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University Drive, Suite A, Rochester, MI 48307\\n\u00a0 Mailing Address: P.O. Box 82263, Rochester, MI 48308-2263\",\"type\":\"control_text\"},null,null,null,null,null,null,{\"name\":\"image\",\"qid\":\"61\",\"text\":\"cclogo.430\",\"type\":\"control_image\"},null,null,null,null,{\"name\":\"beneficiaryAddress\",\"qid\":\"66\",\"text\":\"Beneficiary Address\",\"type\":\"control_address\"},{\"name\":\"signature67\",\"qid\":\"67\",\"text\":\"Signature\",\"type\":\"control_textbox\"},{\"name\":\"date\",\"qid\":\"68\",\"text\":\"Date\",\"type\":\"control_textbox\"},null,{\"name\":\"input70\",\"qid\":\"70\",\"text\":\"I hereby apply for enrollment in the PLEA Legal Defense Fund and Participation in the PLEA Trust.  I agree to abide by all terms and conditions thereof.  I understand that no coverage is in effect until this application is approved by the Plan Administrator.  To my knowledge, I am not presently named in any suits, actions, or proceedings, nor under investigation for a duty-related incident, except the following, for which there would be no coverage under the plan:\",\"type\":\"control_textarea\",\"wysiwyg\":\"Disable\"},{\"description\":\"\",\"name\":\"payment\",\"qid\":\"71\",\"text\":\"Payment\",\"type\":\"control_authnet\"},{\"name\":\"phoneNumber\",\"qid\":\"72\",\"text\":\"Phone Number\",\"type\":\"control_textbox\"}]);}, 20); \n<\/script>\n<\/head>\n<body>\n<form class=\"jotform-form\" onsubmit=\"return typeof testSubmitFunction !== 'undefined' && testSubmitFunction();\" action=\"https:\/\/pci.jotform.com\/submit\/40416701431947\" method=\"post\" name=\"form_40416701431947\" id=\"40416701431947\" accept-charset=\"utf-8\" autocomplete=\"on\"><input type=\"hidden\" name=\"formID\" value=\"40416701431947\" \/><input type=\"hidden\" id=\"JWTContainer\" value=\"\" \/><input type=\"hidden\" id=\"cardinalOrderNumber\" value=\"\" \/><input type=\"hidden\" id=\"jsExecutionTracker\" name=\"jsExecutionTracker\" value=\"build-date-1709097727217\" \/><input type=\"hidden\" id=\"submitSource\" name=\"submitSource\" value=\"unknown\" \/><input type=\"hidden\" id=\"buildDate\" name=\"buildDate\" value=\"1709097727217\" \/>\n  <div id=\"formCoverLogo\" style=\"margin-bottom:10px\" class=\"form-cover-wrapper form-has-cover form-page-cover-image-align-center\">\n    <div class=\"form-page-cover-image-wrapper\" style=\"max-width:650px\"><img src=\"https:\/\/www.jotform.com\/uploads\/pleanet\/form_files\/team%20legal%20logo%20-%20color.63ffb82acfe625.47213625.jpg\" class=\"form-page-cover-image\" width=\"140\" aria-label=\"Form Logo\" style=\"aspect-ratio:140\/140\" \/><\/div>\n  <\/div>\n  <div role=\"main\" class=\"form-all\">\n    <ul class=\"form-section page-section\">\n      <li id=\"cid_50\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-large\">\n          <div class=\"header-text httal htvam\">\n            <h1 id=\"header_50\" class=\"form-header\" data-component=\"header\">YOUR INFORMATION<\/h1>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_fullname\" id=\"id_7\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_7\" for=\"first_7\" aria-hidden=\"false\"> Full Name<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_7\" class=\"form-input-wide jf-required\">\n          <div data-wrapper-react=\"true\" class=\"extended\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"first\"><input type=\"text\" id=\"first_7\" name=\"q7_fullName7[first]\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" autoComplete=\"section-input_7 given-name\" size=\"10\" data-component=\"first\" aria-labelledby=\"label_7 sublabel_7_first\" required=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"first_7\" id=\"sublabel_7_first\" style=\"min-height:13px\">First Name<\/label><\/span><span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"middle\"><input type=\"text\" id=\"middle_7\" name=\"q7_fullName7[middle]\" class=\"form-textbox\" data-defaultvalue=\"\" autoComplete=\"section-input_7 additional-name\" size=\"10\" data-component=\"middle\" aria-labelledby=\"label_7 sublabel_7_middle\" required=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"middle_7\" id=\"sublabel_7_middle\" style=\"min-height:13px\">Middle Name<\/label><\/span><span class=\"form-sub-label-container\" style=\"vertical-align:top\" data-input-type=\"last\"><input type=\"text\" id=\"last_7\" name=\"q7_fullName7[last]\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" autoComplete=\"section-input_7 family-name\" size=\"15\" data-component=\"last\" aria-labelledby=\"label_7 sublabel_7_last\" required=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"last_7\" id=\"sublabel_7_last\" style=\"min-height:13px\">Last Name<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_72\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_72\" for=\"input_72\" aria-hidden=\"false\"> Phone Number<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_72\" class=\"form-input-wide jf-required\"> <input type=\"text\" id=\"input_72\" name=\"q72_phoneNumber\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" size=\"20\" placeholder=\"ex: xxx-xxx-xxxx\" data-component=\"textbox\" aria-labelledby=\"label_72\" required=\"\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_address\" id=\"id_9\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_9\" for=\"input_9_addr_line1\" aria-hidden=\"false\"> Address <\/label>\n        <div id=\"cid_9\" class=\"form-input-wide\">\n          <div summary=\"\" class=\"form-address-table jsTest-addressField\">\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\"><span class=\"form-address-line form-address-street-line jsTest-address-lineField\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_9_addr_line1\" name=\"q9_address9[addr_line1]\" class=\"form-textbox form-address-line\" data-defaultvalue=\"\" autoComplete=\"section-input_9 address-line1\" data-component=\"address_line_1\" aria-labelledby=\"label_9 sublabel_9_addr_line1\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_9_addr_line1\" id=\"sublabel_9_addr_line1\" style=\"min-height:13px\">Street Address<\/label><\/span><\/span><\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\"><span class=\"form-address-line form-address-street-line jsTest-address-lineField\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_9_addr_line2\" name=\"q9_address9[addr_line2]\" class=\"form-textbox form-address-line\" data-defaultvalue=\"\" autoComplete=\"section-input_9 address-line2\" data-component=\"address_line_2\" aria-labelledby=\"label_9 sublabel_9_addr_line2\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_9_addr_line2\" id=\"sublabel_9_addr_line2\" style=\"min-height:13px\">Street Address Line 2<\/label><\/span><\/span><\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\"><span class=\"form-address-line form-address-city-line jsTest-address-lineField \"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_9_city\" name=\"q9_address9[city]\" class=\"form-textbox form-address-city\" data-defaultvalue=\"\" autoComplete=\"section-input_9 address-level2\" data-component=\"city\" aria-labelledby=\"label_9 sublabel_9_city\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_9_city\" id=\"sublabel_9_city\" style=\"min-height:13px\">City<\/label><\/span><\/span><span class=\"form-address-line form-address-state-line jsTest-address-lineField \"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_9_state\" name=\"q9_address9[state]\" class=\"form-textbox form-address-state\" data-defaultvalue=\"\" autoComplete=\"section-input_9 address-level1\" data-component=\"state\" aria-labelledby=\"label_9 sublabel_9_state\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_9_state\" id=\"sublabel_9_state\" style=\"min-height:13px\">State \/ Province<\/label><\/span><\/span><\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\"><span class=\"form-address-line form-address-zip-line jsTest-address-lineField \"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_9_postal\" name=\"q9_address9[postal]\" class=\"form-textbox form-address-postal\" data-defaultvalue=\"\" autoComplete=\"section-input_9 postal-code\" data-component=\"zip\" aria-labelledby=\"label_9 sublabel_9_postal\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_9_postal\" id=\"sublabel_9_postal\" style=\"min-height:13px\">Postal \/ Zip Code<\/label><\/span><\/span><\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_10\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_10\" for=\"input_10\" aria-hidden=\"false\"> Group Affiliation: (Type &quot;Individual&quot; if not applicable)<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_10\" class=\"form-input-wide jf-required\"> <input type=\"text\" id=\"input_10\" name=\"q10_groupAffiliation\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" size=\"45\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_10\" required=\"\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_12\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_12\" for=\"input_12\" aria-hidden=\"false\"> SSN (Last 4 Digit) <\/label>\n        <div id=\"cid_12\" class=\"form-input-wide\"> <input type=\"text\" id=\"input_12\" name=\"q12_ssnlast\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" size=\"20\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_12\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_30\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_30\" for=\"input_30\" aria-hidden=\"false\"> Date of Birth: <\/label>\n        <div id=\"cid_30\" class=\"form-input-wide\"> <input type=\"text\" id=\"input_30\" name=\"q30_dateOf\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" size=\"47\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_30\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_email\" id=\"id_13\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_13\" for=\"input_13\" aria-hidden=\"false\"> E-mail<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_13\" class=\"form-input-wide jf-required\"> <input type=\"email\" id=\"input_13\" name=\"q13_email13\" class=\"form-textbox validate[required, Email]\" data-defaultvalue=\"\" autoComplete=\"section-input_13 email\" size=\"45\" placeholder=\" \" data-component=\"email\" aria-labelledby=\"label_13\" required=\"\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_14\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_14\" for=\"input_14_0\" aria-hidden=\"false\"> Email Invoice <\/label>\n        <div id=\"cid_14\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_14\" data-component=\"checkbox\"><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_14\" class=\"form-checkbox\" id=\"input_14_0\" name=\"q14_emailInvoice[]\" value=\"I would like to receive all future invoices electronically sent to the above Email address\" \/><label id=\"label_input_14_0\" for=\"input_14_0\">I would like to receive all future invoices electronically sent to the above Email address<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_16\">\n        <div id=\"cid_16\" class=\"form-input-wide\">\n          <div id=\"text_16\" class=\"form-html\" data-component=\"text\" tabindex=\"0\">\n            <p><span style=\"font-size:small;\"><strong style=\"font-family:Arial;font-size:13px;text-align:justify;\"><span style=\"color:#ff0000;\">*<\/span>How did you hear about us? (click below. For multiple choices use Ctrl + Click)<\/strong><\/span><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_dropdown\" id=\"id_15\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_15\" for=\"input_15\" aria-hidden=\"false\"> Please Select<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_15\" class=\"form-input-wide jf-required\"> <select class=\"form-dropdown validate[required]\" id=\"input_15\" name=\"q15_pleaseSelect\" style=\"width:200px\" data-component=\"dropdown\" required=\"\" aria-label=\"Please Select\">\n            <option value=\"\">Please Select<\/option>\n            <option selected=\"\" value=\"PLEA Newsletter\">PLEA Newsletter<\/option>\n            <option value=\"Current PLEA Member\">Current PLEA Member<\/option>\n            <option value=\"Search Engine\">Search Engine<\/option>\n            <option value=\"Lodge\">Lodge<\/option>\n            <option value=\"Packet Recieved\">Packet Recieved<\/option>\n            <option value=\"A Lodge Presentation\">A Lodge Presentation<\/option>\n            <option value=\"A fellow Officer\/Friend\">A fellow Officer\/Friend<\/option>\n            <option value=\"I am a former member of PLEA\">I am a former member of PLEA<\/option>\n            <option value=\"Other - Explain Below\">Other - Explain Below<\/option>\n          <\/select> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_17\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_17\" for=\"input_17\" aria-hidden=\"false\"> Other Please Explain <\/label>\n        <div id=\"cid_17\" class=\"form-input-wide\"> <input type=\"text\" id=\"input_17\" name=\"q17_otherPlease\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" size=\"45\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_17\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_18\">\n        <div id=\"cid_18\" class=\"form-input-wide\">\n          <div id=\"text_18\" class=\"form-html\" data-component=\"text\" tabindex=\"0\">\n            <p><span style=\"font-size:small;\"><strong style=\"font-family:Arial;font-size:13px;text-align:justify;\">Please provide the following information to continue processing of our Application:<\/strong><\/span><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_19\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_19\" for=\"input_19\" aria-hidden=\"false\"> Name of Employer:<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_19\" class=\"form-input-wide jf-required\"> <input type=\"text\" id=\"input_19\" name=\"q19_nameOf19\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" size=\"20\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_19\" required=\"\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_20\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_20\" for=\"input_20\" aria-hidden=\"false\"> Position:<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_20\" class=\"form-input-wide jf-required\"> <input type=\"text\" id=\"input_20\" name=\"q20_position\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" size=\"20\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_20\" required=\"\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_21\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_21\" for=\"input_21\" aria-hidden=\"false\"> Years With Current Employer:<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_21\" class=\"form-input-wide jf-required\"> <input type=\"text\" id=\"input_21\" name=\"q21_yearsWith\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" size=\"20\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_21\" required=\"\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_22\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_22\" for=\"input_22\" aria-hidden=\"false\"> Other Professional Affiliations:<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_22\" class=\"form-input-wide jf-required\"> <input type=\"text\" id=\"input_22\" name=\"q22_otherProfessional\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" size=\"45\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_22\" required=\"\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1\" data-type=\"control_textarea\" id=\"id_70\"><label class=\"form-label form-label-top\" id=\"label_70\" for=\"input_70\" aria-hidden=\"false\"> I hereby apply for enrollment in the PLEA Legal Defense Fund and Participation in the PLEA Trust. I agree to abide by all terms and conditions thereof. I understand that no coverage is in effect until this application is approved by the Plan Administrator. To my knowledge, I am not presently named in any suits, actions, or proceedings, nor under investigation for a duty-related incident, except the following, for which there would be no coverage under the plan: <\/label>\n        <div id=\"cid_70\" class=\"form-input-wide\"> <textarea id=\"input_70\" class=\"form-textarea\" name=\"q70_input70\" cols=\"55\" rows=\"4\" data-component=\"textarea\" aria-labelledby=\"label_70\"><\/textarea> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_25\">\n        <div id=\"cid_25\" class=\"form-input-wide\">\n          <div id=\"text_25\" class=\"form-html\" data-component=\"text\" tabindex=\"0\">\n            <p><strong style=\"font-family:Arial;font-size:small;text-align:justify;\">By typing my name below, in the Signature field, I am signing my name to enroll in the PLEA Legal Defense Fund and Participation in the PLEA Legal Defense Plan. \u00a0 I am bound by all laws regarding an \u00a0electronic signature.