</div>
1399    
1400</div>
1401
1402
1403<div id="cph_main_ctl59_tr_controlRow" class="form-column">
1404    <div id="cph_main_ctl59_LabelLiteral">
1405			<span id="cph_main_ctl59_lbl_TextBoxMulti_636870477377776581_59" class="formFieldText" style="font-weight:bold;">If yes, provide details (type, frequency of use, date quit)</span>
1406		</div>
1407
1408    
1409    <div id="cph_main_ctl59_control_space">
1410			<textarea name="ctl00$cph_main$ctl59$TextBoxMulti_636870477377776581_59" rows="2" cols="20" id="cph_main_ctl59_TextBoxMulti_636870477377776581_59" aria-label="Health Information If yes, provide details (type, frequency of use, date quit)">
1411</textarea>
1412		</div>
1413    
1414</div>
1415
1416
1417<div id="cph_main_ctl60_tr_controlRow" class="form-column">
1418    <div id="cph_main_ctl60_LabelLiteral">
1419			<span id="cph_main_ctl60_lbl_RadioButtonList_636888621597804119_60" class="formFieldText" style="font-weight:bold;">Cannabis/Marijuana products (currently using)</span>
1420		</div>
1421
1422    
1423    <div id="cph_main_ctl60_control_space">
1424			<span id="cph_main_ctl60_RadioButtonList_636888621597804119_60" class="plainText rblCntrl"><input id="cph_main_ctl60_RadioButtonList_636888621597804119_60_0" type="radio" name="ctl00$cph_main$ctl60$RadioButtonList_636888621597804119_60" value="No " /><label for="cph_main_ctl60_RadioButtonList_636888621597804119_60_0">No </label><br /><input id="cph_main_ctl60_RadioButtonList_636888621597804119_60_1" type="radio" name="ctl00$cph_main$ctl60$RadioButtonList_636888621597804119_60" value="Yes" /><label for="cph_main_ctl60_RadioButtonList_636888621597804119_60_1">Yes</label></span>
1425		</div>
1426    
1427</div>
1428
1429
1430<div id="cph_main_ctl61_tr_controlRow" class="form-column">
1431    <div id="cph_main_ctl61_LabelLiteral">
1432			<span id="cph_main_ctl61_lbl_TextBox_639077015774902967_61" class="formFieldText" style="font-weight:bold;">If yes, in what form? (Smoke, vape, edibles, other)</span>
1433		</div>
1434
1435    
1436    <div id="cph_main_ctl61_control_space">
1437			<input name="ctl00$cph_main$ctl61$TextBox_639077015774902967_61" type="text" maxlength="50" id="cph_main_ctl61_TextBox_639077015774902967_61" aria-label="Health Information If yes, in what form? (Smoke, vape, edibles, other)" />
1438		</div>
1439    
1440</div>
1441
1442
1443<div id="cph_main_ctl62_tr_controlRow" class="form-column">
1444    <div id="cph_main_ctl62_LabelLiteral">
1445			<span id="cph_main_ctl62_lbl_DropDown_636888623713599504_62" class="formFieldText" style="font-weight:bold;">If yes, how often?</span>
1446		</div>
1447
1448    
1449    <div id="cph_main_ctl62_control_space">
1450			<select name="ctl00$cph_main$ctl62$DropDown_636888623713599504_62" id="cph_main_ctl62_DropDown_636888623713599504_62" aria-label="Health Information If yes, how often?">
1451				<option value=""></option>
1452				<option value="1x week ">1x week </option>
1453				<option value="1x month">1x month</option>
1454				<option value="4x month">4x month</option>
1455				<option value="1-2x year">1-2x year</option>
1456				<option value="More often">More often</option>
1457
1458			</select>
1459		</div>
1460    
1461</div>
1462
1463
1464<div id="cph_main_ctl63_tr_controlRow" class="form-column">
1465    <div id="cph_main_ctl63_LabelLiteral">
1466			<span id="cph_main_ctl63_lbl_TextBox_636870477445432836_63" class="formFieldText" style="font-weight:bold;">Physician Name</span>
1467		</div>
1468
1469    
1470    <div id="cph_main_ctl63_control_space">
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1489
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1505Details of any immediate family member's (Mother, Father, Brother, Sister) diagnosis of, and/or death from: disease, cancer, heart attack or heart disease BEFORE AGE 60. 1.Relationship to you 2.Type of diagnosis 3.Age of diagnosis 4.Age of death</span>
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1521
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1536
1537<div id="cph_main_ctl69_tr_controlRow" class="form-column">
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1550
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1564
1565<div id="cph_main_ctl71_tr_controlRow" class="form-column">
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1568		</div>
1569
1570    
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1578
1579<div id="cph_main_ctl72_tr_controlRow" class="form-column">
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1589</div>
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1591
1592<div id="cph_main_ctl73_tr_controlRow" class="form-column">
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1597    
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1604
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1610    
