{"id":722,"date":"2014-02-19T19:54:11","date_gmt":"2014-02-19T19:54:11","guid":{"rendered":"http:\/\/www.srcpi.com\/WP\/?page_id=722"},"modified":"2014-03-06T22:26:40","modified_gmt":"2014-03-06T22:26:40","slug":"surveillance-request-form","status":"publish","type":"page","link":"https:\/\/www.srcpi.com\/WP\/surveillance-request-form\/","title":{"rendered":"Service Request Form"},"content":{"rendered":"<div id=\"vfb-form-2\" class=\"visual-form-builder-container\"><form id=\"surveillance-request-form-2\" class=\"visual-form-builder vfb-form-2 \" method=\"post\" enctype=\"multipart\/form-data\">\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"2\" \/><fieldset class=\"vfb-fieldset vfb-fieldset-1 surveillance-request-form \" id=\"item-vfb-11\"><div class=\"vfb-legend\"><h3>Surveillance Request Form<\/h3><\/div><ul class=\"vfb-section vfb-section-1\"><div id=\"item-vfb-33\" class=\"vfb-section-div \"><h4>Company Information<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-15\"><label for=\"vfb-15\" class=\"vfb-desc\">Company \/ Adjuster Name  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-15\" id=\"vfb-15\" value=\"\" class=\"vfb-text  vfb-large  required  \" \/><\/li><li class=\"vfb-item vfb-item-email   vfb-right-half\" id=\"item-vfb-31\"><label for=\"vfb-31\" class=\"vfb-desc\">Email Address  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"email\" name=\"vfb-31\" id=\"vfb-31\" value=\"\" class=\"vfb-text  vfb-medium  required  email \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-21\"><label for=\"vfb-21\" class=\"vfb-desc\">Address <\/label><input type=\"text\" name=\"vfb-21\" id=\"vfb-21\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-half\" id=\"item-vfb-22\"><label for=\"vfb-22\" class=\"vfb-desc\">City\/State\/Zip Code <\/label><input type=\"text\" name=\"vfb-22\" id=\"vfb-22\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-number   vfb-left-third\" id=\"item-vfb-27\"><label for=\"vfb-27\" class=\"vfb-desc\"># of Hours <\/label><input type=\"text\" name=\"vfb-27\" id=\"vfb-27\" value=\"\" class=\"vfb-text  vfb-small   digits \" \/><\/li><li class=\"vfb-item vfb-item-number   vfb-middle-third\" id=\"item-vfb-28\"><label for=\"vfb-28\" class=\"vfb-desc\">Over # of Days <\/label><input type=\"text\" name=\"vfb-28\" id=\"vfb-28\" value=\"\" class=\"vfb-text  vfb-small   digits \" \/><\/li><li class=\"vfb-item vfb-item-date   vfb-right-third\" id=\"item-vfb-29\"><label for=\"vfb-29\" class=\"vfb-desc\">Due Date <\/label><input type=\"text\" name=\"vfb-29\" id=\"vfb-29\" value=\"\" class=\"vfb-text vfb-date-picker  vfb-medium  \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><div id=\"item-vfb-32\" class=\"vfb-section-div \"><h4>Claimant Information:<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-text   vfb-left-third\" id=\"item-vfb-30\"><label for=\"vfb-30\" class=\"vfb-desc\">Claimant\/Subject  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-30\" id=\"vfb-30\" value=\"\" class=\"vfb-text  vfb-medium  required  \" \/><\/li><li class=\"vfb-item vfb-item-phone   vfb-middle-third\" id=\"item-vfb-34\"><label for=\"vfb-34\" class=\"vfb-desc\">Phone <\/label><input type=\"tel\" name=\"vfb-34\" id=\"vfb-34\" value=\"\" class=\"vfb-text  vfb-medium   phone \" \/><\/li><li class=\"vfb-item vfb-item-phone   vfb-right-third\" id=\"item-vfb-35\"><label for=\"vfb-35\" class=\"vfb-desc\">Cell <\/label><input type=\"tel\" name=\"vfb-35\" id=\"vfb-35\" value=\"\" class=\"vfb-text  vfb-medium   phone \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-23\"><label for=\"vfb-23\" class=\"vfb-desc\">Residential Address <\/label><input type=\"text\" name=\"vfb-23\" id=\"vfb-23\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-half\" id=\"item-vfb-36\"><label for=\"vfb-36\" class=\"vfb-desc\">Mailing Address (if different) <\/label><input type=\"text\" name=\"vfb-36\" id=\"vfb-36\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-37\"><label for=\"vfb-37\" class=\"vfb-desc\">Town\/State\/Zip Code <\/label><input type=\"text\" name=\"vfb-37\" id=\"vfb-37\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-date   