quote.legalhelpconnect.com
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188.114.96.3
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URL:
https://quote.legalhelpconnect.com/
Submission: On April 29 via api from US — Scanned from NL
Submission: On April 29 via api from US — Scanned from NL
Form analysis 1 forms found in the DOM
POST
<form method="POST" data-id="heyflow-form" id="legal-help-connect" novalidate="">
<section id="id-6580c581" name="accident-type" data-type="user" class="undefined visible" data-header="header" data-footer="footer">
<div class="block " style=" " data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-d11755a1">
<div class="rich-text" style="padding-top:5px; padding-bottom:20px; ">
<h1>What kind of accident did you have?</h1>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-bar" id="id-76cca142">
<div style="padding-top:20px; padding-bottom:20px; ">
<span class="progress-item filled"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
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<div class="block " style=" " data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-narrow" id="multiple-choice-block-mc-cd647163" data-align-siblings="">
<div style="">
<div class="multiple-choice mc-collapse-list">
<div class="multiple-choice-inner" style="justify-content:center;">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option " hey-nextscreen="" hey-important="" hey-autoredirect="false">
<label>
<div class="option-counter">1</div>
<input type="radio" id="mco-d170a0a2" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="accidenttype" name="mc-cd647163" data-variable="accidenttype" value="mco-d170a0a2" data-answer="Auto Accident"
required="" data-destination="next" data-priority="0" data-tracking-listener="true">
<div class="option-content ">
<div class="selector-container radio-selector">
<span class="radio "></span>
</div>
<div class="label-container">
<div class="label">Auto Accident</div>
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</div>
<div></div>
</label>
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</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option " hey-nextscreen="" hey-important="" hey-autoredirect="false">
<label>
<div class="option-counter">2</div>
<input type="radio" id="mco-33a9470f" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="accidenttype" name="mc-cd647163" data-variable="accidenttype" value="mco-33a9470f" data-answer="Hit and Run"
required="" data-destination="next" data-priority="0" data-tracking-listener="true">
<div class="option-content ">
<div class="selector-container radio-selector">
<span class="radio "></span>
</div>
<div class="label-container">
<div class="label">Hit and Run</div>
</div>
</div>
<div></div>
</label>
</div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option " hey-nextscreen="" hey-important="" hey-autoredirect="false">
<label>
<div class="option-counter">3</div>
<input type="radio" id="mco-ff23e0af" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="accidenttype" name="mc-cd647163" data-variable="accidenttype" value="mco-ff23e0af"
data-answer="Motorcycle Accident" required="" data-destination="next" data-priority="0" data-tracking-listener="true">
<div class="option-content ">
<div class="selector-container radio-selector">
<span class="radio "></span>
</div>
<div class="label-container">
<div class="label">Motorcycle Accident</div>
</div>
</div>
<div></div>
</label>
</div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option " hey-nextscreen="" hey-important="" hey-autoredirect="false">
<label>
<div class="option-counter">4</div>
<input type="radio" id="mco-f04a08b8" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="accidenttype" name="mc-cd647163" data-variable="accidenttype" value="mco-f04a08b8"
data-answer="Pedestrian Accident" required="" data-destination="next" data-priority="0" data-tracking-listener="true">
<div class="option-content ">
<div class="selector-container radio-selector">
<span class="radio "></span>
</div>
<div class="label-container">
<div class="label">Pedestrian Accident</div>
</div>
</div>
<div></div>
</label>
</div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option " hey-nextscreen="" hey-important="" hey-autoredirect="false">
<label>
<div class="option-counter">5</div>
<input type="radio" id="option-92r-qKhjuyD5RhkjtrBdE" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="accidenttype" name="mc-cd647163" data-variable="accidenttype"
value="option-92r-qKhjuyD5RhkjtrBdE" data-answer="Ride-Share or Delivery Driver Accident" required="" data-destination="next" data-priority="0" data-tracking-listener="true">
<div class="option-content ">
<div class="selector-container radio-selector">
<span class="radio "></span>
</div>
<div class="label-container">
<div class="label">Ride-Share or Delivery Driver Accident</div>
</div>
</div>
<div></div>
</label>
</div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option " hey-nextscreen="" hey-important="" hey-autoredirect="false">
<label>
<div class="option-counter">6</div>
<input type="radio" id="option-1a481hI2dU96DRonbGwBC" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="accidenttype" name="mc-cd647163" data-variable="accidenttype"
value="option-1a481hI2dU96DRonbGwBC" data-answer="Trucking Accident" required="" data-destination="next" data-priority="0" data-tracking-listener="true">
<div class="option-content ">
<div class="selector-container radio-selector">
<span class="radio "></span>
</div>
<div class="label-container">
<div class="label">Trucking Accident</div>
</div>
</div>
<div></div>
</label>
</div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option " hey-nextscreen="" hey-important="" hey-autoredirect="false">
<label>
<div class="option-counter">7</div>
<input type="radio" id="option-G3XcJdC5_WcwhAwd5PS3X" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="accidenttype" name="mc-cd647163" data-variable="accidenttype"
