{"id":22604,"date":"2023-10-09T05:59:44","date_gmt":"2023-10-09T05:59:44","guid":{"rendered":"https:\/\/rebrand2.battleface.com\/en-gb\/lloyds-uk-online-claim-form-copy\/"},"modified":"2023-10-09T06:01:48","modified_gmt":"2023-10-09T06:01:48","slug":"manual-policies-online-form-chf","status":"publish","type":"forms","link":"https:\/\/www.battleface.com\/en-us\/manual-policies-online-form-chf\/","title":{"rendered":"Manual policies online form <span class=\"display-none\">CHF<\/span>"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-post\" data-elementor-id=\"22604\" class=\"elementor elementor-22604\" data-elementor-post-type=\"forms\">\n\t\t\t\t<div class=\"elementor-element elementor-element-bed997d e-flex e-con-boxed e-con e-parent\" data-id=\"bed997d\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-4789411 elementor-widget elementor-widget-wp-widget-gform_widget\" data-id=\"4789411\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"wp-widget-gform_widget.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<!--n2css--><!--n2js--><script id=\"wp-dom-ready-js\" src=\"https:\/\/www.battleface.com\/wp-includes\/js\/dist\/dom-ready.min.js?ver=3fe927cab37bf38d6a23\"><\/script>\n<script id=\"wp-hooks-js\" src=\"https:\/\/www.battleface.com\/wp-includes\/js\/dist\/hooks.min.js?ver=f0f188028580e8dc1255\"><\/script>\n<script id=\"wp-i18n-js\" src=\"https:\/\/www.battleface.com\/wp-includes\/js\/dist\/i18n.min.js?ver=1dfe7db3940c23ea9216\"><\/script>\n<script id=\"wp-i18n-js-after\">\nwp.i18n.setLocaleData( { 'text direction\\u0004ltr': [ 'ltr' ] } );\n\/\/# sourceURL=wp-i18n-js-after\n<\/script>\n<script id=\"wp-a11y-js\" src=\"https:\/\/www.battleface.com\/wp-includes\/js\/dist\/a11y.min.js?ver=31c6cec5a4ff7aff483d\"><\/script>\n<script id=\"jquery-core-js\" 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Territories\",\"GA\":\"Gabon\",\"GM\":\"Gambia\",\"GE\":\"Georgia\",\"DE\":\"Germany\",\"GH\":\"Ghana\",\"GI\":\"Gibraltar\",\"GR\":\"Greece\",\"GL\":\"Greenland\",\"GD\":\"Grenada\",\"GP\":\"Guadeloupe\",\"GU\":\"Guam\",\"GT\":\"Guatemala\",\"GG\":\"Guernsey\",\"GN\":\"Guinea\",\"GW\":\"Guinea-Bissau\",\"GY\":\"Guyana\",\"HT\":\"Haiti\",\"HM\":\"Heard Island and McDonald Islands\",\"VA\":\"Holy See\",\"HN\":\"Honduras\",\"HK\":\"Hong Kong\",\"HU\":\"Hungary\",\"IS\":\"Iceland\",\"IN\":\"India\",\"ID\":\"Indonesia\",\"IR\":\"Iran\",\"IQ\":\"Iraq\",\"IE\":\"Ireland\",\"IM\":\"Isle of Man\",\"IL\":\"Israel\",\"IT\":\"Italy\",\"JM\":\"Jamaica\",\"JP\":\"Japan\",\"JE\":\"Jersey\",\"JO\":\"Jordan\",\"KZ\":\"Kazakhstan\",\"KE\":\"Kenya\",\"KI\":\"Kiribati\",\"KP\":\"Korea, Democratic People's Republic of\",\"KR\":\"Korea, Republic of\",\"KW\":\"Kuwait\",\"KG\":\"Kyrgyzstan\",\"LA\":\"Lao People's Democratic Republic\",\"LV\":\"Latvia\",\"LB\":\"Lebanon\",\"LS\":\"Lesotho\",\"LR\":\"Liberia\",\"LY\":\"Libya\",\"LI\":\"Liechtenstein\",\"LT\":\"Lithuania\",\"LU\":\"Luxembourg\",\"MO\":\"Macao\",\"MG\":\"Madagascar\",\"MW\":\"Malawi\",\"MY\":\"Malaysia\",\"MV\":\"Maldives\",\"ML\":\"Mali\",\"MT\":\"Malta\",\"MH\":\"Marshall Islands\",\"MQ\":\"Martinique\",\"MR\":\"Mauritania\",\"MU\":\"Mauritius\",\"YT\":\"Mayotte\",\"MX\":\"Mexico\",\"FM\":\"Micronesia\",\"MD\":\"Moldova\",\"MC\":\"Monaco\",\"MN\":\"Mongolia\",\"ME\":\"Montenegro\",\"MS\":\"Montserrat\",\"MA\":\"Morocco\",\"MZ\":\"Mozambique\",\"MM\":\"Myanmar\",\"NA\":\"Namibia\",\"NR\":\"Nauru\",\"NP\":\"Nepal\",\"NL\":\"Netherlands\",\"NC\":\"New Caledonia\",\"NZ\":\"New Zealand\",\"NI\":\"Nicaragua\",\"NE\":\"Niger\",\"NG\":\"Nigeria\",\"NU\":\"Niue\",\"NF\":\"Norfolk Island\",\"MK\":\"North Macedonia\",\"MP\":\"Northern Mariana Islands\",\"NO\":\"Norway\",\"OM\":\"Oman\",\"PK\":\"Pakistan\",\"PW\":\"Palau\",\"PS\":\"Palestine, State of\",\"PA\":\"Panama\",\"PG\":\"Papua New Guinea\",\"PY\":\"Paraguay\",\"PE\":\"Peru\",\"PH\":\"Philippines\",\"PN\":\"Pitcairn\",\"PL\":\"Poland\",\"PT\":\"Portugal\",\"PR\":\"Puerto Rico\",\"QA\":\"Qatar\",\"RE\":\"R\\u00e9union\",\"RO\":\"Romania\",\"RU\":\"Russian Federation\",\"RW\":\"Rwanda\",\"BL\":\"Saint Barth\\u00e9lemy\",\"SH\":\"Saint Helena, Ascension and Tristan da Cunha\",\"KN\":\"Saint Kitts and Nevis\",\"LC\":\"Saint Lucia\",\"MF\":\"Saint Martin\",\"PM\":\"Saint Pierre and Miquelon\",\"VC\":\"Saint Vincent and the Grenadines\",\"WS\":\"Samoa\",\"SM\":\"San Marino\",\"ST\":\"Sao Tome and Principe\",\"SA\":\"Saudi Arabia\",\"SN\":\"Senegal\",\"RS\":\"Serbia\",\"SC\":\"Seychelles\",\"SL\":\"Sierra Leone\",\"SG\":\"Singapore\",\"SX\":\"Sint