{"id":730,"date":"2014-02-19T20:48:44","date_gmt":"2014-02-19T20:48:44","guid":{"rendered":"http:\/\/www.srcpi.com\/WP\/?page_id=730"},"modified":"2014-02-19T21:17:25","modified_gmt":"2014-02-19T21:17:25","slug":"statement-request-form","status":"publish","type":"page","link":"https:\/\/www.srcpi.com\/WP\/statement-request-form\/","title":{"rendered":"Statement Request Form"},"content":{"rendered":"<div id=\"vfb-form-3\" class=\"visual-form-builder-container\"><form id=\"statement-request-form-3\" class=\"visual-form-builder vfb-form-3 \" method=\"post\" enctype=\"multipart\/form-data\">\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"3\" \/><fieldset class=\"vfb-fieldset vfb-fieldset-1 statement-request-form \" id=\"item-vfb-61\"><div class=\"vfb-legend\"><h3>Statement Request Form<\/h3><\/div><ul class=\"vfb-section vfb-section-1\"><div id=\"item-vfb-65\" 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-66\"><label for=\"vfb-66\" class=\"vfb-desc\">Company\/Adjuster Name:  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-66\" id=\"vfb-66\" value=\"\" class=\"vfb-text  vfb-medium  required  \" \/><\/li><li class=\"vfb-item vfb-item-email   vfb-right-half\" id=\"item-vfb-142\"><label for=\"vfb-142\" class=\"vfb-desc\">Email  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"email\" name=\"vfb-142\" id=\"vfb-142\" value=\"\" class=\"vfb-text  vfb-medium  required  email \" \/><\/li><li class=\"vfb-item vfb-item-date   vfb-left-half\" id=\"item-vfb-67\"><label for=\"vfb-67\" class=\"vfb-desc\">Date Requested: <\/label><input type=\"text\" name=\"vfb-67\" id=\"vfb-67\" value=\"\" class=\"vfb-text vfb-date-picker  vfb-medium  \" data-dp-dateFormat=\"mm\/dd\/yy\" \/><\/li><li class=\"vfb-item vfb-item-date   vfb-right-half\" id=\"item-vfb-68\"><label for=\"vfb-68\" class=\"vfb-desc\">Date Due: <\/label><input type=\"text\" name=\"vfb-68\" id=\"vfb-68\" 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-69\"><label for=\"vfb-69\" class=\"vfb-desc\">If New Client (Address 1) <\/label><input type=\"text\" name=\"vfb-69\" id=\"vfb-69\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-half\" id=\"item-vfb-70\"><label for=\"vfb-70\" class=\"vfb-desc\">Address 2 <\/label><input type=\"text\" name=\"vfb-70\" id=\"vfb-70\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-71\"><label for=\"vfb-71\" class=\"vfb-desc\">Town \/ State \/ Zip Code <\/label><input type=\"text\" name=\"vfb-71\" id=\"vfb-71\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-half\" id=\"item-vfb-72\"><label for=\"vfb-72\" class=\"vfb-desc\">Recorded In Person Statement <\/label><input type=\"text\" name=\"vfb-72\" id=\"vfb-72\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-84\"><label for=\"vfb-84\" class=\"vfb-desc\">File #  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-84\" id=\"vfb-84\" value=\"\" class=\"vfb-text  vfb-medium  required  \" \/><\/li><div id=\"item-vfb-75\" 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-76\"><label for=\"vfb-76\" class=\"vfb-desc\">Statement Of:  <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"text\" name=\"vfb-76\" id=\"vfb-76\" value=\"\" class=\"vfb-text  vfb-medium  required  \" \/><\/li><li class=\"vfb-item vfb-item-phone   vfb-middle-third\" id=\"item-vfb-77\"><label for=\"vfb-77\" class=\"vfb-desc\">Phone <\/label><input type=\"tel\" name=\"vfb-77\" id=\"vfb-77\" value=\"\" class=\"vfb-text  vfb-medium   phone \" \/><\/li><li class=\"vfb-item vfb-item-phone   