value="option-G3XcJdC5_WcwhAwd5PS3X" data-answer="Other" required="" data-destination="next" data-priority="0" data-tracking-listener="true">
<div class="option-content ">
<div class="selector-container radio-selector">
<span class="radio "></span>
</div>
<div class="label-container">
<div class="label">Other</div>
</div>
</div>
<div></div>
</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-rich-text-78bd6840">
<div class="rich-text" style="">
<p>By clicking Next, you consent to the use of site visit recordation technology to memorialize your site visit. Please see our <a target="_blank" href="https://legalhelpconnect.com/privacy.php">privacy policy</a> for more information.</p>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="generic-button">
<div class="block-content generic-button-block inner-narrow" id="generic-button-block-id-70b47dab">
<div style="padding-bottom:20px; ">
<button id="id-70b47dab" class="generic-button continue medium"
onclick="window.heyflow['legal-help-connect'].buttonClick(this, 'next', '', '{"containerClass":"inner-narrow","label":"NEXT","nextAction":"next","type":"generic-button","tracking":true,"paddingBottom":20,"name":"button-continue","action":"next","contentClass":"align-center","id":"id-70b47dab","paddingTop":0,"class":"continue&nbsp;medium"}')">
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
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<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
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<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
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<div class="content align-center">
<div class="label-container ">
<span class="label">NEXT</span>
</div>
<span class="graphic">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="40" y1="128" x2="216" y2="128" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<polyline points="144 56 216 128 144 200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg>
</span>
</div>
</button>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="separator">
<div class="block-content separator-block inner-mid" id="separator-block-id-4e3af5a8">
<div style="padding-top:20px; padding-bottom:20px; ">
<div class="show-line"></div>
</div>
</div>
</div>
<div class="block hide_mobile hide_desktop " style=" " data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav" id="id-1a9d5c8a-container">
<div style="padding-top:20px; padding-bottom:20px; ">
<label for="id-1a9d5c8a">s1</label>
<div class="input ">
<div class="input-inner">
<div style="flex:1;position:relative;">
<input type="text" id="id-1a9d5c8a" data-type="input" data-label="s2" data-variable="s2" data-mask="" name="id-1a9d5c8a" placeholder="Placeholder" pattern="" maxlength="" data-trim="" autocomplete="off" class=""
data-initialized="true">
<div class="input-floating-label"><span>s1</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
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<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
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</svg></div>
</div>
</div>
<datalist id="datalist-id-1a9d5c8a">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span>
</div>
</div>
</div>
</div>
</div>
<div class="block hide_mobile hide_desktop " style=" " data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav" id="id-f4c440e4-container">
<div style="padding-top:20px; padding-bottom:20px; ">
<label for="id-f4c440e4">s2</label>
<div class="input ">
<div class="input-inner">
<div style="flex:1;position:relative;">
<input type="text" id="id-f4c440e4" data-type="input" data-label="s3" data-variable="s3" data-mask="" name="id-f4c440e4" placeholder="Placeholder" pattern="" maxlength="" data-trim="" autocomplete="off" class=""
data-initialized="true">
<div class="input-floating-label"><span>s2</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
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</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
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</svg></div>
</div>
</div>
<datalist id="datalist-id-f4c440e4">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span>
</div>
</div>
</div>
</div>
</div>
<div class="block hide_mobile hide_desktop " style=" " data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav" id="id-d281e62d-container">
<div style="padding-top:20px; padding-bottom:20px; ">
<label for="id-d281e62d">s3</label>
<div class="input ">
<div class="input-inner">
<div style="flex:1;position:relative;">
<input type="text" id="id-d281e62d" data-type="input" data-label="s4" data-variable="s4" data-mask="" name="id-d281e62d" placeholder="Placeholder" pattern="" maxlength="" data-trim="" autocomplete="off" class=""
data-initialized="true">
<div class="input-floating-label"><span>s3</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
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</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
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</svg></div>
</div>
</div>
<datalist id="datalist-id-d281e62d">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span>
</div>
</div>
</div>
</div>
</div>
<div class="block hide_mobile hide_desktop " style=" " data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav" id="id-b574ae9b-container">
<div style="padding-top:20px; padding-bottom:20px; ">
<label for="id-b574ae9b">s4</label>
<div class="input ">
<div class="input-inner">
<div style="flex:1;position:relative;">
<input type="text" id="id-b574ae9b" data-type="input" data-label="s5" data-variable="s5" data-mask="" name="id-b574ae9b" placeholder="Placeholder" pattern="" maxlength="" data-trim="" autocomplete="off" class=""
data-initialized="true">
<div class="input-floating-label"><span>s4</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div>
<datalist id="datalist-id-b574ae9b">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span>
</div>
</div>
</div>
</div>
</div>
<div class="block hide_mobile hide_desktop " style=" " data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav" id="id-f86e272c-container">