vfb-right-half\" id=\"item-vfb-38\"><label for=\"vfb-38\" class=\"vfb-desc\">Date of Birth <\/label><input type=\"text\" name=\"vfb-38\" id=\"vfb-38\" value=\"\" class=\"vfb-text vfb-date-picker  vfb-medium  \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-39\"><label for=\"vfb-39\" class=\"vfb-desc\">Insured <\/label><input type=\"text\" name=\"vfb-39\" id=\"vfb-39\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-half\" id=\"item-vfb-40\"><label for=\"vfb-40\" class=\"vfb-desc\">Job Title <\/label><input type=\"text\" name=\"vfb-40\" id=\"vfb-40\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-third\" id=\"item-vfb-41\"><label for=\"vfb-41\" class=\"vfb-desc\">Work Status <\/label><input type=\"text\" name=\"vfb-41\" id=\"vfb-41\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-two-thirds\" id=\"item-vfb-42\"><label for=\"vfb-42\" class=\"vfb-desc\">If working, current schedule or Contact Person <\/label><input type=\"text\" name=\"vfb-42\" id=\"vfb-42\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-third\" id=\"item-vfb-43\"><label for=\"vfb-43\" class=\"vfb-desc\">Marital Status <\/label><input type=\"text\" name=\"vfb-43\" id=\"vfb-43\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-middle-third\" id=\"item-vfb-44\"><label for=\"vfb-44\" class=\"vfb-desc\">Number of Dependents <\/label><input type=\"text\" name=\"vfb-44\" id=\"vfb-44\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-third\" id=\"item-vfb-45\"><label for=\"vfb-45\" class=\"vfb-desc\">File #  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-45\" id=\"vfb-45\" value=\"\" class=\"vfb-text  vfb-medium  required  \" \/><\/li><div id=\"item-vfb-47\" class=\"vfb-section-div \"><h4>Additional Information<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-48\"><label for=\"vfb-48\" class=\"vfb-desc\">Description of Subject, Vehicles, Etc ... <\/label><div><textarea name=\"vfb-48\" id=\"vfb-48\" class=\"vfb-textarea  vfb-medium  \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-date   vfb-left-third\" id=\"item-vfb-49\"><label for=\"vfb-49\" class=\"vfb-desc\">Date of Injury <\/label><input type=\"text\" name=\"vfb-49\" id=\"vfb-49\" value=\"\" class=\"vfb-text vfb-date-picker  vfb-medium  \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-middle-third\" id=\"item-vfb-50\"><label for=\"vfb-50\" class=\"vfb-desc\">Type of Injury <\/label><input type=\"text\" name=\"vfb-50\" id=\"vfb-50\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-third\" id=\"item-vfb-51\"><label for=\"vfb-51\" class=\"vfb-desc\">Restrictions <\/label><input type=\"text\" name=\"vfb-51\" id=\"vfb-51\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-checkbox   vfb-left-third\" id=\"item-vfb-52\"><label class=\"vfb-desc\">Is Subject Represented <\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-52[]\" id=\"vfb-52-0\" value=\"Yes\" class=\"vfb-checkbox  \" \/><label for=\"vfb-52-0\" class=\"vfb-choice\">Yes<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-52[]\" id=\"vfb-52-1\" value=\"No\" class=\"vfb-checkbox  \" \/><label for=\"vfb-52-1\" class=\"vfb-choice\">No<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-text   vfb-middle-third\" id=\"item-vfb-53\"><label for=\"vfb-53\" class=\"vfb-desc\">By Whom <\/label><input type=\"text\" name=\"vfb-53\" id=\"vfb-53\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-checkbox   vfb-right-third\" id=\"item-vfb-54\"><label class=\"vfb-desc\">Being Paid? <\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-54[]\" id=\"vfb-54-0\" value=\"Yes\" class=\"vfb-checkbox  \" \/><label for=\"vfb-54-0\" class=\"vfb-choice\">Yes<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-54[]\" id=\"vfb-54-1\" value=\"No\" class=\"vfb-checkbox  \" \/><label for=\"vfb-54-1\" class=\"vfb-choice\">No<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-55\"><label for=\"vfb-55\" class=\"vfb-desc\">Scheduled I.M.E.