Maarten\",\"SK\":\"Slovakia\",\"SI\":\"Slovenia\",\"SB\":\"Solomon Islands\",\"SO\":\"Somalia\",\"ZA\":\"South Africa\",\"GS\":\"South Georgia and the South Sandwich Islands\",\"SS\":\"South Sudan\",\"ES\":\"Spain\",\"LK\":\"Sri Lanka\",\"SD\":\"Sudan\",\"SR\":\"Suriname\",\"SJ\":\"Svalbard and Jan Mayen\",\"SE\":\"Sweden\",\"CH\":\"Switzerland\",\"SY\":\"Syria Arab Republic\",\"TW\":\"Taiwan\",\"TJ\":\"Tajikistan\",\"TZ\":\"Tanzania, the United Republic of\",\"TH\":\"Thailand\",\"TL\":\"Timor-Leste\",\"TG\":\"Togo\",\"TK\":\"Tokelau\",\"TO\":\"Tonga\",\"TT\":\"Trinidad and Tobago\",\"TN\":\"Tunisia\",\"TR\":\"T\\u00fcrkiye\",\"TM\":\"Turkmenistan\",\"TC\":\"Turks and Caicos Islands\",\"TV\":\"Tuvalu\",\"UG\":\"Uganda\",\"UA\":\"Ukraine\",\"AE\":\"United Arab Emirates\",\"GB\":\"United Kingdom\",\"US\":\"United States\",\"UY\":\"Uruguay\",\"UM\":\"US Minor Outlying Islands\",\"UZ\":\"Uzbekistan\",\"VU\":\"Vanuatu\",\"VE\":\"Venezuela\",\"VN\":\"Viet Nam\",\"VG\":\"Virgin Islands, British\",\"VI\":\"Virgin Islands, U.S.\",\"WF\":\"Wallis and Futuna\",\"EH\":\"Western Sahara\",\"YE\":\"Yemen\",\"ZM\":\"Zambia\",\"ZW\":\"Zimbabwe\"},\"strings\":{\"newRowAdded\":\"New row added.\",\"rowRemoved\":\"Row 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action='\/en-us\/wp-json\/wp\/v2\/forms\/22604#gf_28' data-formid='28' novalidate><div class='gf_invisible ginput_recaptchav3' data-sitekey='6LfVOvcsAAAAAP4PgmPvNA6OWkBDC2ZxKb3gcE7y' data-tabindex='0'><input id=\"input_dbf4617115b02b1abf801dd0d005c3ff\" class=\"gfield_recaptcha_response\" type=\"hidden\" name=\"input_dbf4617115b02b1abf801dd0d005c3ff\" value=\"\"\/><\/div><div id='gf_page_steps_28' class='gf_page_steps'><div id='gf_step_28_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span><span class='gf_step_label'>Details<\/span><\/div><div id='gf_step_28_2' class='gf_step gf_step_last gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span><span class='gf_step_label'>Confirmation<\/span><\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_28_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_28' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_28_7\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Main Applicant<\/h3><\/div><fieldset id=\"field_28_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Name<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_28_1'>\n                            \n                            <span id='input_28_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_28_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_28_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            <span id='input_28_1_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.4' id='input_28_1_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_28_1_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                <\/span>\n                            <span id='input_28_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_28_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_28_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_28_2\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_2'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_2' id='input_28_2' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_28_4\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_4'><span class='gform-field-label__text'>Phone\/Mobile<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_28_4' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_28_5\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_5'><span class='gform-field-label__text'>Date of Birth<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='dd\/mm\/yyyy'\n\t\t\t\t\tid='input_28_5'\n\t\t\t\t\tclass='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_5'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_28_5' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_28_5' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_28_5' aria-label='Date of Birth: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_28_6\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Address<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_28_6' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_28_6_1_container' >\n                                        <input type='text' name='input_6.1' id='input_28_6_1' value=''    aria-required='true'    \/>\n                                        <label for='input_28_6_1' id='input_28_6_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_28_6_2_container' >\n                                        <input type='text' name='input_6.2' id='input_28_6_2' value=''     aria-required='false'   \/>\n                                        <label for='input_28_6_2' id='input_28_6_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_28_6_3_container' >\n                                    <input type='text' name='input_6.3' id='input_28_6_3' value=''    aria-required='true'    \/>\n                                    <label for='input_28_6_3' id='input_28_6_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_28_6_4_container' >\n                                        <input type='text' name='input_6.4' id='input_28_6_4' value=''      aria-required='true'    \/>\n                                        <label for='input_28_6_4' id='input_28_6_4_label' class='gform-field-label gform-field-label--type-sub '>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_28_6_5_container' >\n                                    <input type='text' name='input_6.5' id='input_28_6_5' value=''    aria-required='true'    \/>\n                                    <label for='input_28_6_5' id='input_28_6_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ Postal Code<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_28_6_6_container' >\n                                        <select name='input_6.6' id='input_28_6_6'   aria-required='true'    ><option value='' ><\/option><option value='AF' >Afghanistan<\/option><option value='AX' >\u00c5land Islands<\/option><option value='AL' >Albania<\/option><option value='DZ' >Algeria<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorra<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctica<\/option><option value='AG' >Antigua and Barbuda<\/option><option value='AR' >Argentina<\/option><option value='AM' >Armenia<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australia<\/option><option value='AT' >Austria<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbados<\/option><option value='BY' >Belarus<\/option><option value='BE' >Belgium<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermuda<\/option><option value='BT' >Bhutan<\/option><option value='BO' >Bolivia<\/option><option value='BQ' >Bonaire, Sint Eustatius and Saba<\/option><option value='BA' >Bosnia and Herzegovina<\/option><option value='BW' >Botswana<\/option><option value='BV' >Bouvet Island<\/option><option value='BR' >Brazil<\/option><option value='IO' >British Indian Ocean Territory<\/option><option value='BN' >Brunei Darussalam<\/option><option value='BG' >Bulgaria<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='CV' >Cabo Verde<\/option><option value='KH' >Cambodia<\/option><option value='CM' >Cameroon<\/option><option value='CA' >Canada<\/option><option value='KY' >Cayman Islands<\/option><option value='CF' >Central African Republic<\/option><option value='TD' >Chad<\/option><option value='CL' >Chile<\/option><option value='CN' >China<\/option><option value='CX' >Christmas Island<\/option><option value='CC' >Cocos Islands<\/option><option value='CO' >Colombia<\/option><option value='KM' >Comoros<\/option><option value='CG' >Congo<\/option><option value='CD' >Congo, Democratic Republic of the<\/option><option value='CK' >Cook Islands<\/option><option value='CR' >Costa Rica<\/option><option value='CI' >C\u00f4te d&#039;Ivoire<\/option><option value='HR' >Croatia<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CY' >Cyprus<\/option><option value='CZ' >Czechia<\/option><option value='DK' >Denmark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominica<\/option><option value='DO' >Dominican Republic<\/option><option value='EC' >Ecuador<\/option><option value='EG' >Egypt<\/option><option value='SV' >El Salvador<\/option><option value='GQ' >Equatorial Guinea<\/option><option value='ER' >Eritrea<\/option><option value='EE' >Estonia<\/option><option value='SZ' >Eswatini<\/option><option value='ET' >Ethiopia<\/option><option value='FK' >Falkland Islands<\/option><option value='FO' >Faroe Islands<\/option><option value='FJ' >Fiji<\/option><option value='FI' >Finland<\/option><option value='FR' >France<\/option><option value='GF' >French Guiana<\/option><option value='PF' >French Polynesia<\/option><option value='TF' >French Southern Territories<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambia<\/option><option value='GE' >Georgia<\/option><option value='DE' >Germany<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Greece<\/option><option