{"id":112,"date":"2014-07-01T11:27:31","date_gmt":"2014-07-01T11:27:31","guid":{"rendered":"http:\/\/www.ocbis.com\/?page_id=112"},"modified":"2014-07-11T05:55:10","modified_gmt":"2014-07-11T05:55:10","slug":"disability-income-quote-request","status":"publish","type":"page","link":"https:\/\/www.ocbis.com\/index.php\/disability-income-quote-request\/","title":{"rendered":"DISABILITY INCOME QUOTE REQUEST"},"content":{"rendered":"<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f232-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><\/div>\n<form action=\"\/index.php\/wp-json\/wp\/v2\/pages\/112#wpcf7-f232-o1\" method=\"post\" class=\"wpcf7-form\" novalidate=\"novalidate\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"232\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.0.5\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f232-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<\/div>\n<table class=\"LTC-form-table LTC-form-table-01\">\n<tr>\n<td colspan=\"4\"class=\"agent-info\">\n<h3 class=\"LTC-heading\">Agent Information<\/h3>\n<\/td>\n<\/tr>\n<tr>\n<td>Date Requested:<\/td>\n<td><span class=\"wpcf7-form-control-wrap DateRequested\"><input type=\"text\" name=\"DateRequested\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required\" id=\"datepicker1\" aria-required=\"true\" \/> <\/span><\/td>\n<td>Date Needed By:<\/td>\n<td><span class=\"wpcf7-form-control-wrap DateNeededBy\"><input type=\"text\" name=\"DateNeededBy\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required\" id=\"datepicker2\" aria-required=\"true\" \/> <\/span><\/td>\n<\/tr>\n<tr>\n<td>Agent Name:<\/td>\n<td><span class=\"wpcf7-form-control-wrap AgentName\"><input type=\"text\" name=\"AgentName\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>Agent E-Mail Address:<\/td>\n<td><span class=\"wpcf7-form-control-wrap AgentE-MailAddress\"><input type=\"email\" name=\"AgentE-MailAddress\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/td>\n<\/tr>\n<tr>\n<td>Phone Number:<\/td>\n<td><span class=\"wpcf7-form-control-wrap PhoneNumber\"><input type=\"tel\" name=\"PhoneNumber\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>Fax Number:<\/td>\n<td><span class=\"wpcf7-form-control-wrap FaxNumber\"><input type=\"tel\" name=\"FaxNumber\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-required wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/td>\n<\/tr>\n<\/table>\n<table class=\"LTC-form-table LTC-form-table-04\">\n<tr>\n<td colspan=\"8\"class=\"agent-info\">\n<h3 class=\"LTC-heading\"> Client Information <\/h3>\n<\/td>\n<\/tr>\n<tr>\n<td class=\"firstchild\">#1 Name:<\/td>\n<td class=\"secondchild\"><span class=\"wpcf7-form-control-wrap Name1\"><input type=\"text\" name=\"Name1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>Date of Birth:<\/td>\n<td><span class=\"wpcf7-form-control-wrap AgeDOB1\"><input type=\"text\" name=\"AgeDOB1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required\" id=\"datepicker3\" aria-required=\"true\" \/> <\/span><\/td>\n<td style=\"text-align:right\">Sex:<\/td>\n<td><span class=\"wpcf7-form-control-wrap Sex1\"><select name=\"Sex1\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Male\">Male<\/option><option value=\"Female\">Female<\/option><\/select><\/span>\n\t\t\t\t<\/td>\n<td>Non Smoker:<\/td>\n<td> <span class=\"wpcf7-form-control-wrap Non-Smoker1\"><select name=\"Non-Smoker1\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\t\t   <\/td>\n<\/tr>\n<tr>\n<td class=\"firstchild\">#2 Name:<\/td>\n<td class=\"secondchild\"><span class=\"wpcf7-form-control-wrap Name2\"><input type=\"text\" name=\"Name2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>Date of Birth:<\/td>\n<td><span class=\"wpcf7-form-control-wrap AgeDOB2\"><input type=\"text\" name=\"AgeDOB2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-date\" id=\"datepicker4\" \/> <\/span><\/td>\n<td style=\"text-align:right\">Sex:<\/td>\n<td><span class=\"wpcf7-form-control-wrap Sex2\"><select name=\"Sex2\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Male\">Male<\/option><option value=\"Female\">Female<\/option><\/select><\/span>\n\t\t\t   <\/td>\n<td>Non Smoker:<\/td>\n<td><span class=\"wpcf7-form-control-wrap Non-Smoker2\"><select name=\"Non-Smoker2\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\t\t    <\/td>\n<\/tr>\n<\/table>\n<table class=\"LTC-form-table\">\n<tr>\n<td colspan=\"6\"class=\"agent-info\">\n<h3 class=\"LTC-heading\">Disability Income Insurance Information<\/h3>\n<\/td>\n<\/tr>\n<tr>\n<td>Gross Monthly Income:<\/td>\n<td><span class=\"wpcf7-form-control-wrap GrossMonthlyIncome\"><input type=\"text\" name=\"GrossMonthlyIncome\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>Occupation:<\/td>\n<td