{"id":197,"date":"2024-03-27T07:06:03","date_gmt":"2024-03-27T07:06:03","guid":{"rendered":"https:\/\/fnblegal.com\/?page_id=197"},"modified":"2019-01-24T20:26:06","modified_gmt":"2019-01-24T20:26:06","slug":"form-1","status":"publish","type":"page","link":"https:\/\/fnblegal.com\/backup\/form-1\/","title":{"rendered":"Car\/Motorcycle\/Pedestrian Accident Form"},"content":{"rendered":"<div id=\"modal-ready\"><h1 style=\"text-align: center;\">New Client Intake Form &#8211; Car\/Motorcycle\/Pedestrian Accident<\/h1>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f201-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"201\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/backup\/wp-json\/wp\/v2\/pages\/197#wpcf7-f201-o1\" method=\"post\" class=\"wpcf7-form init intake\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"201\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f201-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<div class=\"flex\">\n\t<div class=\"column one-second2\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Email\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column one-second2\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Full Name (First, Middle, Last)\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex\">\n\t<div class=\"column one-second2\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"home-addr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Home Address\" value=\"\" type=\"text\" name=\"home-addr\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column one-second2\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"mod-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Mobile Phone\" value=\"\" type=\"text\" name=\"mod-phone\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex\">\n\t<div class=\"column one-second2\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"home-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Home Phone\" value=\"\" type=\"text\" name=\"home-phone\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column one-second2\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"date-birth\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Date of Birth *\" value=\"\" type=\"text\" name=\"date-birth\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex\">\n\t<div class=\"column one-second2\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"soc-sec\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Social Security Number *\" value=\"\" type=\"text\" name=\"soc-sec\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column one-second2\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"date-accid\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Date of Accident *\" value=\"\" type=\"text\" name=\"date-accid\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex\">\n\t<div class=\"column full\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"loc-accid\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Location of Accident (State, City, Street - name) *\" value=\"\" type=\"text\" name=\"loc-accid\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"injuries-accid\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"I am experiencing pain in... (list body parts)*\" value=\"\" type=\"text\" name=\"injuries-accid\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex\">\n\t<div class=\"column fullcolumn\">\n\t\t<p><label class=\"n\"> <span class=\"wpcf7-form-control-wrap\" data-name=\"brief-desc\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Brief Description of Accident\" name=\"brief-desc\"><\/textarea><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label>I was the... *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"was-driver\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"was-driver\" value=\"Driver\" \/><span class=\"wpcf7-list-item-label\">Driver<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"radio\" name=\"was-driver\" value=\"Passenger\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">Passenger<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"was-driver\" value=\"Pedestrian\" \/><span class=\"wpcf7-list-item-label\">Pedestrian<\/span><\/span><\/span><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label>I went to the hospital as a result of the accident *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"went-hospital\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"went-hospital\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"went-hospital\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label>I have previously been injured in an accident *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"previously-injured\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"previously-injured\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"previously-injured\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label>I own\/lease an automobile OR I live with an immediate family member who owns an automobile *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"who-avtouser\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"who-avtouser\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"who-avtouser\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label>I am a Medicare Beneficiary *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"medicare-beneficiary\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"medicare-beneficiary\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"medicare-beneficiary\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label> I am a Medicaid Beneficiary *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"medicaid-beneficiary\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"medicaid-beneficiary\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"medicaid-beneficiary\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label> I have Health Insurance<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"health-insurance\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"health-insurance\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"health-insurance\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div style=\"clear:both\">\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label>Police \/ Accident Report<br \/>\n<span class=\"wpcf7-form-control-wrap accident-repord\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-multifile\" multiple=\"multiple\" aria-invalid=\"false\" type=\"file\" name=\"accident-repord[]\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label>Accident Images (location)<br \/>\n<span class=\"wpcf7-form-control-wrap accident-imageslocation\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-multifile\" multiple=\"multiple\" aria-invalid=\"false\" type=\"file\" name=\"accident-imageslocation[]\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label>Accident Images (injuries)<br \/>\n<span class=\"wpcf7-form-control-wrap accident-imagesinjuries\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-multifile\" multiple=\"multiple\" aria-invalid=\"false\" type=\"file\" name=\"accident-imagesinjuries[]\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label>Health Insurance Card<br \/>\n<span class=\"wpcf7-form-control-wrap health-insurancecart\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-multifile\" multiple=\"multiple\" aria-invalid=\"false\" type=\"file\" name=\"health-insurancecart[]\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label> Automobile Insurance Declaration Page<br \/>\n<span class=\"wpcf7-form-control-wrap insurance-declaration\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-multifile\" multiple=\"multiple\" aria-invalid=\"false\" type=\"file\" name=\"insurance-declaration[]\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex oryoucan\">\n\t<div class=\"column one-second2\">\n\t\t<p>Or you can attach files via cloud Storage\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column full one-second2\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"cloud-link\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"Enter Cloud Storage Link\" type=\"text\" name=\"cloud-link\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n<\/p><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n<\/div>","protected":false},"excerpt":{"rendered":"<p>New Client Intake Form &ndash; Car\/Motorcycle\/Pedestrian Accident<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"noform.php","meta":{"_acf_changed":false,"footnotes":""},"class_list":["post-197","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/fnblegal.com\/backup\/wp-json\/wp\/v2\/pages\/197","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/fnblegal.com\/backup\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/fnblegal.com\/backup\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/fnblegal.com\/backup\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/fnblegal.com\/backup\/wp-json\/wp\/v2\/comments?post=197"}],"version-history":[{"count":0,"href":"https:\/\/fnblegal.com\/backup\/wp-json\/wp\/v2\/pages\/197\/revisions"}],"wp:attachment":[{"href":"https:\/\/fnblegal.com\/backup\/wp-json\/wp\/v2\/media?parent=197"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}