value='GL' >Greenland<\/option><option value='GD' >Grenada<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernsey<\/option><option value='GN' >Guinea<\/option><option value='GW' >Guinea-Bissau<\/option><option value='GY' >Guyana<\/option><option value='HT' >Haiti<\/option><option value='HM' >Heard Island and McDonald Islands<\/option><option value='VA' >Holy See<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hungary<\/option><option value='IS' >Iceland<\/option><option value='IN' >India<\/option><option value='ID' >Indonesia<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Ireland<\/option><option value='IM' >Isle of Man<\/option><option value='IL' >Israel<\/option><option value='IT' >Italy<\/option><option value='JM' >Jamaica<\/option><option value='JP' >Japan<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordan<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='KP' >Korea, Democratic People&#039;s Republic of<\/option><option value='KR' >Korea, Republic of<\/option><option value='KW' >Kuwait<\/option><option value='KG' >Kyrgyzstan<\/option><option value='LA' >Lao People&#039;s Democratic Republic<\/option><option value='LV' >Latvia<\/option><option value='LB' >Lebanon<\/option><option value='LS' >Lesotho<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libya<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lithuania<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao<\/option><option value='MG' >Madagascar<\/option><option value='MW' >Malawi<\/option><option value='MY' >Malaysia<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malta<\/option><option value='MH' >Marshall Islands<\/option><option value='MQ' >Martinique<\/option><option value='MR' >Mauritania<\/option><option value='MU' >Mauritius<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexico<\/option><option value='FM' >Micronesia<\/option><option value='MD' >Moldova<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolia<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MA' >Morocco<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibia<\/option><option value='NR' >Nauru<\/option><option value='NP' >Nepal<\/option><option value='NL' >Netherlands<\/option><option value='NC' >New Caledonia<\/option><option value='NZ' >New Zealand<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='NF' >Norfolk Island<\/option><option value='MK' >North Macedonia<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norway<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/option><option value='PS' >Palestine, State of<\/option><option value='PA' >Panama<\/option><option value='PG' >Papua New Guinea<\/option><option value='PY' >Paraguay<\/option><option value='PE' >Peru<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Poland<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='QA' >Qatar<\/option><option value='RE' >R\u00e9union<\/option><option value='RO' >Romania<\/option><option value='RU' >Russian Federation<\/option><option value='RW' >Rwanda<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='SH' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='KN' >Saint Kitts and Nevis<\/option><option value='LC' >Saint Lucia<\/option><option value='MF' >Saint Martin<\/option><option value='PM' >Saint Pierre and Miquelon<\/option><option value='VC' >Saint Vincent and the Grenadines<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tome and Principe<\/option><option value='SA' >Saudi Arabia<\/option><option value='SN' >Senegal<\/option><option value='RS' >Serbia<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapore<\/option><option value='SX' >Sint Maarten<\/option><option value='SK' >Slovakia<\/option><option value='SI' >Slovenia<\/option><option value='SB' >Solomon Islands<\/option><option value='SO' >Somalia<\/option><option value='ZA' >South Africa<\/option><option value='GS' >South Georgia and the South Sandwich Islands<\/option><option value='SS' >South Sudan<\/option><option value='ES' >Spain<\/option><option value='LK' >Sri Lanka<\/option><option value='SD' >Sudan<\/option><option value='SR' >Suriname<\/option><option value='SJ' >Svalbard and Jan Mayen<\/option><option value='SE' >Sweden<\/option><option value='CH' >Switzerland<\/option><option value='SY' >Syria Arab Republic<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzania, the United Republic of<\/option><option value='TH' >Thailand<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinidad and Tobago<\/option><option value='TN' >Tunisia<\/option><option value='TR' >T\u00fcrkiye<\/option><option value='TM' >Turkmenistan<\/option><option value='TC' >Turks and Caicos Islands<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='AE' >United Arab Emirates<\/option><option value='GB' >United Kingdom<\/option><option value='US' >United States<\/option><option value='UY' >Uruguay<\/option><option value='UM' >US Minor Outlying Islands<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Viet Nam<\/option><option value='VG' >Virgin Islands, British<\/option><option value='VI' >Virgin Islands, U.S.