<div style="padding-top:20px; padding-bottom:20px; ">
<label for="id-f86e272c">s5</label>
<div class="input ">
<div class="input-inner">
<div style="flex:1;position:relative;">
<input type="text" id="id-f86e272c" data-type="input" data-label="s6" data-variable="s6" data-mask="" name="id-f86e272c" placeholder="Placeholder" pattern="" maxlength="" data-trim="" autocomplete="off" class=""
data-initialized="true">
<div class="input-floating-label"><span>s5</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div>
<datalist id="datalist-id-f86e272c">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span>
</div>
</div>
</div>
</div>
</div>
<div class="block hide_mobile hide_desktop " style=" " data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav" id="id-9ac17dd2-container">
<div style="padding-top:20px; padding-bottom:20px; ">
<label for="id-9ac17dd2">oid</label>
<div class="input ">
<div class="input-inner">
<div style="flex:1;position:relative;">
<input type="text" id="id-9ac17dd2" data-type="input" data-label="oid1" data-variable="oid1" data-mask="" name="id-9ac17dd2" placeholder="Placeholder" pattern="" maxlength="" data-trim="" autocomplete="off" class=""
data-initialized="true">
<div class="input-floating-label"><span>oid</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div>
<datalist id="datalist-id-9ac17dd2">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span>
</div>
</div>
</div>
</div>
</div>
<div class="block hide_mobile hide_desktop " style=" " data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav" id="id-df9e7563-container">
<div style="padding-top:20px; padding-bottom:20px; ">
<label for="id-df9e7563">aid</label>
<div class="input ">
<div class="input-inner">
<div style="flex:1;position:relative;">
<input type="text" id="id-df9e7563" data-type="input" data-label="aid1" data-variable="aid1" data-mask="" name="id-df9e7563" placeholder="Placeholder" pattern="" maxlength="" data-trim="" autocomplete="off" class=""
data-initialized="true">
<div class="input-floating-label"><span>aid</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div>
<datalist id="datalist-id-df9e7563">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span>
</div>
</div>
</div>
</div>
</div>
<div class="block hide_mobile hide_desktop " style=" " data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav" id="id-a3afb311-container">
<div style="padding-top:20px; padding-bottom:20px; ">
<label for="id-a3afb311">reqid</label>
<div class="input ">
<div class="input-inner">
<div style="flex:1;position:relative;">
<input type="text" id="id-a3afb311" data-type="input" data-label="reqid1" data-variable="reqid1" data-mask="" name="id-a3afb311" placeholder="Placeholder" pattern="" maxlength="" data-trim="" autocomplete="off" class=""
data-initialized="true">
<div class="input-floating-label"><span>reqid</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div>
<datalist id="datalist-id-a3afb311">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span>
</div>
</div>
</div>
</div>
</div>
<div class="block hide_mobile hide_desktop " style=" " data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav" id="input-4294156f-container">
<div style="padding-top:20px; padding-bottom:20px; ">
<label for="input-4294156f">affkey</label>
<div class="input ">
<div class="input-inner">
<div style="flex:1;position:relative;">
<input type="text" id="input-4294156f" data-type="input" data-label="affkey" data-variable="affkey" data-mask="" name="input-4294156f" placeholder="Placeholder" pattern="" maxlength="" data-trim="" autocomplete="off" class=""
data-initialized="true">
<div class="input-floating-label"><span>affkey</span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div>
<datalist id="datalist-input-4294156f">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please specify an answer</span>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-9436799f" name="accident-date" data-type="user" data-header="header">
<div class="block " style=" " data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-bar" id="progress-b6f6c20b">
<div style="padding-top:40px; padding-bottom:20px; ">
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-9a0f6925">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px; ">
<h2>Please provide the date when the motor vehicle accident occurred.</h2>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="date-picker">
<div id="date-picker-0f37b6ad" class="block-content date-picker-block inner-narrow"
data-attributes="{"containerClass":"inner-narrow","dateFormat":"YYYY-MM-DD","workdaysOnly":false,"fromToday":false,"errorMessage":"Please&nbsp;select&nbsp;a&nbsp;date.","range":false,"label":"","type":"date-picker","required":true,"systemLabel":"accidentdate","tillToday":false,"paddingBottom":0,"name":"date-picker","variable":"accidentdate","id":"0f37b6ad","paddingTop":0,"placeholder":"Click&nbsp;to&nbsp;select","startWeekOnMonday":true}">
<div style="" class="date-picker-block-body">
<div class="date-picker-block-content ">
<div class="input">
<div class="wrapper">
<input id="date-picker-input-0f37b6ad" class="date-picker-input" placeholder="Click to select" data-required="true" data-type="input" data-block-type="date-picker" data-label="accidentdate" name="0f37b6ad"
data-variable="accidentdate">
<input class="date-picker-dummy-input" tabindex="-1" value="any-non-empty-value">
</div>
<div class="error-box">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please select a date.</span>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="generic-button">
<div class="block-content generic-button-block inner-narrow" id="generic-button-block-button-5216d7a1">
<div style="padding-top:20px; padding-bottom:20px; ">
<button id="button-5216d7a1" class="generic-button continue medium"