colspan=\"3\"><span class=\"wpcf7-form-control-wrap Occupation\"><input type=\"text\" name=\"Occupation\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text occupation-field\" aria-invalid=\"false\" \/><\/span><\/td>\n<\/tr>\n<tr>\n<td>Benefit Amount:<\/td>\n<td><span class=\"wpcf7-form-control-wrap BenefitAmount\"><input type=\"text\" name=\"BenefitAmount\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>Number of Employees:<\/td>\n<td colspan=\"3\"><span class=\"wpcf7-form-control-wrap NumberofEmployees\"><input type=\"text\" name=\"NumberofEmployees\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/td>\n<\/tr>\n<tr>\n<td>Percent Of Time Doing Manual Labor:<\/td>\n<td><span class=\"wpcf7-form-control-wrap PercentOfTimeDoingManualLabor\"><input type=\"text\" name=\"PercentOfTimeDoingManualLabor\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>Self Employed :<\/td>\n<td><span class=\"wpcf7-form-control-wrap SelfEmployed\"><select name=\"SelfEmployed\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/td>\n<td>Outside Of Home<\/td>\n<td><span class=\"wpcf7-form-control-wrap OutsideOfHome\"><select name=\"OutsideOfHome\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n<\/td>\n<\/tr>\n<tr>\n<td colspan=\"2\">Percent Of Time Traveling Outside Of The Office:<\/td>\n<td colspan=\"4\"><span class=\"wpcf7-form-control-wrap PercentOfTimeTravelingOutsideOfTheOffice\"><input type=\"text\" name=\"PercentOfTimeTravelingOutsideOfTheOffice\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/td>\n<\/tr>\n<tr>\n<td colspan=\"6\">Describe Duties:<br\/><br \/>\n\t\t\t  <span class=\"wpcf7-form-control-wrap DescribeDuties\"><textarea name=\"DescribeDuties\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea ltc-textarea\" aria-invalid=\"false\"><\/textarea><\/span>\n\t\t\t  <\/td>\n<\/tr>\n<\/table>\n<table class=\"LTC-form-table\">\n<tr>\n<td colspan=\"11\"class=\"agent-info\">\n<h3 class=\"LTC-heading\">Health Impairments<\/h3>\n<\/td>\n<\/tr>\n<tr>\n<td>Height:<\/td>\n<td><span class=\"wpcf7-form-control-wrap Height\"><input type=\"text\" name=\"Height\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>Weight:<\/td>\n<td><span class=\"wpcf7-form-control-wrap Weight\"><input type=\"text\" name=\"Weight\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>Weight Lost In Last 12 Months:<\/td>\n<td ><span class=\"wpcf7-form-control-wrap WeightLostInLast12Months\"><input type=\"text\" name=\"WeightLostInLast12Months\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<td>Weight Gained In Last 12 Months:<\/td>\n<td ><span class=\"wpcf7-form-control-wrap WeightGainedInLast12Months\"><input type=\"text\" name=\"WeightGainedInLast12Months\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<\/tr>\n<tr>\n<td>High Blood Pressure:<\/td>\n<td><span class=\"wpcf7-form-control-wrap HighBloodPressure\"><select name=\"HighBloodPressure\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\t<\/td>\n<td>Taking Medication:<\/td>\n<td><span class=\"wpcf7-form-control-wrap TakingMedication\"><select name=\"TakingMedication\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/td>\n<td>Current BP Readings:<\/td>\n<td><span class=\"wpcf7-form-control-wrap CurrentBPReadings\"><input type=\"text\" name=\"CurrentBPReadings\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/td>\n<\/tr>\n<tr>\n<td colspan=\"11\" class=\"sub-table-heading\"><strong>Cardiovascular Disease<\/strong> <\/td>\n<\/tr>\n<tr>\n<td>Bypass Surgery?<\/td>\n<td><span class=\"wpcf7-form-control-wrap BypassSurgery\"><select name=\"BypassSurgery\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/td>\n<td>Date:<\/td>\n<td><span class=\"wpcf7-form-control-wrap Date\"><input type=\"text\" name=\"Date\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-date\" id=\"datepicker5\" \/> <\/span><\/td>\n<td># of Vessels:<\/td>\n<td>\n\t\t   \t\t\t<span class=\"wpcf7-form-control-wrap Vessels\"><select name=\"Vessels\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"0\">0<\/option><option value=\"1\">1<\/option><option value=\"2\">2<\/option><option value=\"3\">3<\/option><option value=\"4\">4<\/option><\/select><\/span>\n\t\t   \t\t<\/td>\n<\/tr>\n<tr class=\"new-tr new-tr02\">\n<td>Angioplasty:<\/td>\n<td><span class=\"wpcf7-form-control-wrap Angioplasty\"><select name=\"Angioplasty\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/td>\n<td>Date #1:<\/td>\n<td><span class=\"wpcf7-form-control-wrap Date1\"><input type=\"text\" name=\"Date1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-date\" id=\"datepicker6\" \/> <\/span><\/td>\n<td>Date #2:<\/td>\n<td><span class=\"wpcf7-form-control-wrap Date2\"><input