<\/option><option value='WF' >Wallis and Futuna<\/option><option value='EH' >Western Sahara<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambia<\/option><option value='ZW' >Zimbabwe<\/option><\/select>\n                                        <label for='input_28_6_6' id='input_28_6_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><div class='gfield_description' id='gfield_description_28_6'>Please note USA, Canada, Australia, Iran, North Korea, Syria, Cuba, Crimea, Belarus, Russia, South Sudan, and Venezuela as the home country are excluded<\/div><\/fieldset><div id=\"field_28_8\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><br><br><h3>Travel Information<\/h3>\nbattleface Policy cannot be purchased more than 365 days in advance<\/div><fieldset id=\"field_28_9\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Are you already travelling?<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description' id='gfield_description_28_9'>if already travelling, cover will start 24-hours after purchase <\/div><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_28_9'>\n\t\t\t<div class='gchoice gchoice_28_9_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='Yes'  id='choice_28_9_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_28_9\"   \/>\n\t\t\t\t\t<label for='choice_28_9_0' id='label_28_9_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_28_9_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_9' type='radio' value='No'  id='choice_28_9_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_28_9_1' id='label_28_9_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_28_11\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_11'><span class='gform-field-label__text'>Start Date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='dd\/mm\/yyyy'\n\t\t\t\t\tid='input_28_11'\n\t\t\t\t\tclass='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_11'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_28_11' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_28_11' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_28_11' aria-label='Start Date: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_28_10\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_10'><span class='gform-field-label__text'>End Date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='dd\/mm\/yyyy'\n\t\t\t\t\tid='input_28_10'\n\t\t\t\t\tclass='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_10'\n\t\t\t\t\tvalue=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_28_10' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_28_10' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_28_10' aria-label='End Date: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_28_12\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_28_12'><span class='gform-field-label__text'>Destination<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_12' id='input_28_12' type='text' value='' class='large'  aria-describedby=\"gfield_description_28_12\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_28_12'>Please list all countries you will be travelling to. Example: Spain, Portugal, Australia<\/div><\/div><fieldset id=\"field_28_13\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Additional Travellers<\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Full Name<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Date of Birth<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_13_cell1 gform-grid-col' data-label='Full Name'><input aria-invalid='false'   aria-label='Full Name, Row 1' data-aria-label-template='Full Name, Row {0}' type='text' name='input_13[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_13_cell2 gform-grid-col' data-label='Date of Birth'><input aria-invalid='false'   aria-label='Date of Birth, Row 1' data-aria-label-template='Date of Birth, Row {0}' type='text' name='input_13[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Add another row' onclick='gformAddListItem(this, 