<\/strong><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line jf-required\" data-type=\"control_textbox\" id=\"id_52\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_52\" for=\"input_52\" aria-hidden=\"false\"> SIGNATURE<span class=\"form-required\">*<\/span> <\/label>\n        <div id=\"cid_52\" class=\"form-input-wide jf-required\"> <input type=\"text\" id=\"input_52\" name=\"q52_signature\" data-type=\"input-textbox\" class=\"form-textbox validate[required]\" data-defaultvalue=\"\" size=\"45\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_52\" required=\"\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_checkbox\" id=\"id_28\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_28\" for=\"input_28_0\" aria-hidden=\"false\"> AD&amp;D Opt Out <\/label>\n        <div id=\"cid_28\" class=\"form-input-wide\">\n          <div class=\"form-single-column\" role=\"group\" aria-labelledby=\"label_28\" data-component=\"checkbox\"><span class=\"form-checkbox-item\" style=\"clear:left\"><span class=\"dragger-item\"><\/span><input type=\"checkbox\" aria-describedby=\"label_28\" class=\"form-checkbox\" id=\"input_28_0\" name=\"q28_addOpt[]\" value=\"check here to opt out of the $5,000 AD&amp;D coverage.\" \/><label id=\"label_input_28_0\" for=\"input_28_0\">check here to opt out of the $5,000 AD&amp;D coverage.<\/label><\/span><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_29\">\n        <div id=\"cid_29\" class=\"form-input-wide\">\n          <div id=\"text_29\" class=\"form-html\" data-component=\"text\" tabindex=\"0\">\n            <p><strong style=\"font-family: Arial; font-size: 13px; text-align: justify;\">NOTE: If this information below is NOT completed you will NOT receive this free benefit.<\/strong><\/p>\n            <p><strong style=\"font-family: Arial; font-size: 13px; text-align: justify;\">NO REFUNDS<\/strong><\/p>\n            <p><span style=\"font-size: medium;\"><strong style=\"font-family: Arial; font-size: 13px; text-align: justify;\"><strong style=\"text-align: left;\">You\u00a0<span style=\"text-decoration: underline;\">must<\/span> complete the following information below to receive the free $5,000\u00a0<span style=\"color: #0000ff;\"><a href=\"http:\/\/mdev6.com\/plea\/development\/images\/ADD.pdf\" target=\"_blank\" rel=\"nofollow\">AD&amp;D<\/a>\u00a0<span style=\"color: #000000;\">coverage:<\/span><\/span><\/strong><\/strong><\/span><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_31\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_31\" for=\"input_31\" aria-hidden=\"false\"> Beneficiary Name: <\/label>\n        <div id=\"cid_31\" class=\"form-input-wide\"> <input type=\"text\" id=\"input_31\" name=\"q31_beneficiaryName31\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" size=\"47\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_31\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_address\" id=\"id_66\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_66\" for=\"input_66_addr_line1\" aria-hidden=\"false\"> Beneficiary Address <\/label>\n        <div id=\"cid_66\" class=\"form-input-wide\">\n          <div summary=\"\" class=\"form-address-table jsTest-addressField\">\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\"><span class=\"form-address-line form-address-street-line jsTest-address-lineField\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_66_addr_line1\" name=\"q66_beneficiaryAddress[addr_line1]\" class=\"form-textbox form-address-line\" data-defaultvalue=\"\" autoComplete=\"section-input_66 address-line1\" data-component=\"address_line_1\" aria-labelledby=\"label_66 sublabel_66_addr_line1\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_66_addr_line1\" id=\"sublabel_66_addr_line1\" style=\"min-height:13px\">Street Address<\/label><\/span><\/span><\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\"><span class=\"form-address-line form-address-street-line jsTest-address-lineField\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_66_addr_line2\" name=\"q66_beneficiaryAddress[addr_line2]\" class=\"form-textbox form-address-line\" data-defaultvalue=\"\" autoComplete=\"section-input_66 address-line2\" data-component=\"address_line_2\" aria-labelledby=\"label_66 sublabel_66_addr_line2\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_66_addr_line2\" id=\"sublabel_66_addr_line2\" style=\"min-height:13px\">Street Address Line 2<\/label><\/span><\/span><\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\"><span class=\"form-address-line form-address-city-line jsTest-address-lineField \"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_66_city\" name=\"q66_beneficiaryAddress[city]\" class=\"form-textbox form-address-city\" data-defaultvalue=\"\" autoComplete=\"section-input_66 address-level2\" data-component=\"city\" aria-labelledby=\"label_66 sublabel_66_city\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_66_city\" id=\"sublabel_66_city\" style=\"min-height:13px\">City<\/label><\/span><\/span><span class=\"form-address-line form-address-state-line jsTest-address-lineField \"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_66_state\" name=\"q66_beneficiaryAddress[state]\" class=\"form-textbox form-address-state\" data-defaultvalue=\"\" autoComplete=\"section-input_66 address-level1\" data-component=\"state\" aria-labelledby=\"label_66 sublabel_66_state\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_66_state\" id=\"sublabel_66_state\" style=\"min-height:13px\">State \/ Province<\/label><\/span><\/span><\/div>\n            <div class=\"form-address-line-wrapper jsTest-address-line-wrapperField\"><span class=\"form-address-line form-address-zip-line jsTest-address-lineField \"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_66_postal\" name=\"q66_beneficiaryAddress[postal]\" class=\"form-textbox form-address-postal\" data-defaultvalue=\"\" autoComplete=\"section-input_66 postal-code\" data-component=\"zip\" aria-labelledby=\"label_66 sublabel_66_postal\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_66_postal\" id=\"sublabel_66_postal\" style=\"min-height:13px\">Postal \/ Zip Code<\/label><\/span><\/span><\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_32\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_32\" for=\"input_32\" aria-hidden=\"false\"> Relationship: <\/label>\n        <div id=\"cid_32\" class=\"form-input-wide\"> <input type=\"text\" id=\"input_32\" name=\"q32_relationship\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" size=\"45\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_32\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_67\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_67\" for=\"input_67\" aria-hidden=\"false\"> Signature <\/label>\n        <div id=\"cid_67\" class=\"form-input-wide\"> <input type=\"text\" id=\"input_67\" name=\"q67_signature67\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" size=\"45\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_67\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_textbox\" id=\"id_68\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_68\" for=\"input_68\" aria-hidden=\"false\"> Date <\/label>\n        <div id=\"cid_68\" class=\"form-input-wide\"> <input type=\"text\" id=\"input_68\" name=\"q68_date\" data-type=\"input-textbox\" class=\"form-textbox\" data-defaultvalue=\"\" size=\"20\" placeholder=\" \" data-component=\"textbox\" aria-labelledby=\"label_68\" value=\"\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_35\">\n        <div id=\"cid_35\" class=\"form-input-wide\">\n          <div id=\"text_35\" class=\"form-html\" data-component=\"text\" tabindex=\"0\">\n            <p class=\"MsoNormal\" style=\"font-family:Arial;font-size:13px;margin:0px 15px;\"><span style=\"text-decoration:underline;\"><span style=\"font-size:8pt;\">CHOICE OF COUNSEL<\/span><\/span><\/p>\n            <p class=\"MsoNormal\" style=\"font-family:Arial;font-size:13px;margin:0px 15px;text-align:justify;\"><span style=\"font-size:8pt;\">The Participant has the free and unrestricted right to employ an attorney of his or her choice.