vfb-right-third\" id=\"item-vfb-78\"><label for=\"vfb-78\" class=\"vfb-desc\">Cell Phone <\/label><input type=\"tel\" name=\"vfb-78\" id=\"vfb-78\" value=\"\" class=\"vfb-text  vfb-medium   phone \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-half\" id=\"item-vfb-79\"><label for=\"vfb-79\" class=\"vfb-desc\">Residential Address <\/label><input type=\"text\" name=\"vfb-79\" id=\"vfb-79\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-half\" id=\"item-vfb-80\"><label for=\"vfb-80\" class=\"vfb-desc\">Mailing Address <\/label><input type=\"text\" name=\"vfb-80\" id=\"vfb-80\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-left-two-thirds\" id=\"item-vfb-81\"><label for=\"vfb-81\" class=\"vfb-desc\">Town \/ State \/ Zip Code <\/label><input type=\"text\" name=\"vfb-81\" id=\"vfb-81\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-date   vfb-right-third\" id=\"item-vfb-82\"><label for=\"vfb-82\" class=\"vfb-desc\">Date of Birth <\/label><input type=\"text\" name=\"vfb-82\" id=\"vfb-82\" 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-two-thirds\" id=\"item-vfb-83\"><label for=\"vfb-83\" class=\"vfb-desc\">Insured: <\/label><input type=\"text\" name=\"vfb-83\" id=\"vfb-83\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><div id=\"item-vfb-85\" class=\"vfb-section-div \"><h4>Additional Information<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-date   vfb-left-third\" id=\"item-vfb-86\"><label for=\"vfb-86\" class=\"vfb-desc\">Date of Injury <\/label><input type=\"text\" name=\"vfb-86\" id=\"vfb-86\" 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-87\"><label for=\"vfb-87\" class=\"vfb-desc\">Type of Injury <\/label><input type=\"text\" name=\"vfb-87\" id=\"vfb-87\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-text   vfb-right-third\" id=\"item-vfb-88\"><label for=\"vfb-88\" class=\"vfb-desc\">Locus of Injury <\/label><input type=\"text\" name=\"vfb-88\" id=\"vfb-88\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-checkbox   vfb-left-half\" id=\"item-vfb-89\"><label class=\"vfb-desc\">Is Claimant Represented <\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-89[]\" id=\"vfb-89-0\" value=\"Yes\" class=\"vfb-checkbox  \" \/><label for=\"vfb-89-0\" class=\"vfb-choice\">Yes<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-89[]\" id=\"vfb-89-1\" value=\"No\" class=\"vfb-checkbox  \" \/><label for=\"vfb-89-1\" class=\"vfb-choice\">No<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-text   vfb-right-half\" id=\"item-vfb-90\"><label for=\"vfb-90\" class=\"vfb-desc\">By Whom: <\/label><input type=\"text\" name=\"vfb-90\" id=\"vfb-90\" value=\"\" class=\"vfb-text  vfb-medium   \" \/><\/li><li class=\"vfb-item vfb-item-textarea  \" id=\"item-vfb-91\"><label for=\"vfb-91\" class=\"vfb-desc\">Please List All Treating Physicians <\/label><div><textarea name=\"vfb-91\" id=\"vfb-91\" class=\"vfb-textarea  vfb-small  \"><\/textarea><\/div><\/li><div id=\"item-vfb-92\" class=\"vfb-section-div \"><h4>Please Check If You Need Any Of The Following<\/h4><\/div><div class=\"vfb-clear\"><\/div><li class=\"vfb-item vfb-item-checkbox  vfb-two-column \" id=\"item-vfb-93\"><label class=\"vfb-desc\">We Require: <\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-93[]\" id=\"vfb-93-0\" value=\"Photographs of Locus\" class=\"vfb-checkbox  \" \/><label for=\"vfb-93-0\" class=\"vfb-choice\">Photographs of Locus<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-93[]\" id=\"vfb-93-1\" value=\"Photograph of