0)'>Add<\/button>   <button type='button'  class='delete_list_item' aria-label='Remove row 1' data-aria-label-template='Remove row {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Remove<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><fieldset id=\"field_28_14\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Consent<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_28_14'><div class='gfield_consent_description_text gform-theme__no-reset--children' tabindex='0'>To purchase battleface Travel Medical Insurance, EACH applicant MUST be able to confirm the following statements:<br \/>\n<br \/>\n<ul><li>I have (or will have) received all immunisations recommended by a qualified doctor in my Home Country prior to entering the destination country.<\/li><li>I will be over one month old on the date I require cover to commence and under 80 years on the date I require cover to cease.<\/li><li>I will not be an active member of any military or para military force at any time during the Policy Period.<\/li><\/ul><\/div><\/div><div class='ginput_container ginput_container_consent'><input name='input_14.1' id='input_28_14_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_28_14\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_28_14_1' ><span class='gform-field-label__text'>I acknowledge these Terms and Conditions<\/span><\/label><input type='hidden' name='input_14.2' value='I acknowledge these Terms and Conditions' class='gform_hidden' \/><input type='hidden' name='input_14.3' value='20' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_28_40\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >For information about how we collect and process your data, as well as your rights, please see our <a href=\"https:\/\/www.battleface.com\/en-gb\/privacy-policy\/\" target-\"_blank\">privacy policy<\/a>.<\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <button type='button' id='gform_next_button_28_25' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' >Next<\/button> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_28_2' class='gform_page' data-js='page-field-id-25' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_28_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_28_49\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3>Confirmation<\/h3><\/div><fieldset id=\"field_28_27\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>statement<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_28_27'><div class='gfield_consent_description_text gform-theme__no-reset--children' tabindex='0'>I, the Main Applicant have been authorised by each of the persons named in this application to apply for this insurance on their behalf, and confirm that a copy of the Policy Summary Insurance Product Information Document and Policy Document has been made available to each Applicant for review prior to purchasing this insurance.<br \/>\n<br \/>\nI and each of the Applicants:<br \/>\n<ul><br \/>\n  <li>have confirmed that they can answer Yes to the Eligibility Statements detailed in step 1 of this Application.<\/li><br \/>\n<li>reside at the same address, being the address provided in this Application.<\/li><br \/>\n<li>request and expressly agree that this insurance policy be provided to me in English, that this insurance shall be governed exclusively by the law and practice of\u202fEngland and Wales\u202funless otherwise required by applicable law, and that all communication of and in connection with this Policy shall be in the English language.<\/li><br \/>\n<li>understand the insurance applied for is not a general health insurance policy, but is intended to cover unforseen injury or illness occurring outside my\/our Home Country, during the journey for which I\/we are buying cover, and contains a Pre-existing Condition exclusion, a Pre-certification process and other restrictions and limits.<\/li><br \/>\n<li>understand that other taxes or costs may exist that are not paid through the Plan Administrator or imposed by it.<\/li><br \/>\n<li>understand that my\/our insurance terminates upon returning to my\/our Home Country.<\/li><br \/>\n<li>hereby apply to Lloyd\u2019s\u202fthrough battleface Insurance Services Limited\u202ffor the insurance described in the battleface Policy Document.<\/li><br \/>\n<li>agree to receiving my policy documents via email<\/li><br \/>\n<\/ul><\/div><\/div><div class='ginput_container ginput_container_consent'><input name='input_27.1' id='input_28_27_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_28_27\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_28_27_1' ><span class='gform-field-label__text'>Please tick this box to confirm the statements above and to continue purchasing this insurance.