\u00a0 The Plan has no obligation to recommend counsel and is not a guarantor in any manner of the skill of counsel chosen by participant, even if the attorney is a Participating Attorney.<\/span><\/p>\n\n            <p class=\"MsoNormal\" style=\"font-family:Arial;font-size:13px;margin:0px 15px;text-align:justify;\"><span style=\"font-size:8pt;\">The Plan does not guaranty the availability of a Participating Attorney in the Participant\u2019s geographical area.\u00a0 This may result in the Participant\u2019s need to hire a Non-Participating Attorney at added expense to the Participant.\u00a0 The Plan is not obligated to pay for the costs of a Non-Participating Attorney except as set forth in the Schedules of Benefits in the Plan Description.<\/span><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li id=\"cid_51\" class=\"form-input-wide\" data-type=\"control_head\">\n        <div class=\"form-header-group  header-large\">\n          <div class=\"header-text httal htvam\">\n            <h1 id=\"header_51\" class=\"form-header\" data-component=\"header\">PAYMENT INFORMATION:<\/h1>\n            <div id=\"subHeader_51\" class=\"form-subHeader\">We accept the following payments: Visa, MasterCard or Discover.<\/div>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line form-line-column form-col-1\" data-type=\"control_image\" id=\"id_61\">\n        <div id=\"cid_61\" class=\"form-input-wide\"> <img alt=\"Image-61\" loading=\"lazy\" class=\"form-image\" style=\"border:0\" src=\"https:\/\/www.jotform.com\/uploads\/pleanet\/form_files\/cclogo.430.jpg\" height=\"80px\" width=\"125px\" data-component=\"image\" role=\"none\" aria-hidden=\"true\" tabindex=\"-1\" \/> <\/div>\n      <\/li>\n      <li class=\"form-line card-1col\" data-type=\"control_authnet\" id=\"id_71\" data-payment=\"true\"><label class=\"form-label form-label-top form-label-auto\" id=\"label_71\" for=\"input_71\" aria-hidden=\"false\"> Payment <\/label>\n        <div id=\"cid_71\" class=\"form-input-wide\">\n          <div data-wrapper-react=\"true\">\n            <div data-wrapper-react=\"true\" class=\"product-container-wrapper\">\n              <div class=\"filter-container\"><\/div><input type=\"hidden\" name=\"simple_fpc\" data-payment_type=\"authnet\" data-component=\"payment1\" value=\"71\" \/><input type=\"hidden\" name=\"payment_transaction_uuid\" id=\"paymentTransactionId\" \/><input type=\"hidden\" name=\"payment_version\" id=\"payment_version\" value=\"3\" \/><input type=\"hidden\" name=\"payment_total_checksum\" id=\"payment_total_checksum\" data-component=\"payment2\" \/><input type=\"hidden\" name=\"payment_discount_value\" id=\"payment_discount_value\" data-component=\"payment3\" \/>\n              <div id=\"image-overlay\" class=\"overlay-content\" style=\"display:none\"><img id=\"current-image\" \/><span class=\"lb-prev-button\">prev<\/span><span class=\"lb-next-button\">next<\/span><span class=\"lb-close-button\">( X )<\/span><span class=\"image-overlay-product-container\">\n                  <ul class=\"form-overlay-item\" pid=\"1001\" hasicon=\"false\" hasimages=\"false\" iconvalue=\"\"><\/ul>\n                  <ul class=\"form-overlay-item\" pid=\"1002\" hasicon=\"false\" hasimages=\"false\" iconvalue=\"\"><\/ul>\n                  <ul class=\"form-overlay-item\" pid=\"1003\" hasicon=\"false\" hasimages=\"false\" iconvalue=\"\"><\/ul>\n                  <ul class=\"form-overlay-item\" pid=\"1004\" hasicon=\"false\" hasimages=\"false\" iconvalue=\"\"><\/ul>\n                <\/span><\/div>\n              <div data-wrapper-react=\"true\"><span class=\"form-product-item hover-product-item \" categories=\"non-categorized\" pid=\"1001\">\n                  <div data-wrapper-react=\"true\" class=\"form-product-item-detail\"><input type=\"checkbox\" class=\"form-checkbox  form-product-input\" id=\"input_71_1001\" name=\"q71_payment[][id]\" value=\"1001\" checked=\"\" disabled=\"\" required=\"\" \/><label for=\"input_71_1001\" class=\"form-product-container\"><span data-wrapper-react=\"true\"><span class=\"form-product-name\" id=\"product-name-input_71_1001\">Civil &amp; Criminal<\/span><span class=\"form-product-details\"><b><span data-wrapper-react=\"true\">$<span id=\"input_71_1001_price\">116.00<\/span><\/span><\/b><\/span><\/span>\n                      <div class=\"form-product-description\" id=\"product-name-description-input_71_1001\"><\/div>\n                    <\/label><\/div>\n                <\/span><br \/><span class=\"form-product-item hover-product-item \" categories=\"non-categorized\" pid=\"1002\">\n                  <div data-wrapper-react=\"true\" class=\"form-product-item-detail\"><input type=\"checkbox\" class=\"form-checkbox  form-product-input\" id=\"input_71_1002\" name=\"q71_payment[][id]\" value=\"1002\" checked=\"\" \/><label for=\"input_71_1002\" class=\"form-product-container\"><span data-wrapper-react=\"true\"><span class=\"form-product-name\" id=\"product-name-input_71_1002\">Telephone Consultation Program<\/span><span class=\"form-product-details\"><b><span data-wrapper-react=\"true\">$<span id=\"input_71_1002_price\">39.00<\/span><\/span><\/b><\/span><\/span><\/label><\/div>\n                <\/span><br \/><span class=\"form-product-item hover-product-item \" categories=\"non-categorized\" pid=\"1003\">\n                  <div data-wrapper-react=\"true\" class=\"form-product-item-detail\"><input type=\"checkbox\" class=\"form-checkbox  form-product-input\" id=\"input_71_1003\" name=\"q71_payment[][id]\" value=\"1003\" \/><label for=\"input_71_1003\" class=\"form-product-container\"><span data-wrapper-react=\"true\"><span class=\"form-product-name\" id=\"product-name-input_71_1003\">HR 218 Add-on Option<\/span><span class=\"form-product-details\"><b><span data-wrapper-react=\"true\">$<span id=\"input_71_1003_price\">60.00<\/span><\/span><\/b><\/span><\/span><\/label><br \/><br \/><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><label class=\"form-sub-label\" for=\"input_71_custom_1003_0\" style=\"min-height:13px\">H.R. 218<\/label><select class=\"form-dropdown\" name=\"q71_payment[special_1003][item_0]\" id=\"input_71_custom_1003_0\">\n                        <option value=\"Plan B - $10,000 Criminal &amp; $20,000 Civil\">Plan B - $10,000 Criminal &amp; $20,000 Civil<\/option>\n                        <option value=\"Plan C - $15,000 Criminal &amp; $30,000 Civil\">Plan C - $15,000 Criminal &amp; $30,000 Civil<\/option>\n                        <option value=\"Plan D - $20,000 Criminal &amp; $40,000 Civil\">Plan D - $20,000 Criminal &amp; $40,000 Civil<\/option>\n                        <option value=\"Plan E - $25,000 Criminal &amp; $50,000 Civil\">Plan E - $25,000 Criminal &amp; $50,000 Civil<\/option>\n                        <option value=\"Plan F - $30,000 Criminal &amp; $60,000 Civil\">Plan F - $30,000 