onclick="window.heyflow['legal-help-connect'].buttonClick(this, 'next', '', '{"redirectURL":"https://heyflow.com","containerClass":"inner-narrow","label":"NEXT","nextAction":"next","type":"generic-button","tracking":true,"target":"_self","paddingBottom":20,"name":"button-continue","contentClass":"align-center","action":"next","id":"button-5216d7a1","paddingTop":20,"class":"continue&nbsp;medium"}')">
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
<div class="content align-center">
<div class="label-container ">
<span class="label">NEXT</span>
</div>
<span class="graphic">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="40" y1="128" x2="216" y2="128" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<polyline points="144 56 216 128 144 200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg>
</span>
</div>
</button>
</div>
</div>
</div>
</section>
<section id="id-0f5ce607" name="zipcode" data-type="user">
<div class="block " style=" " data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-bar" id="id-3e6aeb3a">
<div style="padding-top:40px; padding-bottom:20px; ">
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-a643b96e">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px; ">
<h2>Please Enter your Zip Code:</h2>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav" id="input-fd3d4cd2-container">
<div style="">
<div class="input ">
<div class="input-inner">
<div style="flex:1;position:relative;">
<input type="text" id="input-fd3d4cd2" data-type="input" data-label="zip" data-variable="zip" data-mask="" name="input-fd3d4cd2" placeholder="Your Zip Code" pattern="^\d{5}$" maxlength="" data-trim="" required="required"
autocomplete="off" class="">
<div class="input-floating-label"><span></span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div>
<datalist id="datalist-input-fd3d4cd2">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Enter valid zipcode</span>
</div>
</div>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="generic-button">
<div class="block-content generic-button-block inner-narrow" id="generic-button-block-id-ce0689d5">
<div style="padding-top:20px; padding-bottom:20px; ">
<button id="id-ce0689d5" class="generic-button continue medium"
onclick="window.heyflow['legal-help-connect'].buttonClick(this, 'next', '', '{"redirectURL":"https://heyflow.com","containerClass":"inner-narrow","label":"NEXT","nextAction":"next","type":"generic-button","tracking":true,"target":"_self","paddingBottom":20,"name":"button-continue","contentClass":"align-center","action":"next","id":"id-ce0689d5","paddingTop":20,"class":"continue&nbsp;medium"}')">
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
<div class="content align-center">
<div class="label-container ">
<span class="label">NEXT</span>
</div>
<span class="graphic">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="40" y1="128" x2="216" y2="128" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
<polyline points="144 56 216 128 144 200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg>
</span>
</div>
</button>
</div>
</div>
</div>
</section>
<section id="id-d3936445" name="your-fault" data-type="user">
<div class="block " style=" " data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-bar" id="id-462fbcab">
<div style="padding-top:40px; padding-bottom:20px; ">
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-0866ea0e">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px; ">
<h2>Did this Event Occur Due to Your Fault?</h2>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-mc-c085b0b9" data-align-siblings="false">
<div style="padding-top:5px; padding-bottom:5px; ">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option " hey-nextscreen="" hey-important="" hey-autoredirect="true">
<label>
<div class="option-counter">1</div>
<input onclick="window.heyflow['legal-help-connect'].navigation.navigate('next','');" type="radio" id="mco-8e272688" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="fault" name="mc-c085b0b9"
data-variable="fault" value="mco-8e272688" data-conditional="true" data-answer="Yes" required="" data-destination="next" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector">
<span class="radio "></span>
</div>
<div class="image-container">
<div class="svg-container">
<svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 512 512">
<path
d="M173.898 439.404l-166.4-166.4c-9.997-9.997-9.997-26.206 0-36.204l36.203-36.204c9.997-9.998 26.207-9.998 36.204 0L192 312.69 432.095 72.596c9.997-9.997 26.207-9.997 36.204 0l36.203 36.204c9.997 9.997 9.997 26.206 0 36.204l-294.4 294.401c-9.998 9.997-26.207 9.997-36.204-.001z">
</path>
</svg>
</div>
</div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label>
</div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option " hey-nextscreen="" hey-important="" hey-autoredirect="true">
<label>
<div class="option-counter">2</div>
<input onclick="window.heyflow['legal-help-connect'].navigation.navigate('next','');" type="radio" id="mco-6d21ea5e" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="fault" name="mc-c085b0b9"
data-variable="fault" value="mco-6d21ea5e" data-conditional="true" data-answer="No" required="" data-destination="next" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector">
<span class="radio "></span>
</div>
<div class="image-container">
<div class="svg-container">
<svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 512 512">
<path
d="M256 8C119 8 8 119 8 256s111 248 248 248 248-111 248-248S393 8 256 8zm121.6 313.1c4.7 4.7 4.7 12.3 0 17L338 377.6c-4.7 4.7-12.3 4.7-17 0L256 312l-65.1 65.6c-4.7 4.7-12.3 4.7-17 0L134.4 338c-4.7-4.7-4.7-12.3 0-17l65.6-65-65.6-65.1c-4.7-4.7-4.7-12.3 0-17l39.6-39.6c4.7-4.7 12.3-4.7 17 0l65 65.7 65.1-65.6c4.7-4.7 12.3-4.7 17 0l39.6 39.6c4.7 4.7 4.7 12.3 0 17L312 256l65.6 65.1z">
</path>
</svg>
</div>
</div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-054ee302" name="police-report" data-type="user">
<div class="block " style=" " data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-bar" id="id-0814130a">
<div style="padding-top:40px; padding-bottom:20px; ">
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-b813a928">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px; ">