<\/span><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/label><input type='hidden' name='input_27.2' value='Please tick this box to confirm the statements above and to continue purchasing this insurance.' class='gform_hidden' \/><input type='hidden' name='input_27.3' value='20' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_28_41\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_28_30\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>pre-contractual info<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_28_30'><div class='gfield_consent_description_text gform-theme__no-reset--children' tabindex='0'>The insurance you have applied for is underwritten by certain underwriters at Lloyd\u2019s of London, One Lime Street, London EC3M 7AH. The Coverholder under which the Plan has been placed with Underwriters under Unique Market Reference B0621F33104822 is battleface Insurance Services Limited, Suite 102, 80 Churchill Square, Kings Hill, West Malling, Kent, ME19 4YU, UK. The Coverholder acts as Underwriters\u2019 agent in binding risks, issuing documentation and the collection and processing of premiums and return premiums.<br \/>\n<br \/>\nFull details of the complaints procedure and the Policy cancellation provisions are detailed in the Policy Summary and Policy Document. Information provided to Underwriters will be processed by them and their agents in compliance with the provisions of the General Data Protection Regulations 2018 of England and Wales, for the purpose of administering this insurance and handling claims, if any. The information may also be sent for processing to other entities, including those located outside the European Economic Area and others where there is a legal obligation to provide it.<br \/>\n<br \/>\nAs a consumer, you have a duty to take reasonable care to answer questions fully and accurately. This duty exists before coverage is placed and throughout the entire duration of the insurance. If you do not do so, your insurer may be able to void the Policy from inception.<br \/>\n<br \/>\nThis policy meets the needs of those who require personal accident and medical expenses cover whilst travelling or working abroad. It also meets the needs of those travelling to potentially dangerous territories and conflict zones and therefore may require enhanced benefits and limits such as crisis response, evacuation, war and terrorism, kidnap and political threat coverage. You have chosen the benefit limits which meet your individual requirements. We have not made any personal recommendation as to the suitability of this product.<br \/>\n<br \/>\nWe arrange a policy with the insurer on your behalf. You do not pay us a fee for doing this. We receive commission from the insurer which is a percentage of the total annual premium.<br \/>\n<\/div><\/div><div class='ginput_container ginput_container_consent'><input name='input_30.1' id='input_28_30_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_28_30\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_28_30_1' ><span class='gform-field-label__text'>I request and expressly agree that this insurance policy and all pre-contractual information be provided to me in English and confirm that I understand and accept the contract and agree to be bound by its terms and conditions.<\/span><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/label><input type='hidden' name='input_30.2' value='I request and expressly agree that this insurance policy and all pre-contractual information be provided to me in English and confirm that I understand and accept the contract and agree to be bound by its terms and conditions.' class='gform_hidden' \/><input type='hidden' name='input_30.3' value='20' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_28_42\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_28_31\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>language<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_31.1' id='input_28_31_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_28_31_1' ><span class='gform-field-label__text'>I understand and agree that this insurance is subject to English law unless otherwise required by applicable law.