Criminal &amp; $60,000 Civil<\/option>\n                      <\/select><\/span><br \/><span class=\"form-special-subtotal\"><span class=\"form-item-subtotal\">Item subtotal:<\/span><span data-wrapper-react=\"true\">$<span id=\"input_71_1003_item_subtotal\">0.00<\/span><\/span><\/span><\/div>\n                <\/span><br \/><span class=\"form-product-item hover-product-item \" categories=\"non-categorized\" pid=\"1004\">\n                  <div data-wrapper-react=\"true\" class=\"form-product-item-detail\"><input type=\"checkbox\" class=\"form-checkbox  form-product-input\" id=\"input_71_1004\" name=\"q71_payment[][id]\" value=\"1004\" \/><label for=\"input_71_1004\" class=\"form-product-container\"><span data-wrapper-react=\"true\"><span class=\"form-product-name\" id=\"product-name-input_71_1004\">Pre-Paid Legal Program<\/span><span class=\"form-product-details\"><b><span data-wrapper-react=\"true\">$<span id=\"input_71_1004_price\">120.00<\/span><\/span><\/b><\/span><\/span>\n                      <div class=\"form-product-description\" id=\"product-name-description-input_71_1004\"><\/div>\n                    <\/label><\/div>\n                <\/span><br \/>\n                <div id=\"coupon-container\" style=\"border:1px solid lightgray;padding:5px;border-radius:6px;width:200px;margin-top:8px\">\n                  <table id=\"coupon-table\">\n                    <tr>\n                      <th colSpan=\"2\" style=\"text-align:left\"><label id=\"coupon-header\" for=\"coupon-input\">Enter coupon<\/label><\/th>\n                    <\/tr>\n                    <tr>\n                      <td><input type=\"text\" name=\"coupon-input\" id=\"coupon-input\" data-stripe=\"false\" size=\"15\" autoComplete=\"off\" aria-labelledby=\"coupon-header coupon-message\" \/><\/td>\n                      <td width=\"40%\" style=\"text-align:center\"><img loading=\"lazy\" src=\"https:\/\/cdn.jotfor.ms\/\/images\/ajax-loader.gif\" alt=\"coupon loading\" id=\"coupon-loader\" style=\"display:none;vertical-align:top\" \/><button type=\"button\" id=\"coupon-button\" data-qid=\"input_71\" value=\"\">Apply<\/button><\/td>\n                    <\/tr>\n                    <tr>\n                      <th colSpan=\"2\" style=\"text-align:left\"><span id=\"coupon-message\" role=\"alert\"><\/span><\/th>\n                    <\/tr>\n                  <\/table>\n                <\/div><br \/><input type=\"hidden\" id=\"input_71_coupon\" name=\"coupon\" \/><span class=\"form-payment-total\"><b><span id=\"total-text\">Total<\/span>\u00a0<span class=\"form-payment-price\"><span data-wrapper-react=\"true\">$<span id=\"payment_total\">0.00<\/span><\/span><\/span><\/b><\/span>\n              <\/div>\n              <hr \/>\n            <\/div>\n            <table class=\"form-address-table payment-form-table\" cellPadding=\"0\" cellSpacing=\"0\" role=\"presentation\">\n              <tbody>\n                <tr>\n                  <td class=\"payment-form-table-header\" style=\"font-weight:bold;text-align:left;margin-top:20px;display:table\" colSpan=\"2\" id=\"ccTitle71\">Credit Card<\/td>\n                <\/tr>\n                <tr>\n                  <td width=\"50%\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_71_cc_firstName\" name=\"q71_payment[cc_firstName]\" class=\"form-textbox cc_firstName\" data-defaultvalue=\"\" size=\"20\" data-component=\"cc_firstName\" aria-label=\"Credit Card First Name\" aria-labelledby=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_71_cc_firstName\" id=\"sublabel_cc_firstName\" style=\"min-height:13px;margin:0 0 3px 0\">First Name<\/label><\/span><\/td>\n                  <td width=\"50%\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_71_cc_lastName\" name=\"q71_payment[cc_lastName]\" class=\"form-textbox cc_lastName\" data-defaultvalue=\"\" size=\"20\" data-component=\"cc_lastName\" aria-label=\"Credit Card Last Name\" aria-labelledby=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_71_cc_lastName\" id=\"sublabel_cc_lastName\" style=\"min-height:13px;margin:0 0 3px 0\">Last Name<\/label><\/span><\/td>\n                <\/tr>\n                <tr class=\"if_cc_field\">\n                  <td width=\"50%\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"number\" id=\"input_71_cc_number\" name=\"q71_payment[cc_number]\" class=\"form-textbox cc_number\" data-defaultvalue=\"\" autoComplete=\"nope\" size=\"20\" data-component=\"cc_number\" aria-label=\"Credit Card Number\" aria-labelledby=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_71_cc_number\" id=\"sublabel_cc_number\" style=\"min-height:13px;margin:0 0 3px 0\">Credit Card Number<\/label><\/span><\/td>\n                  <td width=\"50%\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"number\" id=\"input_71_cc_ccv\" name=\"q71_payment[cc_ccv]\" class=\"form-textbox cc_ccv\" data-defaultvalue=\"\" autoComplete=\"nope\" style=\"width:52px\" data-component=\"cc_ccv\" aria-label=\"CVV\" aria-labelledby=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_71_cc_ccv\" id=\"sublabel_cc_ccv\" style=\"min-height:13px;margin:0 0 3px 0\">Security Code<\/label><\/span><\/td>\n                <\/tr>\n                <tr>\n                  <td width=\"50%\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><select aria-label=\"Expiration Month\" class=\"form-dropdown cc_exp_month\" name=\"q71_payment[cc_exp_month]\" id=\"input_71_cc_exp_month\" data-component=\"cc_exp_month\">\n                        <option><\/option>\n                        <option value=\"January\">January<\/option>\n                        <option value=\"February\">February<\/option>\n                        <option value=\"March\">March<\/option>\n                        <option value=\"April\">April<\/option>\n                        <option value=\"May\">May<\/option>\n                        <option value=\"June\">June<\/option>\n                        <option value=\"July\">July<\/option>\n                        <option value=\"August\">August<\/option>\n                        <option value=\"September\">September<\/option>\n                        <option value=\"October\">October<\/option>\n                        <option value=\"November\">November<\/option>\n                        <option value=\"December\">December<\/option>\n                      <\/select><label class=\"form-sub-label\" for=\"input_71_cc_exp_month\" id=\"sublabel_cc_exp_month\" style=\"min-height:13px;margin:0 0 3px 0\">Expiration Month<\/label><\/span><\/td>\n                  <td width=\"50%\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><select aria-label=\"Expiration Year\" class=\"form-dropdown cc_exp_year\" name=\"q71_payment[cc_exp_year]\" id=\"input_71_cc_exp_year\" data-component=\"cc_exp_year\">\n                        <option><\/option>\n                        <option value=\"2024\">2024<\/option>\n                        <option value=\"2025\">2025<\/option>\n                        <option value=\"2026\">2026<\/option>\n                        <option value=\"2027\">2027<\/option>\n                        <option value=\"2028\">2028<\/option>\n                        <option value=\"2029\">2029<\/option>\n                        <option value=\"2030\">2030<\/option>\n                        <option value=\"2031\">2031<\/option>\n                        <option value=\"2032\">2032<\/option>\n                        <option value=\"2033\">2033<\/option>\n                      <\/select><label class=\"form-sub-label\" for=\"input_71_cc_exp_year\" id=\"sublabel_cc_exp_year\" style=\"min-height:13px;margin:0 0 3px 0\">Expiration Year<\/label><\/span><\/td>\n                <\/tr>\n                <tr>\n                  <td class=\"payment-form-table-header\" colSpan=\"2\" style=\"font-weight:bold;text-align:left;margin-top:20px;display:table\">Billing Address<\/td>\n                <\/tr>\n                <tr>\n                  <td