Claimant\" class=\"vfb-checkbox  \" \/><label for=\"vfb-93-1\" class=\"vfb-choice\">Photograph of Claimant<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-93[]\" id=\"vfb-93-2\" value=\"Medical Authorizations Required\" class=\"vfb-checkbox  \" \/><label for=\"vfb-93-2\" class=\"vfb-choice\">Medical Authorizations Required<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-93[]\" id=\"vfb-93-3\" value=\"Incident Reports\" class=\"vfb-checkbox  \" \/><label for=\"vfb-93-3\" class=\"vfb-choice\">Incident Reports<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-checkbox  vfb-two-column \" id=\"item-vfb-94\"><label class=\"vfb-desc\">We customize Your Service - please check Service Desired <\/label><div><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-94[]\" id=\"vfb-94-0\" value=\"I prefer verbal updates\" class=\"vfb-checkbox  \" \/><label for=\"vfb-94-0\" class=\"vfb-choice\">I prefer verbal updates<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-94[]\" id=\"vfb-94-1\" value=\"Mail Hard Copy Report\" class=\"vfb-checkbox  \" \/><label for=\"vfb-94-1\" class=\"vfb-choice\">Mail Hard Copy Report<\/label><\/span><span class=\"vfb-span\"><input type=\"checkbox\" name=\"vfb-94[]\" id=\"vfb-94-2\" value=\"I Prefer E-Mail Updates\" class=\"vfb-checkbox  \" \/><label for=\"vfb-94-2\" class=\"vfb-choice\">I Prefer E-Mail Updates<\/label><\/span><div style=\"clear:both\"><\/div><\/div><\/li><li class=\"vfb-item vfb-item-email   vfb-left-half\" id=\"item-vfb-143\"><label for=\"vfb-143\" class=\"vfb-desc\">Please CC on e-mail: <\/label><input type=\"email\" name=\"vfb-143\" id=\"vfb-143\" value=\"\" class=\"vfb-text  vfb-medium   email \" \/><\/li><li class=\"vfb-item vfb-item-instructions  \" id=\"item-vfb-97\"><label class=\"vfb-desc\">All recorded statements will be transcribed with a written narrative unless otherwise requested. <\/label><\/li><li class=\"vfb-item vfb-item-email  \" id=\"item-vfb-165\"><label for=\"vfb-165\" class=\"vfb-desc\">Email <\/label><input type=\"email\" name=\"vfb-165\" id=\"vfb-165\" value=\"\" class=\"vfb-text  vfb-medium   email \" \/><\/li><\/ul>&nbsp;<\/fieldset><fieldset class=\"vfb-fieldset vfb-fieldset-2 verification \" id=\"item-vfb-62\" 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-63\" class=\"vfb-desc\">Please enter any two digits <span class=\"vfb-required-asterisk\">*<\/span><\/label><input type=\"hidden\" name=\"_vfb-secret\" value=\"vfb-63\" \/><span class=\"vfb-span\"><input type=\"text\" name=\"vfb-63\" id=\"vfb-63\" 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-64\">\n\t\t\t\t\t\t<input type=\"submit\" name=\"vfb-submit\" id=\"vfb-64\" 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\/730\" \/><\/form><\/div> <!-- .visual-form-builder-container -->\n","protected":false},"excerpt":{"rendered":"<p> &hellip; <a class=\"more-link\" href=\"https:\/\/www.srcpi.com\/WP\/statement-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-730","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.srcpi.com\/WP\/wp-json\/wp\/v2\/pages\/730","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=730"}],"version-history":[{"count":1,"href":"https:\/\/www.srcpi.com\/WP\/wp-json\/wp\/v2\/pages\/730\/revisions"}],"predecessor-version":[{"id":732,"href":"https:\/\/www.srcpi.com\/WP\/wp-json\/wp\/v2\/pages\/730\/revisions\/732"}],"wp:attachment":[{"href":"https:\/\/www.srcpi.com\/WP\/wp-json\/wp\/v2\/media?parent=730"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}