<\/span><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/label><input type='hidden' name='input_31.2' value='I understand and agree that this insurance is subject to English law unless otherwise required by applicable law.' class='gform_hidden' \/><input type='hidden' name='input_31.3' value='20' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_28_43\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_28_33\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_above hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>data info<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_28_33'><div class='gfield_consent_description_text gform-theme__no-reset--children' tabindex='0'>battleface Insurance Services Limited, Lloyd\u2019s of London and other related insurance market participants may need to collect certain Special Categories of Personal Data about you in connection with your insurance cover, such as any pre-existing medical or other health conditions.<br \/>\n<br \/>\nYou are not under any obligation to consent for us to process your health information and may withdraw your consent at any time by emailing\u202finfo@battleface.com. However, if you withdraw your consent this may result in us applying a restriction on your policy or in some instances, withdrawing your cover altogether.<br \/>\n<\/div><\/div><div class='ginput_container ginput_container_consent'><input name='input_33.1' id='input_28_33_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_28_33\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_28_33_1' ><span class='gform-field-label__text'>I consent to the use of certain special categories of personal data such as information on my racial or ethnic origin, genetic or biometric data, health, set life, or sexual orientation in connection with my insurance cover.<\/span><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/label><input type='hidden' name='input_33.2' value='I consent to the use of certain special categories of personal data such as information on my racial or ethnic origin, genetic or biometric data, health, set life, or sexual orientation in connection with my insurance cover.' class='gform_hidden' \/><input type='hidden' name='input_33.3' value='20' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_28_46\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_28_50\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Please <a href=\"https:\/\/app.battleface.com\/cms\/files\/battleface-IPID-CHF.pdf\" target=\"_blank\">click here<\/a> to read through the insurance product information document.<\/div><fieldset id=\"field_28_35\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>product docs<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_35.1' id='input_28_35_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_28_35_1' ><span class='gform-field-label__text'>I acknowledge that I have read through insurance product information document.<\/span><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/label><input type='hidden' name='input_35.2' value='I acknowledge that I have read through insurance product information document.' class='gform_hidden' \/><input type='hidden' name='input_35.3' value='20' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_28_47\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_28_38\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>store my name<\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_38.1' id='input_28_38_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_28_38_1' ><span class='gform-field-label__text'>I agree to store my name and email address to receive updates, newsletters and commercial offers from battleface.<\/span><\/label><input type='hidden' name='input_38.2' value='I agree to store my name and email address to receive updates, newsletters and commercial offers from battleface.' class='gform_hidden' \/><input type='hidden' name='input_38.3' value='20' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_28_48\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_28_39\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>register<\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_39.1' id='input_28_39_1' type='checkbox' value='1'    aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_28_39_1' ><span class='gform-field-label__text'>I would like to register for a battleface account.<\/span><\/label><input type='hidden' name='input_39.2' value='I would like to register for a battleface account.' class='gform_hidden' \/><input type='hidden' 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