colSpan=\"2\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_71_addr_line1\" name=\"q71_payment[addr_line1]\" class=\"form-textbox form-address-line\" data-defaultvalue=\"\" data-component=\"addr_line1\" aria-label=\"Billing Address Line 1\" aria-labelledby=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_71_addr_line1\" id=\"sublabel_71_addr_line1\" style=\"min-height:13px\">Street Address<\/label><\/span><\/td>\n                <\/tr>\n                <tr>\n                  <td colSpan=\"2\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_71_addr_line2\" name=\"q71_payment[addr_line2]\" class=\"form-textbox form-address-line\" data-defaultvalue=\"\" size=\"46\" data-component=\"addr_line2\" aria-label=\"Billing Address Line 2\" aria-labelledby=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_71_addr_line2\" id=\"sublabel_71_addr_line2\" style=\"min-height:13px\">Street Address Line 2<\/label><\/span><\/td>\n                <\/tr>\n                <tr>\n                  <td width=\"50%\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_71_city\" name=\"q71_payment[city]\" class=\"form-textbox form-address-city\" data-defaultvalue=\"\" size=\"21\" data-component=\"city\" aria-label=\"City\" aria-labelledby=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_71_city\" id=\"sublabel_71_city\" style=\"min-height:13px\">City<\/label><\/span><\/td>\n                  <td><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_71_state\" name=\"q71_payment[state]\" class=\"form-textbox form-address-state\" data-defaultvalue=\"\" size=\"22\" data-component=\"state\" aria-label=\"State\" aria-labelledby=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_71_state\" id=\"sublabel_71_state\" style=\"min-height:13px\">State \/ Province<\/label><\/span><\/td>\n                <\/tr>\n                <tr>\n                  <td width=\"50%\"><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><input type=\"text\" id=\"input_71_postal\" name=\"q71_payment[postal]\" class=\"form-textbox form-address-postal\" data-defaultvalue=\"\" size=\"10\" data-component=\"postal\" aria-label=\"Postal \/ Zip Code\" aria-labelledby=\"\" value=\"\" \/><label class=\"form-sub-label\" for=\"input_71_postal\" id=\"sublabel_71_postal\" style=\"min-height:13px\">Postal \/ Zip Code<\/label><\/span><\/td>\n                  <td><span class=\"form-sub-label-container\" style=\"vertical-align:top\"><select aria-label=\"Country\" class=\"form-dropdown form-address-country\" name=\"q71_payment[country]\" id=\"input_71_country\" data-component=\"country\">\n                        <option value=\"\" selected=\"\">Please Select<\/option>\n                        <option value=\"United States\">United States<\/option>\n                        <option value=\"Afghanistan\">Afghanistan<\/option>\n                        <option value=\"Albania\">Albania<\/option>\n                        <option value=\"Algeria\">Algeria<\/option>\n                        <option value=\"American Samoa\">American Samoa<\/option>\n                        <option value=\"Andorra\">Andorra<\/option>\n                        <option value=\"Angola\">Angola<\/option>\n                        <option value=\"Anguilla\">Anguilla<\/option>\n                        <option value=\"Antigua and Barbuda\">Antigua and Barbuda<\/option>\n                        <option value=\"Argentina\">Argentina<\/option>\n                        <option value=\"Armenia\">Armenia<\/option>\n                        <option value=\"Aruba\">Aruba<\/option>\n                        <option value=\"Australia\">Australia<\/option>\n                        <option value=\"Austria\">Austria<\/option>\n                        <option value=\"Azerbaijan\">Azerbaijan<\/option>\n                        <option value=\"The Bahamas\">The Bahamas<\/option>\n                        <option value=\"Bahrain\">Bahrain<\/option>\n                        <option value=\"Bangladesh\">Bangladesh<\/option>\n                        <option value=\"Barbados\">Barbados<\/option>\n                        <option value=\"Belarus\">Belarus<\/option>\n                        <option value=\"Belgium\">Belgium<\/option>\n                        <option value=\"Belize\">Belize<\/option>\n                        <option value=\"Benin\">Benin<\/option>\n                        <option value=\"Bermuda\">Bermuda<\/option>\n                        <option value=\"Bhutan\">Bhutan<\/option>\n                        <option value=\"Bolivia\">Bolivia<\/option>\n                        <option value=\"Bosnia and Herzegovina\">Bosnia and Herzegovina<\/option>\n                        <option value=\"Botswana\">Botswana<\/option>\n                        <option value=\"Brazil\">Brazil<\/option>\n                        <option value=\"Brunei\">Brunei<\/option>\n                        <option value=\"Bulgaria\">Bulgaria<\/option>\n                        <option value=\"Burkina Faso\">Burkina Faso<\/option>\n                        <option value=\"Burundi\">Burundi<\/option>\n                        <option value=\"Cambodia\">Cambodia<\/option>\n                        <option value=\"Cameroon\">Cameroon<\/option>\n                        <option value=\"Canada\">Canada<\/option>\n                        <option value=\"Cape Verde\">Cape Verde<\/option>\n                        <option value=\"Cayman Islands\">Cayman Islands<\/option>\n                        <option value=\"Central African Republic\">Central African Republic<\/option>\n                        <option value=\"Chad\">Chad<\/option>\n                        <option value=\"Chile\">Chile<\/option>\n                        <option value=\"China\">China<\/option>\n                        <option value=\"Christmas Island\">Christmas Island<\/option>\n                        <option value=\"Cocos (Keeling) Islands\">Cocos (Keeling) Islands<\/option>\n                        <option value=\"Colombia\">Colombia<\/option>\n                        <option value=\"Comoros\">Comoros<\/option>\n                        <option value=\"Congo\">Congo<\/option>\n                        <option value=\"Cook Islands\">Cook Islands<\/option>\n                        <option value=\"Costa Rica\">Costa Rica<\/option>\n                        <option value=\"Cote d&#x27;Ivoire\">Cote d&#x27;Ivoire<\/option>\n                        <option value=\"Croatia\">Croatia<\/option>\n                        <option value=\"Cuba\">Cuba<\/option>\n                        <option value=\"Cura\u00e7ao\">Cura\u00e7ao<\/option>\n                        <option value=\"Cyprus\">Cyprus<\/option>\n                        <option value=\"Czech Republic\">Czech Republic<\/option>\n                        <option value=\"Democratic Republic of the Congo\">Democratic Republic of the Congo<\/option>\n                        <option value=\"Denmark\">Denmark<\/option>\n                        <option value=\"Djibouti\">Djibouti<\/option>\n                        <option value=\"Dominica\">Dominica<\/option>\n                        <option value=\"Dominican Republic\">Dominican Republic<\/option>\n                        <option value=\"Ecuador\">Ecuador<\/option>\n                        <option value=\"Egypt\">Egypt<\/option>\n                        <option value=\"El Salvador\">El Salvador<\/option>\n                        <option value=\"Equatorial Guinea\">Equatorial Guinea<\/option>\n                        <option value=\"Eritrea\">Eritrea<\/option>\n                        <option value=\"Estonia\">Estonia<\/option>\n                        <option value=\"Ethiopia\">Ethiopia<\/option>\n                        <option value=\"Falkland Islands\">Falkland Islands<\/option>\n                        <option value=\"Faroe Islands\">Faroe Islands<\/option>\n                        <option value=\"Fiji\">Fiji<\/option>\n                        <option value=\"Finland\">Finland<\/option>\n                        <option value=\"France\">France<\/option>\n                        <option value=\"French Polynesia\">French Polynesia<\/option>\n                        <option value=\"Gabon\">Gabon<\/option>\n                        <option value=\"The Gambia\">The Gambia<\/option>\n                        <option value=\"Georgia\">Georgia<\/option>\n                        <option value=\"Germany\">Germany<\/option>\n                        <option value=\"Ghana\">Ghana<\/option>\n                        <option value=\"Gibraltar\">Gibraltar<\/option>\n                        <option value=\"Greece\">Greece<\/option>\n                        <option value=\"Greenland\">Greenland<\/option>\n                        <option value=\"Grenada\">Grenada<\/option>\n                        <option value=\"Guadeloupe\">Guadeloupe<\/option>\n                        <option value=\"Guam\">Guam<\/option>\n                        <option value=\"Guatemala\">Guatemala<\/option>\n                        <option value=\"Guernsey\">Guernsey<\/option>\n                        <option value=\"Guinea\">Guinea<\/option>\n                        <option value=\"Guinea-Bissau\">Guinea-Bissau<\/option>\n                        <option value=\"Guyana\">Guyana<\/option>\n                        <option value=\"Haiti\">Haiti<\/option>\n                        <option value=\"Honduras\">Honduras<\/option>\n                        <option value=\"Hong Kong\">Hong Kong<\/option>\n                        <option value=\"Hungary\">Hungary<\/option>\n                        <option value=\"Iceland\">Iceland<\/option>\n                        <option value=\"India\">India<\/option>\n                        <option value=\"Indonesia\">Indonesia<\/option>\n                        <option value=\"Iran\">Iran<\/option>\n                        <option value=\"Iraq\">Iraq<\/option>\n                        <option value=\"Ireland\">Ireland<\/option>\n                        <option value=\"Israel\">Israel<\/option>\n                        <option value=\"Italy\">Italy<\/option>\n                        <option value=\"Jamaica\">Jamaica<\/option>\n                        <option value=\"Japan\">Japan<\/option>\n                        <option value=\"Jersey\">Jersey<\/option>\n                        <option value=\"Jordan\">Jordan<\/option>\n                        <option value=\"Kazakhstan\">Kazakhstan<\/option>\n                        <option value=\"Kenya\">Kenya<\/option>\n                        <option value=\"Kiribati\">Kiribati<\/option>\n                        <option value=\"North Korea\">North Korea<\/option>\n                        <option value=\"South Korea\">South Korea<\/option>\n                        <option value=\"Kosovo\">Kosovo<\/option>\n                        <option value=\"Kuwait\">Kuwait<\/option>\n                        <option value=\"Kyrgyzstan\">Kyrgyzstan<\/option>\n                        <option value=\"Laos\">Laos<\/option>\n                        <option value=\"Latvia\">Latvia<\/option>\n                        <option value=\"Lebanon\">Lebanon<\/option>\n                        <option value=\"Lesotho\">Lesotho<\/option>\n                        <option value=\"Liberia\">Liberia<\/option>\n                        <option value=\"Libya\">Libya<\/option>\n                        <option value=\"Liechtenstein\">Liechtenstein<\/option>\n                        <option value=\"Lithuania\">Lithuania<\/option>\n                        <option value=\"Luxembourg\">Luxembourg<\/option>\n                        <option value=\"Macau\">Macau<\/option>\n                        <option value=\"Macedonia\">Macedonia<\/option>\n                        <option value=\"Madagascar\">Madagascar<\/option>\n                        <option value=\"Malawi\">Malawi<\/option>\n                        <option value=\"Malaysia\">Malaysia<\/option>\n                        <option value=\"Maldives\">Maldives<\/option>\n                        <option value=\"Mali\">Mali<\/option>\n                        <option value=\"Malta\">Malta<\/option>\n                        <option value=\"Marshall Islands\">Marshall Islands<\/option>\n                        <option value=\"Martinique\">Martinique<\/option>\n                        <option value=\"Mauritania\">Mauritania<\/option>\n                        <option value=\"Mauritius\">Mauritius<\/option>\n                        <option value=\"Mayotte\">Mayotte<\/option>\n                        <option value=\"Mexico\">Mexico<\/option>\n                        <option value=\"Micronesia\">Micronesia<\/option>\n                        <option value=\"Moldova\">Moldova<\/option>\n                        <option value=\"Monaco\">Monaco<\/option>\n                        <option value=\"Mongolia\">Mongolia<\/option>\n                        <option value=\"Montenegro\">Montenegro<\/option>\n                        <option value=\"Montserrat\">Montserrat<\/option>\n                        <option value=\"Morocco\">Morocco<\/option>\n                        <option value=\"Mozambique\">Mozambique<\/option>\n                        <option value=\"Myanmar\">Myanmar<\/option>\n                        <option value=\"Nagorno-Karabakh\">Nagorno-Karabakh<\/option>\n                        <option value=\"Namibia\">Namibia<\/option>\n                        <option value=\"Nauru\">Nauru<\/option>\n                        <option value=\"Nepal\">Nepal<\/option>\n                        <option value=\"Netherlands\">Netherlands<\/option>\n                        <option value=\"Netherlands Antilles\">Netherlands Antilles<\/option>\n                        <option value=\"New Caledonia\">New Caledonia<\/option>\n                        <option value=\"New Zealand\">New Zealand<\/option>\n                        <option value=\"Nicaragua\">Nicaragua<\/option>\n                        <option value=\"Niger\">Niger<\/option>\n                        <option value=\"Nigeria\">Nigeria<\/option>\n                        <option value=\"Niue\">Niue<\/option>\n                        <option value=\"Norfolk Island\">Norfolk Island<\/option>\n                        <option value=\"Turkish Republic of Northern Cyprus\">Turkish Republic of Northern Cyprus<\/option>\n                        <option value=\"Northern Mariana\">Northern Mariana<\/option>\n                        <option value=\"Norway\">Norway<\/option>\n                        <option value=\"Oman\">Oman<\/option>\n                        <option value=\"Pakistan\">Pakistan<\/option>\n                        <option value=\"Palau\">Palau<\/option>\n                        <option value=\"Palestine\">Palestine<\/option>\n                        <option value=\"Panama\">Panama<\/option>\n                        <option value=\"Papua New Guinea\">Papua New Guinea<\/option>\n                        <option value=\"Paraguay\">Paraguay<\/option>\n                        <option value=\"Peru\">Peru<\/option>\n                        <option value=\"Philippines\">Philippines<\/option>\n                        <option value=\"Pitcairn Islands\">Pitcairn Islands<\/option>\n                        <option value=\"Poland\">Poland<\/option>\n                        <option value=\"Portugal\">Portugal<\/option>\n                        <option value=\"Puerto Rico\">Puerto Rico<\/option>\n                        <option value=\"Qatar\">Qatar<\/option>\n                        <option value=\"Republic of the Congo\">Republic of the Congo<\/option>\n                        <option value=\"Romania\">Romania<\/option>\n                        <option value=\"Russia\">Russia<\/option>\n                        <option value=\"Rwanda\">Rwanda<\/option>\n                        <option value=\"Saint Barthelemy\">Saint Barthelemy<\/option>\n                        <option value=\"Saint Helena\">Saint Helena<\/option>\n                        <option value=\"Saint Kitts and Nevis\">Saint