<h2>Has a police report been filed?</h2>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-48055149" data-align-siblings="false">
<div style="padding-top:5px; padding-bottom:5px; ">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option " hey-nextscreen="" hey-important="" hey-autoredirect="true">
<label>
<div class="option-counter">1</div>
<input onclick="window.heyflow['legal-help-connect'].navigation.navigate('next','');" type="radio" id="id-055ac50a" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="police" name="id-48055149"
data-variable="police" value="id-055ac50a" data-conditional="true" data-answer="Yes" required="" data-destination="next" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector">
<span class="radio "></span>
</div>
<div class="image-container">
<div class="svg-container">
<svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 512 512">
<path
d="M173.898 439.404l-166.4-166.4c-9.997-9.997-9.997-26.206 0-36.204l36.203-36.204c9.997-9.998 26.207-9.998 36.204 0L192 312.69 432.095 72.596c9.997-9.997 26.207-9.997 36.204 0l36.203 36.204c9.997 9.997 9.997 26.206 0 36.204l-294.4 294.401c-9.998 9.997-26.207 9.997-36.204-.001z">
</path>
</svg>
</div>
</div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label>
</div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option " hey-nextscreen="" hey-important="" hey-autoredirect="true">
<label>
<div class="option-counter">2</div>
<input onclick="window.heyflow['legal-help-connect'].navigation.navigate('next','');" type="radio" id="id-214d72da" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="police" name="id-48055149"
data-variable="police" value="id-214d72da" data-conditional="true" data-answer="No" required="" data-destination="next" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector">
<span class="radio "></span>
</div>
<div class="image-container">
<div class="svg-container">
<svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 512 512">
<path
d="M256 8C119 8 8 119 8 256s111 248 248 248 248-111 248-248S393 8 256 8zm121.6 313.1c4.7 4.7 4.7 12.3 0 17L338 377.6c-4.7 4.7-12.3 4.7-17 0L256 312l-65.1 65.6c-4.7 4.7-12.3 4.7-17 0L134.4 338c-4.7-4.7-4.7-12.3 0-17l65.6-65-65.6-65.1c-4.7-4.7-4.7-12.3 0-17l39.6-39.6c4.7-4.7 12.3-4.7 17 0l65 65.7 65.1-65.6c4.7-4.7 12.3-4.7 17 0l39.6 39.6c4.7 4.7 4.7 12.3 0 17L312 256l65.6 65.1z">
</path>
</svg>
</div>
</div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-b16cd557" name="have-attorney" data-type="user">
<div class="block " style=" " data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-bar" id="id-0cbdd811">
<div style="padding-top:40px; padding-bottom:20px; ">
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-761c6670">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px; ">
<h2>Are You Currently Represented by an Attorney in this Matter?</h2>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-e8a342ca" data-align-siblings="false">
<div style="padding-top:5px; padding-bottom:5px; ">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
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<div class="multiple-choice-option " hey-nextscreen="" hey-important="" hey-autoredirect="true">
<label>
<div class="option-counter">1</div>
<input onclick="window.heyflow['legal-help-connect'].navigation.navigate('next','');" type="radio" id="id-053195fe" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="attorney" name="id-e8a342ca"
data-variable="attorney" value="id-053195fe" data-conditional="true" data-answer="Yes" required="" data-destination="next" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector">
<span class="radio "></span>
</div>
<div class="image-container">
<div class="svg-container">
<svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 512 512">
<path
d="M173.898 439.404l-166.4-166.4c-9.997-9.997-9.997-26.206 0-36.204l36.203-36.204c9.997-9.998 26.207-9.998 36.204 0L192 312.69 432.095 72.596c9.997-9.997 26.207-9.997 36.204 0l36.203 36.204c9.997 9.997 9.997 26.206 0 36.204l-294.4 294.401c-9.998 9.997-26.207 9.997-36.204-.001z">
</path>
</svg>
</div>
</div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label>
</div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option " hey-nextscreen="" hey-important="" hey-autoredirect="true">
<label>
<div class="option-counter">2</div>
<input onclick="window.heyflow['legal-help-connect'].navigation.navigate('next','');" type="radio" id="id-739518b5" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="attorney" name="id-e8a342ca"
data-variable="attorney" value="id-739518b5" data-conditional="true" data-answer="No" required="" data-destination="next" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector">
<span class="radio "></span>
</div>
<div class="image-container">
<div class="svg-container">
<svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 512 512">
<path
d="M256 8C119 8 8 119 8 256s111 248 248 248 248-111 248-248S393 8 256 8zm121.6 313.1c4.7 4.7 4.7 12.3 0 17L338 377.6c-4.7 4.7-12.3 4.7-17 0L256 312l-65.1 65.6c-4.7 4.7-12.3 4.7-17 0L134.4 338c-4.7-4.7-4.7-12.3 0-17l65.6-65-65.6-65.1c-4.7-4.7-4.7-12.3 0-17l39.6-39.6c4.7-4.7 12.3-4.7 17 0l65 65.7 65.1-65.6c4.7-4.7 12.3-4.7 17 0l39.6 39.6c4.7 4.7 4.7 12.3 0 17L312 256l65.6 65.1z">
</path>
</svg>
</div>
</div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-f7be24c1" name="medical-treatment" data-type="user">
<div class="block " style=" " data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-bar" id="id-c595b1b6">
<div style="padding-top:40px; padding-bottom:20px; ">
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item"></span>
<span class="progress-item"></span>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-504bc473">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px; ">
<h2>Did You Seek Medical Treatment at the Time of the Accident?</h2>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-d6e2edfa" data-align-siblings="false">
<div style="padding-top:5px; padding-bottom:5px; ">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option " hey-nextscreen="" hey-important="" hey-autoredirect="true">
