{"id":293,"date":"2014-07-25T05:17:57","date_gmt":"2014-07-25T05:17:57","guid":{"rendered":"http:\/\/www.ocbis.com\/?page_id=293"},"modified":"2014-07-28T10:39:53","modified_gmt":"2014-07-28T10:39:53","slug":"exam-order-form","status":"publish","type":"page","link":"https:\/\/www.ocbis.com\/index.php\/exam-order-form\/","title":{"rendered":"Exam Order Form"},"content":{"rendered":"<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f296-o1\" lang=\"en-US\" dir=\"ltr\">\n<div class=\"screen-reader-response\"><\/div>\n<form action=\"\/index.php\/wp-json\/wp\/v2\/pages\/293#wpcf7-f296-o1\" method=\"post\" class=\"wpcf7-form\" novalidate=\"novalidate\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"296\" \/>\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-f296-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<\/div>\n<table class=\"LTC-form-table LTC-form-table-06\">\n<tr>\n<td colspan=\"6\" class=\"agent-info\">\n<h3 class=\"LTC-heading\">Agent Information<\/h3>\n<\/td>\n<\/tr>\n<tr>\n<td class=\"agent_name\">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 class=\"agent_date\">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 wpcf7-validates-as-required\" aria-required=\"true\" \/> <\/span><\/td>\n<td class=\"agent_phone\">Phone #:<\/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<\/tr>\n<\/table>\n<table class=\"LTC-form-table LTC-form-table-10\">\n<tr>\n<td colspan=\"6\" class=\"agent-info\">\n<h3 class=\"LTC-heading\"> Proposed Insured Information <\/h3>\n<\/td>\n<\/tr>\n<tr>\n<td>Name:<\/td>\n<td><span class=\"wpcf7-form-control-wrap Name\"><input type=\"text\" name=\"Name\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>Gender:<\/td>\n<td><span class=\"wpcf7-form-control-wrap gender\"><select name=\"gender\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required select-box-ltc\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Male\">Male<\/option><option value=\"Female\">Female<\/option><\/select><\/span>\t<\/td>\n<td>Address:<\/td>\n<td><span class=\"wpcf7-form-control-wrap address\"><textarea name=\"address\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required address\" aria-required=\"true\" aria-invalid=\"false\"><\/textarea><\/span><\/td>\n<\/tr>\n<\/table>\n<table class=\"LTC-form-table LTC-form-table-10\">\n<tr>\n<td>City:<\/td>\n<td><span class=\"wpcf7-form-control-wrap City\"><input type=\"text\" name=\"City\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>State:<\/td>\n<td><span class=\"wpcf7-form-control-wrap State\"><input type=\"text\" name=\"State\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>Zip:<\/td>\n<td><span class=\"wpcf7-form-control-wrap USCANZipCode\"><input type=\"text\" name=\"USCANZipCode\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span> <\/td>\n<\/tr>\n<tr>\n<td>SSN:<\/td>\n<td><span class=\"wpcf7-form-control-wrap SSN\"><input type=\"tel\" name=\"SSN\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-tel wpcf7-validates-as-tel\" aria-invalid=\"false\" \/><\/span>  <\/td>\n<td>Date of Birth:<\/td>\n<td><span class=\"wpcf7-form-control-wrap dob\"><input type=\"text\" name=\"dob\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required\" aria-required=\"true\" \/> <\/span><\/td>\n<td>Best Time To Contact:<\/td>\n<td><span class=\"wpcf7-form-control-wrap TimeToContact\"><input type=\"text\" name=\"TimeToContact\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span><\/td>\n<\/tr>\n<tr>\n<td>Home #:<\/td>\n<td><span class=\"wpcf7-form-control-wrap HomeNumber\"><input type=\"tel\" name=\"HomeNumber\" 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>Work #:<\/td>\n<td><span class=\"wpcf7-form-control-wrap WorkNumber\"><input type=\"tel\" name=\"WorkNumber\" 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>Cell #:<\/td>\n<td><span class=\"wpcf7-form-control-wrap CellNumber\"><input type=\"tel\" name=\"CellNumber\" 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 class=\"email_address\">Email Address (optional):<\/td>\n<td colspan=\"2\"><span class=\"wpcf7-form-control-wrap email\"><input type=\"email\" name=\"email\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-email\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>More Than One Carrier?:<\/td>\n<td><span class=\"wpcf7-form-control-wrap MoreCarrier\"><select name=\"MoreCarrier\" class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required select-box-ltc\" aria-required=\"true\" aria-invalid=\"false\"><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/td>\n<\/tr>\n<tr>\n<td class=\"carrier_apply\">Insurance Carrier Applying To:<\/td>\n<td colspan=\"2\"><span class=\"wpcf7-form-control-wrap InsuranceCarrierApplyingTo1\"><input type=\"text\" name=\"InsuranceCarrierApplyingTo1\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" \/><\/span><\/td>\n<td>Insurance Carrier <br>  Applying To:<\/td>\n<td colspan=\"2\"><span class=\"wpcf7-form-control-wrap InsuranceCarrierApplyingTo2\"><input type=\"text\" name=\"InsuranceCarrierApplyingTo2\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" \/><\/span> <\/td>\n<\/tr>\n<tr>\n<td>Face Amount:<\/td>\n<td><span class=\"wpcf7-form-control-wrap FaceAmount\"><input type=\"text\" name=\"FaceAmount\" value=\"\" size=\"40\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" placeholder=\"$\" \/><\/span><\/td>\n<\/tr>\n<tr>\n<td>&nbsp;<\/td>\n<td colspan=\"4\">(Note: If your client has an existing policy with the same carrier you are ordering for this exam you MUST add the existing face amount to this order for an accurate total line of coverage)<\/td>\n<td>&nbsp;<\/td>\n<\/tr>\n<tr>\n<td class=\"sub-table-heading\" colspan=\"6\"><strong> Special Instructions:<\/strong><\/td>\n<\/tr>\n<tr>\n<td colspan=\"6\"><span class=\"wpcf7-form-control-wrap SpecialInstruction\"><textarea name=\"SpecialInstruction\" cols=\"40\" rows=\"10\" class=\"wpcf7-form-control wpcf7-textarea ltc-textarea\" aria-invalid=\"false\"><\/textarea><\/span><\/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-293","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/pages\/293"}],"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=293"}],"version-history":[{"count":3,"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/pages\/293\/revisions"}],"predecessor-version":[{"id":302,"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/pages\/293\/revisions\/302"}],"wp:attachment":[{"href":"https:\/\/www.ocbis.com\/index.php\/wp-json\/wp\/v2\/media?parent=293"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}