Kitts and Nevis<\/option>\n                        <option value=\"Saint Lucia\">Saint Lucia<\/option>\n                        <option value=\"Saint Martin\">Saint Martin<\/option>\n                        <option value=\"Saint Pierre and Miquelon\">Saint Pierre and Miquelon<\/option>\n                        <option value=\"Saint Vincent and the Grenadines\">Saint Vincent and the Grenadines<\/option>\n                        <option value=\"Samoa\">Samoa<\/option>\n                        <option value=\"San Marino\">San Marino<\/option>\n                        <option value=\"Sao Tome and Principe\">Sao Tome and Principe<\/option>\n                        <option value=\"Saudi Arabia\">Saudi Arabia<\/option>\n                        <option value=\"Senegal\">Senegal<\/option>\n                        <option value=\"Serbia\">Serbia<\/option>\n                        <option value=\"Seychelles\">Seychelles<\/option>\n                        <option value=\"Sierra Leone\">Sierra Leone<\/option>\n                        <option value=\"Singapore\">Singapore<\/option>\n                        <option value=\"Slovakia\">Slovakia<\/option>\n                        <option value=\"Slovenia\">Slovenia<\/option>\n                        <option value=\"Solomon Islands\">Solomon Islands<\/option>\n                        <option value=\"Somalia\">Somalia<\/option>\n                        <option value=\"Somaliland\">Somaliland<\/option>\n                        <option value=\"South Africa\">South Africa<\/option>\n                        <option value=\"South Ossetia\">South Ossetia<\/option>\n                        <option value=\"South Sudan\">South Sudan<\/option>\n                        <option value=\"Spain\">Spain<\/option>\n                        <option value=\"Sri Lanka\">Sri Lanka<\/option>\n                        <option value=\"Sudan\">Sudan<\/option>\n                        <option value=\"Suriname\">Suriname<\/option>\n                        <option value=\"Svalbard\">Svalbard<\/option>\n                        <option value=\"eSwatini\">eSwatini<\/option>\n                        <option value=\"Sweden\">Sweden<\/option>\n                        <option value=\"Switzerland\">Switzerland<\/option>\n                        <option value=\"Syria\">Syria<\/option>\n                        <option value=\"Taiwan\">Taiwan<\/option>\n                        <option value=\"Tajikistan\">Tajikistan<\/option>\n                        <option value=\"Tanzania\">Tanzania<\/option>\n                        <option value=\"Thailand\">Thailand<\/option>\n                        <option value=\"Timor-Leste\">Timor-Leste<\/option>\n                        <option value=\"Togo\">Togo<\/option>\n                        <option value=\"Tokelau\">Tokelau<\/option>\n                        <option value=\"Tonga\">Tonga<\/option>\n                        <option value=\"Transnistria Pridnestrovie\">Transnistria Pridnestrovie<\/option>\n                        <option value=\"Trinidad and Tobago\">Trinidad and Tobago<\/option>\n                        <option value=\"Tristan da Cunha\">Tristan da Cunha<\/option>\n                        <option value=\"Tunisia\">Tunisia<\/option>\n                        <option value=\"Turkey\">Turkey<\/option>\n                        <option value=\"Turkmenistan\">Turkmenistan<\/option>\n                        <option value=\"Turks and Caicos Islands\">Turks and Caicos Islands<\/option>\n                        <option value=\"Tuvalu\">Tuvalu<\/option>\n                        <option value=\"Uganda\">Uganda<\/option>\n                        <option value=\"Ukraine\">Ukraine<\/option>\n                        <option value=\"United Arab Emirates\">United Arab Emirates<\/option>\n                        <option value=\"United Kingdom\">United Kingdom<\/option>\n                        <option value=\"Uruguay\">Uruguay<\/option>\n                        <option value=\"Uzbekistan\">Uzbekistan<\/option>\n                        <option value=\"Vanuatu\">Vanuatu<\/option>\n                        <option value=\"Vatican City\">Vatican City<\/option>\n                        <option value=\"Venezuela\">Venezuela<\/option>\n                        <option value=\"Vietnam\">Vietnam<\/option>\n                        <option value=\"British Virgin Islands\">British Virgin Islands<\/option>\n                        <option value=\"Isle of Man\">Isle of Man<\/option>\n                        <option value=\"US Virgin Islands\">US Virgin Islands<\/option>\n                        <option value=\"Wallis and Futuna\">Wallis and Futuna<\/option>\n                        <option value=\"Western Sahara\">Western Sahara<\/option>\n                        <option value=\"Yemen\">Yemen<\/option>\n                        <option value=\"Zambia\">Zambia<\/option>\n                        <option value=\"Zimbabwe\">Zimbabwe<\/option>\n                        <option value=\"other\">Other<\/option>\n                      <\/select><label class=\"form-sub-label\" for=\"input_71_country\" id=\"sublabel_71_country\" style=\"min-height:13px\">Country<\/label><\/span><\/td>\n                <\/tr>\n              <\/tbody>\n            <\/table>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_button\" id=\"id_46\">\n        <div id=\"cid_46\" class=\"form-input-wide\">\n          <div data-align=\"left\" class=\"form-buttons-wrapper form-buttons-left   jsTest-button-wrapperField\"><button id=\"input_46\" type=\"submit\" class=\"form-submit-button submit-button jf-form-buttons jsTest-submitField\" data-component=\"button\" data-content=\"\">Submit<\/button><span>\u00a0<\/span><button id=\"input_reset_46\" type=\"reset\" class=\"form-submit-reset jf-form-buttons\" data-component=\"button\">Clear Form<\/button><\/div>\n        <\/div>\n      <\/li>\n      <li class=\"form-line\" data-type=\"control_text\" id=\"id_54\">\n        <div id=\"cid_54\" class=\"form-input-wide\">\n          <div id=\"text_54\" class=\"form-html\" data-component=\"text\" tabindex=\"0\">\n            <p><span style=\"font-size: 12pt;\"><strong>Important:<\/strong> Once Enrollment Form has been approved by the Plan Administrator coverage begins the first or the fifteenth of the month following receipt of the completed enrollment and payment in our office.<\/span><\/p>\n            <p>\u00a0<\/p>\n            <p><span style=\"color: #ea3223;\"><strong>Please note that effective January 1, 2023 our addresses have changed:<\/strong><\/span><\/p>\n            <p><span style=\"color: #ea3223;\"><strong>\u00a0 Physical Address: 850 W. University Drive, Suite A, Rochester, MI 48307<\/strong><\/span><\/p>\n            <p><span style=\"color: #ea3223;\"><strong>\u00a0 Mailing Address: P.O. Box 82263, Rochester, MI 48308-2263<\/strong><\/span><\/p>\n          <\/div>\n        <\/div>\n      <\/li>\n      <li style=\"display:none\">Should be Empty: <input type=\"text\" name=\"website\" value=\"\" type=\"hidden\" \/><\/li>\n    <\/ul>\n  <\/div>\n  <script>\n    JotForm.showJotFormPowered = \"0\";\n  <\/script>\n  <script>\n    JotForm.poweredByText = \"Powered by Jotform\";\n  <\/script><input type=\"hidden\" class=\"simple_spc\" id=\"simple_spc\" name=\"simple_spc\" value=\"40416701431947\" \/>\n  <script type=\"text\/javascript\">\n    var all_spc = document.querySelectorAll(\"form[id='40416701431947'] .si\" + \"mple\" + \"_spc\");\n    for (var i = 0; i < all_spc.length; i++)\n    {\n      all_spc[i].value = \"40416701431947-40416701431947\";\n    }\n  <\/script>\n<\/form><\/body>\n<\/html><script type=\"text\/javascript\">JotForm.isNewSACL=true;<\/script>","PLEA-Team Legal",Array);var permittedDomains=[];try{var renderURLDomain=new URL("https://form.jotform.com/40416701431947").hostname;permittedDomains=[renderURLDomain];}catch(e){permittedDomains=['jotform.com','jotform.pro'];}
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