<label>
<div class="option-counter">1</div>
<input onclick="window.heyflow['legal-help-connect'].navigation.navigate('next','');" type="radio" id="id-dc812b75" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="medical" name="id-d6e2edfa"
data-variable="medical" value="id-dc812b75" data-conditional="true" data-answer="Yes" required="" data-destination="next" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector">
<span class="radio "></span>
</div>
<div class="image-container">
<div class="svg-container">
<svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 512 512">
<path
d="M173.898 439.404l-166.4-166.4c-9.997-9.997-9.997-26.206 0-36.204l36.203-36.204c9.997-9.998 26.207-9.998 36.204 0L192 312.69 432.095 72.596c9.997-9.997 26.207-9.997 36.204 0l36.203 36.204c9.997 9.997 9.997 26.206 0 36.204l-294.4 294.401c-9.998 9.997-26.207 9.997-36.204-.001z">
</path>
</svg>
</div>
</div>
<div class="label-container">
<div class="label">Yes</div>
</div>
</div>
<div></div>
</label>
</div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option " hey-nextscreen="" hey-important="" hey-autoredirect="true">
<label>
<div class="option-counter">2</div>
<input onclick="window.heyflow['legal-help-connect'].navigation.navigate('next','');" type="radio" id="id-d7e516e9" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="medical" name="id-d6e2edfa"
data-variable="medical" value="id-d7e516e9" data-conditional="true" data-answer="No" required="" data-destination="next" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector">
<span class="radio "></span>
</div>
<div class="image-container">
<div class="svg-container">
<svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 512 512">
<path
d="M256 8C119 8 8 119 8 256s111 248 248 248 248-111 248-248S393 8 256 8zm121.6 313.1c4.7 4.7 4.7 12.3 0 17L338 377.6c-4.7 4.7-12.3 4.7-17 0L256 312l-65.1 65.6c-4.7 4.7-12.3 4.7-17 0L134.4 338c-4.7-4.7-4.7-12.3 0-17l65.6-65-65.6-65.1c-4.7-4.7-4.7-12.3 0-17l39.6-39.6c4.7-4.7 12.3-4.7 17 0l65 65.7 65.1-65.6c4.7-4.7 12.3-4.7 17 0l39.6 39.6c4.7 4.7 4.7 12.3 0 17L312 256l65.6 65.1z">
</path>
</svg>
</div>
</div>
<div class="label-container">
<div class="label">No</div>
</div>
</div>
<div></div>
</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-05d4acf6" name="which-language" data-type="user">
<div class="block " style=" " data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-bar" id="id-c6c1cf20">
<div style="padding-top:40px; padding-bottom:20px; ">
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item"></span>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-ff5ce1fd">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px; ">
<h2>In which language would you prefer to receive communications?</h2>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="multiple-choice">
<div class="block-content multiple-choice-block inner-mid" id="multiple-choice-block-id-8a1d506d" data-align-siblings="false">
<div style="padding-top:5px; padding-bottom:5px; ">
<div class="multiple-choice mc-smart-flex picture">
<div class="multiple-choice-inner" style="">
<div class="multiple-choice-option-container">
<div class="multiple-choice-option " hey-nextscreen="" hey-important="" hey-autoredirect="true">
<label>
<div class="option-counter">1</div>
<input onclick="window.heyflow['legal-help-connect'].navigation.navigate('next','');" type="radio" id="id-f5f87c37" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="language" name="id-8a1d506d"
data-variable="language" value="id-f5f87c37" data-conditional="true" data-answer="English" required="" data-destination="next" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector">
<span class="radio "></span>
</div>
<div class="image-container">
<div class="svg-container">
<svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 512 512">
<path
d="M256 32C114.6 32 0 125.1 0 240c0 49.6 21.4 95 57 130.7C44.5 421.1 2.7 466 2.2 466.5c-2.2 2.3-2.8 5.7-1.5 8.7S4.8 480 8 480c66.3 0 116-31.8 140.6-51.4 32.7 12.3 69 19.4 107.4 19.4 141.4 0 256-93.1 256-208S397.4 32 256 32z">
</path>
</svg>
</div>
</div>
<div class="label-container">
<div class="label">English</div>
</div>
</div>
<div></div>
</label>
</div>
</div>
<div class="multiple-choice-option-container">
<div class="multiple-choice-option " hey-nextscreen="" hey-important="" hey-autoredirect="true">
<label>
<div class="option-counter">2</div>
<input onclick="window.heyflow['legal-help-connect'].navigation.navigate('next','');" type="radio" id="id-3c28f84b" data-tracking="true" data-event-name="" data-type="multiple-choice" data-label="language" name="id-8a1d506d"
data-variable="language" value="id-3c28f84b" data-conditional="true" data-answer="Spanish" required="" data-destination="next" data-priority="0">
<div class="option-content picture">
<div class="selector-container radio-selector">
<span class="radio "></span>
</div>
<div class="image-container">
<div class="svg-container">
<svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 512 512">
<path d="M448 0H64C28.7 0 0 28.7 0 64v288c0 35.3 28.7 64 64 64h96v84c0 9.8 11.2 15.5 19.1 9.7L304 416h144c35.3 0 64-28.7 64-64V64c0-35.3-28.7-64-64-64z"></path>
</svg>
</div>
</div>
<div class="label-container">
<div class="label">Spanish</div>
</div>
</div>
<div></div>
</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="id-1035099c" name="loader" data-type="user">
<div class="block " style=" " data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-44048f60">
<div class="rich-text" style="padding-top:40px; padding-bottom:20px; ">
<h2>Evaluating your data…</h2>
<p>This might take a few seconds.</p>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="loader">
<div style="" class="block-content loader-block center inner-narrow" id="loader-block-loader-2703be5d" data-id="loader-2703be5d" data-timeout="2000" data-action="next"