&#039;s <\/label><div><textarea name=\"vfb-55\" id=\"vfb-55\" class=\"vfb-textarea  vfb-small  \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-56\"><label for=\"vfb-56\" class=\"vfb-desc\">Scheduled Hearing, Conferences <\/label><div><textarea name=\"vfb-56\" id=\"vfb-56\" class=\"vfb-textarea  vfb-small  \"><\/textarea><\/div><\/li><li class=\"vfb-item vfb-item-checkbox  vfb-two-column \" id=\"item-vfb-58\"><label class=\"vfb-desc\">Checkbox <\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-58[]\" id=\"vfb-58-0\" value=\"I Prefer Verbal Updates each day my case is worked on\" class=\"vfb-checkbox  \" \/><label for=\"vfb-58-0\" class=\"vfb-choice\">I Prefer Verbal Updates each day my case is worked on<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-58[]\" id=\"vfb-58-1\" value=\"I Prefer e-mail updates each day my case is worked on\" class=\"vfb-checkbox  \" \/><label for=\"vfb-58-1\" class=\"vfb-choice\">I Prefer e-mail updates each day my case is worked on<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-58[]\" id=\"vfb-58-2\" value=\"E-mail Completed Report\" class=\"vfb-checkbox  \" \/><label for=\"vfb-58-2\" class=\"vfb-choice\">E-mail Completed Report<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-58[]\" id=\"vfb-58-3\" value=\"Mail Hard Copy Report, Video CD\" class=\"vfb-checkbox  \" \/><label for=\"vfb-58-3\" class=\"vfb-choice\">Mail Hard Copy Report, Video CD<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-59\"><label for=\"vfb-59\" class=\"vfb-desc\">Please have us CC: <\/label><input type=\"text\" name=\"vfb-59\" id=\"vfb-59\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-textarea   vfb-right-half\" id=\"item-vfb-60\"><label for=\"vfb-60\" class=\"vfb-desc\">Other: (Explain Below) <\/label><div><textarea name=\"vfb-60\" id=\"vfb-60\" class=\"vfb-textarea  vfb-small  \"><\/textarea><\/div><\/li><\/ul>&nbsp;<\/fieldset><fieldset class=\"vfb-fieldset vfb-fieldset-2 verification \" id=\"item-vfb-12\" style=\"display:block\"><div class=\"vfb-legend\"><h3>Verification<\/h3><\/div><ul class=\"vfb-section vfb-section-2\"><li class=\"vfb-item vfb-item-secret\"  style=\"display:block\"><label for=\"vfb-13\" class=\"vfb-desc\">Please enter any two digits <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"hidden\" name=\"_vfb-secret\" value=\"vfb-13\" \/><span class=\"vfb-span\"><input type=\"text\" name=\"vfb-13\" id=\"vfb-13\" value=\"\" class=\"vfb-text  vfb-medium  required {digits:true,maxlength:2,minlength:2} \" style=\"display:block\" \/><label>Example: 12<\/label><\/span><li style=\"display:none;\"><label>This box is for spam protection - <strong>please leave it blank<\/strong>:<\/label><div><input name=\"vfb-spam\" \/><\/div><\/li>\n\t\t\t<li class=\"vfb-item vfb-item-submit\" id=\"item-vfb-14\">\n\t\t\t\t\t\t<input type=\"submit\" name=\"vfb-submit\" id=\"vfb-14\" value=\"Submit\" class=\"vfb-submit \" \/>\n\t\t\t\t\t\t<\/li><\/ul>\n\t\t\t<\/fieldset><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/WP\/wp-json\/wp\/v2\/pages\/722\" \/><\/form><\/div> <!-- .visual-form-builder-container -->\n","protected":false},"excerpt":{"rendered":"<p> &hellip; <a class=\"more-link\" href=\"https:\/\/www.srcpi.com\/WP\/surveillance-request-form\/\">Continue reading <span class=\"meta-nav\">&rarr;<\/span><\/a><\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"open","template":"","meta":{"footnotes":""},"class_list":["post-722","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.srcpi.com\/WP\/wp-json\/wp\/v2\/pages\/722","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.srcpi.com\/WP\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.srcpi.com\/WP\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.srcpi.com\/WP\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/www.srcpi.com\/WP\/wp-json\/wp\/v2\/comments?post=722"}],"version-history":[{"count":2,"href":"https:\/\/www.srcpi.com\/WP\/wp-json\/wp\/v2\/pages\/722\/revisions"}],"predecessor-version":[{"id":725,"href":"https:\/\/www.srcpi.com\/WP\/wp-json\/wp\/v2\/pages\/722\/revisions\/725"}],"wp:attachment":[{"href":"https:\/\/www.srcpi.com\/WP\/wp-json\/wp\/v2\/media?parent=722"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}