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1618<div class='form-captcha'><div><span class='formFieldText'>Submission Validation</span></div><div  class='formFieldRequiredTag'>Required</div><div id='captchaDiv'></div></div><br /><span id="cph_main_capWRN"></span></div><table style="border-width:0;border-collapse:collapse;width:100%;" role="presentation">
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1625</div>
1626    <div style="font-size: 8pt;"><b>Important Notice</b><br />Any 
1627			submissions or payments made via this website do not constitute a 
1628			binding agreement to your policy or coverages. Changes and 
1629			payments to policies are not effective or binding until you, or any 
1630			party involved, receive official notice from either your insurance agent, 
1631			or your insurance company. If you have any questions, please feel free to <a href="/contact.aspx" style="font-size: 8pt;text-decoration:underline">
1632			contact us</a>.<br /><br />Per the terms of our <a href="/privacy.aspx" style="font-size: 8pt;text-decoration:underline">
1633			online privacy policy</a>
1633 we will not resell your information to any third-party.</div>
1634    
1635    <div style="text-align: center; padding: 15px 0px 15px 0px;">
1636        <img id="cph_main_img_ssl" src="/img/library/rapidssl_ssl_certificate.gif" alt="Secured by SSL" /><br />
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1638
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1725                        <div id="footerMain">
1726<div id="footMap">
1727<div class="secBack">
1728<div class="secBack col-xs-12 col-sm-9 col-sm-offset-1 col-md-6 col-md-offset-1 col-lg-4 col-lg-offset-1">
1729<h1 class="uppercased">Contact Us Today! <br class="visible-xs">
1730<b>888-254-4640</b></h1>
1731<div class="row" id="simpleForm">
1732<div class="col-xs-12 col-sm-12 col-md-6">
1733<input data-required-message="Please Complete All Fields" class="sbmtfrm" id="txtFirstName" placeholder="First Name" type="text">
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1736<input data-required-message="Please Complete All Fields" class="sbmtfrm" id="txtLastName" placeholder="Last Name" type="text">
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1738<div class="col-xs-12 col-sm-12 col-md-6">
1739<input data-required-message="Please Complete All Fields" class="sbmtfrm" id="txtEmailAddress" placeholder="Email Address" type="email">
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1768<span class="uppercased">Quick Links</span>
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1781<div class="col-xs-12 col-sm-5 col-md-4" id="footLocation">
1782<span class="uppercased">States Licensed In:</span>
1783<div class="row">
1784<div class="col-xs-12">Alabama, Arizona, Arkansas, <a href="/life/california-insurance.aspx">California</a>, Colorado, Connecticut, Delaware, Florida, Georgia, Hawaii, Idaho, <a href="/life/illinois-insurance.aspx">Illinois</a>, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont Virginia, <a href="/life/washington-insurance.aspx">Washington</a>, West Virginia, Wisconsin, Wyoming, and Washington DC/District of Columbia.</div>
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1789© Copyright. All rights reserved.<br>
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" />
1813</div>
1814
1815<script type="text/javascript">
1816//<![CDATA[
1817$(".homeBody .primaryTable").addClass("col-xs-12");
1818$("#preheader").append($("#hamburgerMenu"));
1819$("#preheader .container .row").append($("#ctl00_rm_upper"));
1820
1821$(function() {
1822    var preheader = $("#preheader");
1823    $(window).scroll(function() {
1824        var scroll = $(window).scrollTop();
1825
1826        if (scroll >= 100) {
1827            preheader.addClass("solidFFF");
1828        } else {
1829            preheader.removeClass("solidFFF");
1830        }
1831    });
1832});
1833
1834function loadCarriers() {
1835	$("#homeCarriers").animate({ opacity: 1 }, 1000);
1836};
1837
1838function loadTestimonials() {
1839    $(function () {
1840        $.ajax({
1841            url: '/resources/data/website_data.ashx?r=testimonials',
1842            dataType: 'json',
1843            success: Testimonials
1844        });
1845    });
1846};
1847
1848function Testimonials(result) {
1849 
1850    $.each(result, function (i, item) {
1851 
1852        var trimmedString = item.text.substring(0, 265) + '...';
1853        var newDiv = $('<div/>', {
1854            html: '"' + trimmedString + '"<br>-' + item.name
1855        }).appendTo('#testimonials');
1856 
1857    });
1858       
1859};
1860
1861function loadBlog() {
1862	var blogFetch = $("<div>");
1863	blogFetch.load("/blog/default.aspx div[itemprop='blogPost']",function(){
1864	var numBlogs = 1;
1865	blogFetch.find("[itemprop='blogPost']").each(function(i, obj){