data-options="{"redirectURL":"https://heyflow.app/","paddingBottom":20,"name":"loader","action":"next","disabled":false,"paddingTop":20,"id":"loader-2703be5d","type":"loader","class":"center&nbsp;inner-narrow","timeout":2000,"target":"_self"}">
<div style="padding-top:20px; padding-bottom:20px; ">
<div id="loader-2703be5d" class="circle-loader">
<div class="circle-loader-checkmark draw"></div>
</div>
</div>
</div>
</div>
</section>
<section id="id-0aaf7976" name="personal-info" data-type="user">
<div class="block " style=" " data-blocktype="progress">
<div class="block-content progress-block inner-narrow progress-items-bar" id="progress-45649a62">
<div style="padding-top:40px; padding-bottom:20px; ">
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
<span class="progress-item filled"></span>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="rich-text">
<div class="block-content text-block align-center inner-mid" id="text-block-id-c3cb30db">
<div class="rich-text" style="padding-top:20px; padding-bottom:20px; ">
<h2>Almost there.</h2>
<h4><br></h4>
<h4>Last few details required.</h4>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav" id="id-322c294b-container">
<div style="padding-bottom:5px; ">
<div class="input ">
<div class="input-inner">
<div style="flex:1;position:relative;">
<input type="text" id="id-322c294b" data-type="input" data-label="firstname" data-variable="firstname" data-mask="" name="id-322c294b" placeholder="First Name" pattern="" maxlength="" data-trim="" required="required"
autocomplete="off" class="">
<div class="input-floating-label"><span></span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div>
<datalist id="datalist-id-322c294b">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please enter first name</span>
</div>
</div>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav" id="id-016b1a39-container">
<div style="padding-bottom:5px; ">
<div class="input ">
<div class="input-inner">
<div style="flex:1;position:relative;">
<input type="text" id="id-016b1a39" data-type="input" data-label="lastname" data-variable="lastname" data-mask="" name="id-016b1a39" placeholder="Last Name" pattern="" maxlength="" data-trim="" required="required" autocomplete="off"
class="">
<div class="input-floating-label"><span></span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div>
<datalist id="datalist-id-016b1a39">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please enter last name</span>
</div>
</div>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav" id="id-5cc862b8-container">
<div style="padding-bottom:5px; ">
<div class="input ">
<div class="input-inner">
<div style="flex:1;position:relative;">
<input type="text" id="id-5cc862b8" data-type="input" data-label="email" data-variable="email" data-mask="" name="id-5cc862b8" placeholder="Email" pattern="^\S+@\S+\.\S+$" maxlength="" data-trim="" required="required"
autocomplete="off" class="">
<div class="input-floating-label"><span></span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div>
<datalist id="datalist-id-5cc862b8">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please enter valid email address</span>
</div>
</div>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav" id="id-b7e0b6a0-container">
<div style="padding-bottom:5px; ">
<div class="input ">
<div class="input-inner">
<div style="flex:1;position:relative;">
<input type="text" id="id-b7e0b6a0" data-type="input" data-label="phone" data-variable="phone" data-mask="" name="id-b7e0b6a0" placeholder="Mobile Phone" pattern="^\(?\d{3}\)?[-.]?\d{3}[-.]?\d{4}$" maxlength="" data-trim=""
required="required" autocomplete="off" class="">
<div class="input-floating-label"><span></span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div>
<datalist id="datalist-id-b7e0b6a0">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please enter valid mobile number</span>
</div>
</div>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="input">
<div class="block-content input-box input-block inner-narrow show-error-on-nav" id="input-469ac2b7-container">
<div style="padding-bottom:5px; ">
<div class="input ">
<div class="input-inner">
<div style="flex:1;position:relative;">
<input type="text" id="input-469ac2b7" data-type="input" data-label="address" data-variable="address" data-mask="" name="input-469ac2b7" placeholder="Street Address"
pattern="^\d+\s+([a-zA-Z0-9\s]+\s+)?[a-zA-Z\s]+(?:Avenue|Ave|Street|St|Road|Rd|Boulevard|Blvd|Drive|Dr|Lane|Ln|Court|Ct|Place|Pl|Circle|Cir|Terrace|Ter|Way|Trail|Trl|Parkway|Pkwy)(?:\s+[a-zA-Z0-9\s]+)*$" maxlength="" data-trim=""
required="required" autocomplete="off" class="">
<div class="input-floating-label"><span></span></div>
</div>
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm45.66,85.66-56,56a8,8,0,0,1-11.32,0l-24-24a8,8,0,0,1,11.32-11.32L112,148.69l50.34-50.35a8,8,0,0,1,11.32,11.32Z"></path>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="40" height="40" fill="currentColor" viewBox="0 0 256 256">
<path
d="M128,24A104,104,0,1,0,232,128,104.11,104.11,0,0,0,128,24Zm37.66,130.34a8,8,0,0,1-11.32,11.32L128,139.31l-26.34,26.35a8,8,0,0,1-11.32-11.32L116.69,128,90.34,101.66a8,8,0,0,1,11.32-11.32L128,116.69l26.34-26.35a8,8,0,0,1,11.32,11.32L139.31,128Z">
</path>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
</div>
<datalist id="datalist-input-469ac2b7">
<option>Option 1</option>
<option>Option 2</option>
</datalist>
<div class="error-box">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please enter street address with no city, state or zipcode</span>
</div>
</div>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="textarea">
<div class="block-content textarea-block inner-narrow show-error-instantly" id="textarea-100a25f1-container">
<div style="padding-bottom:5px; ">
<div class="textarea">
<textarea id="textarea-100a25f1" name="textarea-100a25f1" rows="3" cols="" required="required" placeholder="Briefly describe your case" autocomplete="off" data-label="comment" data-variable="comment" data-type="textarea"></textarea>
<div class="error-box">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg> <span class="text">Please comment on the accident</span>