type=\"text\" name=\"Date2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-date\" id=\"datepicker7\" \/> <\/span><\/td>\n<\/tr>\n<tr class=\"new-tr new-tr02\">\n<td>Valve Replacement:<\/td>\n<td><span class=\"wpcf7-form-control-wrap ValveReplacement\"><select name=\"ValveReplacement\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/td>\n<td>Date:<\/td>\n<td><span class=\"wpcf7-form-control-wrap Date3\"><input type=\"text\" name=\"Date3\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-date\" id=\"datepicker8\" \/> <\/span><\/td>\n<\/tr>\n<tr class=\"new-tr new-tr02\">\n<td>High Cholesterol:<\/td>\n<td><span class=\"wpcf7-form-control-wrap HighCholesterol\"><select name=\"HighCholesterol\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t\t\t<\/td>\n<td>Under Medication:<\/td>\n<td>\n\t\t   \t\t<span class=\"wpcf7-form-control-wrap UnderMedication\"><select name=\"UnderMedication\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span>\n\t\t   \t\t<\/td>\n<td>Cholesterol Level:<\/td>\n<td><span class=\"wpcf7-form-control-wrap CholesterolLevel\"><input type=\"text\" name=\"CholesterolLevel\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>Ratio:<\/td>\n<td><span class=\"wpcf7-form-control-wrap Ratio\"><input type=\"text\" name=\"Ratio\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text width-small\" aria-invalid=\"false\" \/><\/span><\/td>\n<\/tr>\n<tr>\n<td>Diabetes:<\/td>\n<td><span class=\"wpcf7-form-control-wrap Diabetes\"><select name=\"Diabetes\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Oral\">Oral<\/option><option value=\"Injection\">Injection<\/option><option value=\"Diet Controlled\">Diet Controlled<\/option><option value=\"N\/A\">N\/A<\/option><\/select><\/span><\/td>\n<td>Age At Onset:<\/td>\n<td><span class=\"wpcf7-form-control-wrap AgeAtOnset\"><input type=\"text\" name=\"AgeAtOnset\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>Recent A1C:<\/td>\n<td><span class=\"wpcf7-form-control-wrap RecentA1C\"><input type=\"text\" name=\"RecentA1C\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/td>\n<\/tr>\n<tr>\n<td colspan=\"11\" class=\"sub-table-heading\"><strong>Cancer<\/strong><\/td>\n<\/tr>\n<tr>\n<td>Type:<\/td>\n<td class=\"Type-fld\"><span class=\"wpcf7-form-control-wrap Type\"><input type=\"text\" name=\"Type\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>Type Of Treatment:<\/td>\n<td>\n\t\t   \t\t\t<span class=\"wpcf7-form-control-wrap TypeOfTreatment\"><select name=\"TypeOfTreatment\" class=\"wpcf7-form-control wpcf7-select select-box-ltc\" aria-invalid=\"false\"><option value=\"Surgery\">Surgery<\/option><option value=\"Chemotherapy\">Chemotherapy<\/option><option value=\"Radiation\">Radiation<\/option><\/select><\/span>\n\t\t   \t\t<\/td>\n<td>Date Of Onset:<\/td>\n<td><span class=\"wpcf7-form-control-wrap DateOfOnset\"><input type=\"text\" name=\"DateOfOnset\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-date\" id=\"datepicker9\" \/> <\/span><\/td>\n<td>Date Of Last Treatment:<\/td>\n<td><span class=\"wpcf7-form-control-wrap DateOfLastTreatment\"><input type=\"text\" name=\"DateOfLastTreatment\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-date\" id=\"datepicker10\" \/> <\/span><\/td>\n<\/tr>\n<tr>\n<td class=\"sub-table-heading\" colspan=\"11\"><strong>Medications Taken - Special Instructions<\/strong><\/td>\n<\/tr>\n<tr>\n<td class=\"sub-table-heading\" colspan=\"11\">\n                      <span class=\"wpcf7-form-control-wrap MedicationsTaken\"><textarea name=\"MedicationsTaken\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea ltc-textarea textarea-md\" aria-invalid=\"false\"><\/textarea><\/span>\n           <\/td>\n<\/tr>\n<\/table>\n<div class=\"clear\"><\/div>\n<div class=\"login-btn-div2\">\n<input type=\"submit\" value=\"Submit\" class=\"wpcf7-form-control wpcf7-submit login-btn\" \/><input type=\"reset\" class=\"login-btn\" \/>\n<\/div>\n<div class=\"wpcf7-response-output wpcf7-display-none\"><\/div><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":3,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"open","ping_status":"open","template":"page-templates\/form-template.php","meta":{"footnotes":""},"class_list":["post-112","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/pages\/112"}],"collection":[{"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/comments?post=112"}],"version-history":[{"count":3,"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/pages\/112\/revisions"}],"predecessor-version":[{"id":233,"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/pages\/112\/revisions\/233"}],"wp:attachment":[{"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/media?parent=112"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}