1866		if(i < numBlogs) {
1867			if ($(obj).find('div').length) {
1868				blogImage = $(obj).find("div").eq(0).css("background-image").replace('/controls/dynamic_images/blog_image.dynimage?src=','').replace('url(','').replace(')','').split('%2f').join('/').split('"').join('');
1869			} else {
1870				var blogImage = '/img/~www.rwminsurance.com/assets/blog_img.jpg';				  
1871			}
1872			var blogLink = $(obj).find(".plainText:last()").attr("href");
1873			var blogTarget = $(obj).find(".plainText:last()").attr("target");
1874			console.log(blogLink);
1875			$("#blogWrapper").append('<div class="row">' +
1876									'<div class="hidden-xs hidden-sm col-md-4">' +
1877									'<div class="blogImage" style="background-image: url(' + blogImage + ')"></div>' +
1878									'</div>' +
1879									'<div class="col-xs-12 col-sm-12 col-md-8">' +
1880									'<a class="blogLink" href="' + blogLink + '">' + $(obj).find("[itemprop='headline']").eq(0).text() + '</a>' +
1881									'<p>' + $(obj).find("[itemprop='description']").eq(0).text().substring(0,160) + '...</p></div>' +
1882									'</div>' +
1883									'<div class="col-xs-12 alignRight"><a href="' + blogLink + '" target="' + blogTarget + '">Read More</a></div>');
1884			}
1885		});
1886		blogFetch = null;
1887	});
1888}
1889
1890
1891$(document).ready(function() { 
1892	loadCarriers();
1893	loadTestimonials();
1894	loadBlog();
1895	
1896	$("img[src*='employee_photo']").removeClass("img-responsive"); 
1897	
1898	if (location.href.indexOf("/disability/") != -1) {
1899		$('#cph_main_pnl_Info').html($('#cph_main_pnl_Info').html().replace("Disability Insurance", "Disability / Income Replacement Insurance"));
1900	}
1901	
1902	if (location.href.indexOf("apply_for_life_disability_insurance") != -1) {
1903		$("table[id*='controlBuilderTable'] td").addClass("mobileCell");
1904		$("span:contains('Street')").next("div").text("Required to submit your application");
1905		$("span:contains('Social Security Number')").next("div").text("Required to submit your application");
1906		$("span:contains('License Number')").next("div").text("Required to submit your application");
1907	}
1908
1909	function buildNav() {
1910		$("#ctl00_rm_upper.RadMenu.RadMenu_IWB ul.rmRootGroup.rmShadows.rmHorizontal li.rmItem a.rmLink.rmRootLink").addClass("dropdown-li");
1911		var plus = 0;
1912		$("#ctl00_rm_upper.RadMenu.RadMenu_IWB ul.rmRootGroup.rmShadows.rmHorizontal li.rmItem a.rmLink").each(function() {
1913			plus += 1;
1914		});
1915		$("#ctl00_rm_upper.RadMenu.RadMenu_IWB ul.rmRootGroup.rmShadows.rmHorizontal li.rmItem a.rmLink").each(function(i) {
1916			if (i < (plus/2)) {
1917				$(this).clone().appendTo('.mobileMenu')
1918			}
1919		});
1920		$('.mobileMenu .dropdown-li').each(function(){ 
1921			$(this).nextUntil(".dropdown-li").wrapAll('<div class="dropdown-menu" />');
1922		});
1923		$( ".dropdown-li" ).click(function() {
1924			$( ".mobileMenu .dropdown-menu" ).hide();
1925			$(this).next(".mobileMenu .dropdown-menu").slideToggle( "slow" );
1926		});
1927	}
1928	setTimeout(buildNav, 500)
1929	
1930	$('.bxslider').bxSlider({
1931		ticker: true, tickerHover: true, responsive: false, slideMargin: 20, slideWidth: 180, maxSlides: 6, autoStart: true, speed: 60000, pager: false, controls: false
1932	});
1933	
1934	function buildTestimonials() {
1935		$('#testimonials.cycle-slideshow').cycle('reinit');
1936		$("#testimonials.cycle-slideshow").animate({ opacity: 1 }, 2000);
1937	}
1938	setTimeout(buildTestimonials, 1000)
1939	
1940	function showBlog() {
1941		$("#blogWrapper .row").animate({ opacity: 1 }, 1000); 
1942	}
1943	setTimeout(showBlog, 1100)
1944	
1945	$( ".cross" ).hide();
1946	$( ".mobileMenu" ).hide();
1947	$( ".hamburger" ).click(function() {
1948		$( ".mobileMenu" ).slideToggle( "slow", function() {
1949			$( ".hamburger" ).hide();
1950			$( ".cross" ).show();
1951		});
1952	});
1953
1954	$( ".cross" ).click(function() {
1955		$( ".mobileMenu" ).slideToggle( "slow", function() {
1956			$( ".cross" ).hide();
1957			$( ".hamburger" ).show();
1958		});
1959	});	
1960});
1961
1962
1963
1964window.__TsmHiddenField = $get('rsm_Master_TSM');;(function() {
1965                        function loadHandler() {
1966                            var hf = $get('rssm_Master_TSSM');
1967                            if (!hf._RSSM_init) { hf._RSSM_init = true; hf.value = ''; }
1968                            hf.value += ';Telerik.Web.UI, Version=2018.3.910.40, Culture=neutral, PublicKeyToken=121fae78165ba3d4:en-US:df8a796a-503f-421d-9d40-9475fc76f21f:ed2942d4:a3b7d93f';
1969                            Sys.Application.remove_load(loadHandler);
1970                        };
1971                        Sys.Application.add_load(loadHandler);
1972                    })();Sys.Application.add_init(function() {
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