</div>
</div>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="rich-text">
<div class="block-content text-block align-center inner-wide" id="text-block-rich-text-0d4bd0ca">
<div class="rich-text" style="padding-top:5px; padding-bottom:5px; ">
<h6><span style="color: var(--dark-grey)">By clicking the button below, you consent and request to be contacted for a compensation claim review for legal services by
</span><a target="_blank" href="https://legalhelpconnect.com/"><span style="color: var(--blue)">LegalHelpConnect.com</span></a><span style="color: var(--dark-grey)"> -
</span><a target="_blank" href="https://legalhelpconnect.com/marketing-partners.php"><span style="color: var(--blue)">Marketing Partners</span></a><span style="color: var(--dark-grey)">, third parties working on our behalf, and the law
firm you are connected to by phone, email, and text/SMS to the home or mobile number(s) you provided even if your provided number is on a National or State Do Not Call List. In some cases, pre-recorded messages, direct mail physical
mail, and automated technology may be used to contact you for marketing purposes. There is no requirement to provide consent as a condition of any purchase. This consent may be revoked at any time.</span></h6>
</div>
</div>
</div>
<div class="block " style=" " data-blocktype="generic-button">
<div class="block-content generic-button-block inner-narrow" id="generic-button-block-button-ced74bd4">
<div style="padding-top:20px; padding-bottom:20px; ">
<button id="button-ced74bd4" class="generic-button submit medium"
onclick="window.heyflow['legal-help-connect'].buttonClick(this, 'submit', '', '{"redirectURL":"https://legalhelpconnect.com/webhook/process.heyflow.php?accidenttype=@accidenttype&amp;s1=@s1&amp;s2=@s2&amp;s3=@s3&amp;s4=@s4&amp;s5=@s5&amp;aid=@aid&amp;oid=@oid&amp;reqid=@reqid&amp;affkey=@affkey&amp;accidentdate=@accidentdate&amp;zip=@zip&amp;fault=@fault&amp;police=@police&amp;attorney=@attorney&amp;medical=@medical&amp;language=@language&amp;firstname=@firstname&amp;lastname=@lastname&amp;email=@email&amp;phone=@phone&amp;address=@address&amp;xxTrustedFormCertUrl=@xxTrustedFormCertUrl&amp;comment@comment","containerClass":"inner-narrow","urlOmitEmptyVars":true,"label":"Submit","nextAction":"redirect","type":"generic-button","tracking":false,"target":"_self","paddingBottom":20,"name":"button-submit","contentClass":"align-space-between","action":"submit","id":"button-ced74bd4","paddingTop":20,"class":"submit&nbsp;medium"}')">
<div class="status-indicator">
<div class="icon-check-mark"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<polyline points="216 72.005 104 184 48 128.005" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></polyline>
</svg></div>
<div class="icon-x-mark"><svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<line x1="200" y1="56" x2="56" y2="200" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24">
</line>
<line x1="200" y1="200" x2="56" y2="56" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg></div>
<div class="icon-spinner"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" xmlns:xlink="http://www.w3.org/1999/xlink" x="0px" y="0px" width="40px" height="40px" viewBox="0 0 40 40" enable-background="new 0 0 40 40"
xml:space="preserve">
<path opacity="0.3" fill="currentColor"
d="M20.201,5.169c-8.254,0-14.946,6.692-14.946,14.946c0,8.255,6.692,14.946,14.946,14.946 s14.946-6.691,14.946-14.946C35.146,11.861,28.455,5.169,20.201,5.169z M20.201,31.749c-6.425,0-11.634-5.208-11.634-11.634 c0-6.425,5.209-11.634,11.634-11.634c6.425,0,11.633,5.209,11.633,11.634C31.834,26.541,26.626,31.749,20.201,31.749z">
</path>
<path fill="currentColor" d="M26.013,10.047l1.654-2.866c-2.198-1.272-4.743-2.012-7.466-2.012h0v3.312h0 C22.32,8.481,24.301,9.057,26.013,10.047z">
<animateTransform attributeType="xml" attributeName="transform" type="rotate" from="0 20 20" to="360 20 20" dur="0.5s" repeatCount="indefinite"></animateTransform>
</path>
</svg></div>
</div>
<div class="content align-space-between">
<div class="label-container ">
<span class="label">Submit</span>
</div>
<span class="graphic">
<svg xmlns="http://www.w3.org/2000/svg" width="192" height="192" fill="currentColor" viewBox="0 0 256 256">
<rect width="256" height="256" fill="none"></rect>
<path d="M219.53563,121.02,50.62075,26.42762A8,8,0,0,0,39.178,36.09836l31.86106,89.211a8,8,0,0,1,0,5.38138L39.178,219.90164a8,8,0,0,0,11.44277,9.67074l168.91488-94.59233A8,8,0,0,0,219.53563,121.02Z" fill="none" stroke="currentColor"
stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></path>
<line x1="72" y1="128" x2="136" y2="128" fill="none" stroke="currentColor" stroke-linecap="round" stroke-linejoin="round" stroke-width="24"></line>
</svg>
</span>
</div>
</button>
</div>
</div>
</div>
</section>
<section id="template-screen-header" name="template-screen-header" data-type="template" class="template" data-header="header">
</section>
<section id="template-screen-footer" name="template-screen-footer" data-type="template" class="template" data-footer="footer">
</section>
<section id="error" name="error" data-type="system">
<div class="block " style=" " data-blocktype="headline">
<div class="headline inner-mid" id="headline-block-">
<h2>Error</h2>
<h4>Sorry, your response could not be sent. Please check your internet connection.</h4>
</div>
</div>
</section>
<input type="submit" style="display:none;">
<input type="hidden" name="xxTrustedFormToken" id="xxTrustedFormToken_0" value="https://cert.trustedform.com/aafd2d3ef9f99783eead9fea57556159fa1568d4"><input type="hidden" name="xxTrustedFormCertUrl" id="xxTrustedFormCertUrl_0"
value="https://cert.trustedform.com/aafd2d3ef9f99783eead9fea57556159fa1568d4"><input type="hidden" name="xxTrustedFormPingUrl" id="xxTrustedFormPingUrl_0"
value="https://ping.trustedform.com/0.AZnWQotfZleZTq1vwZvH5JvWTllZ4ulavdkAExwF4kC6V0sIL06LgTpmD_0qTVP9S7HQyMZh.2TYY6Fq7GqN9p_5hoL8Nrw.d_h7LVPM7EFQ94b8iw_0KA">
</form>Text Content
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