{"id":48670,"date":"2019-01-23T20:05:43","date_gmt":"2019-01-23T20:05:43","guid":{"rendered":"https:\/\/www.campbellriskmanagement.com\/?page_id=48670"},"modified":"2021-07-08T15:12:11","modified_gmt":"2021-07-08T19:12:11","slug":"for-vendors","status":"publish","type":"page","link":"https:\/\/www.campbellriskmanagement.com\/for-vendors\/","title":{"rendered":"For Vendors"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; fullwidth=&#8221;on&#8221; _builder_version=&#8221;3.22.3&#8243; custom_padding=&#8221;0px|0px|0|0px|false|false&#8221; da_disable_devices=&#8221;off|off|off&#8221; da_is_popup=&#8221;off&#8221; da_exit_intent=&#8221;off&#8221; da_has_close=&#8221;on&#8221; da_alt_close=&#8221;off&#8221; da_dark_close=&#8221;off&#8221; da_not_modal=&#8221;on&#8221; da_is_singular=&#8221;off&#8221; da_with_loader=&#8221;off&#8221; da_has_shadow=&#8221;on&#8221;][et_pb_fullwidth_header title=&#8221;VENDOR \/ PRODUCER INSURANCE&#8221; text_orientation=&#8221;center&#8221; module_class=&#8221;page-header&#8221; _builder_version=&#8221;3.21.1&#8243; title_font=&#8221;Source Sans Pro|900||on|||||&#8221; title_text_align=&#8221;center&#8221; title_text_color=&#8221;#ffffff&#8221; title_font_size=&#8221;50px&#8221; title_line_height=&#8221;70px&#8221; background_color=&#8221;rgba(0,0,0,0.3)&#8221; background_image=&#8221;https:\/\/www.campbellriskmanagement.com\/wp-content\/uploads\/2019\/03\/Depositphotos_5595981_xl-2015.jpg&#8221; background_blend=&#8221;overlay&#8221; custom_padding=&#8221;||90px&#8221; custom_padding_tablet=&#8221;||20px|&#8221; custom_padding_phone=&#8221;||10px|&#8221; custom_padding_last_edited=&#8221;on|phone&#8221; title_font_size_tablet=&#8221;44px&#8221; title_font_size_phone=&#8221;32px&#8221; title_font_size_last_edited=&#8221;on|phone&#8221; title_line_height_tablet=&#8221;60px&#8221; title_line_height_phone=&#8221;42px&#8221; title_line_height_last_edited=&#8221;on|phone&#8221;][\/et_pb_fullwidth_header][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;3.22.3&#8243; custom_padding=&#8221;40px|0px|0|0px|false|false&#8221; da_disable_devices=&#8221;off|off|off&#8221; da_is_popup=&#8221;off&#8221; da_exit_intent=&#8221;off&#8221; da_has_close=&#8221;on&#8221; da_alt_close=&#8221;off&#8221; da_dark_close=&#8221;off&#8221; da_not_modal=&#8221;on&#8221; da_is_singular=&#8221;off&#8221; da_with_loader=&#8221;off&#8221; da_has_shadow=&#8221;on&#8221;][et_pb_row _builder_version=&#8221;3.25&#8243; background_size=&#8221;initial&#8221; background_position=&#8221;top_left&#8221; background_repeat=&#8221;repeat&#8221; width=&#8221;100%&#8221; max_width=&#8221;100%&#8221; use_custom_width=&#8221;on&#8221; width_unit=&#8221;off&#8221; custom_width_percent=&#8221;100%&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;3.25&#8243; custom_padding=&#8221;|||&#8221; custom_padding__hover=&#8221;|||&#8221;][et_pb_text admin_label=&#8221;About Us&#8221; module_class=&#8221;CRM-copy&#8221; _builder_version=&#8221;4.3.4&#8243; text_font=&#8221;||||||||&#8221; text_line_height=&#8221;1.8em&#8221; custom_margin=&#8221;|5%||5%&#8221;]<\/p>\n<p>If you are a Vendor, Exhibitor or Concessionaire wanting to attend farmers markets and like type events. Campbell Risk Management understands your unique product and general liability coverage needs. We understand what event managers are requiring you to have and will help you meet those requirements with as little cost and hassle as possible.\u00a0<\/p>\n<p style=\"text-align: center;\"><strong>Fill out the below form to receive an instant quote, purchase a policy and receive instant proof of insurance.<\/strong><\/p>\n<p style=\"text-align: center;\"><strong>After purchasing this policy, you can add as many additional insureds as needed at no extra cost.\u00a0<\/strong><\/p>\n<p>[\/et_pb_text][et_pb_code admin_label=&#8221;Vendor Form Code&#8221; _builder_version=&#8221;3.19.14&#8243; saved_tabs=&#8221;all&#8221;]<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_7_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form policy-form frm_pro_form \" id=\"form_31xje\"  >\n<div class=\"frm_form_fields  frm_page_num_1\">\n<fieldset>\n<legend class=\"frm_screen_reader\">Vendor Application<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"7\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_7\" id=\"frm_hide_fields_7\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"31xje\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_7\" name=\"frm_submit_entry_7\" value=\"fea0b00f83\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/wp-json\/wp\/v2\/pages\/48670\" \/><div id=\"frm_field_923_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container horizontal_radio\">\r\n    <div  id=\"field_n6d58_label\" class=\"frm_primary_label\">Have you had this type of policy with Campbell Risk Management in the last 12 months?\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_n6d58_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_923-0\"><label for=\"field_n6d58-0\">\t\t<input type=\"radio\" name=\"item_meta[923]\" id=\"field_n6d58-0\" value=\"Existing Customer \"\n\t\t   data-reqmsg=\"This field cannot be blank.\" data-invmsg=\"Have you had this type of policy with Campbell Risk Management in the last 12 months? is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_923-1\"><label for=\"field_n6d58-1\">\t\t<input type=\"radio\" name=\"item_meta[923]\" id=\"field_n6d58-1\" value=\"New Customer\"\n\t\t   data-reqmsg=\"This field cannot be blank.\" data-invmsg=\"Have you had this type of policy with Campbell Risk Management in the last 12 months? is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<input type=\"hidden\" name=\"item_meta[610]\" id=\"field_vhnc7\" value=\"AAV0000 LHW D481967\"  data-frmval=\"AAV0000 LHW D481967\" data-invmsg=\"Text is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[594]\" id=\"field_hr09o\" value=\"04\/27\/2024\"  data-frmval=\"04\/27\/2024\" data-invmsg=\"Created Date is invalid\"   \/>\n<div id=\"frm_field_69_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_half\">\r\n    <label for=\"field_gnpmi\" class=\"frm_primary_label\">Requested policy effective date\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_gnpmi\" name=\"item_meta[69]\" value=\"\"  maxlength=\"10\" data-reqmsg=\"This field cannot be blank.\" aria-required=\"true\" data-invmsg=\"Effective Date is invalid\" class=\"effectiveDate frm_date\" autocomplete=\"off\" readonly=\"readonly\" aria-invalid=\"false\"  \/>\r\n   \r\n    \r\n<\/div>\n<div id=\"frm_field_76_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_half\">\r\n    <label for=\"field_26kov\" class=\"frm_primary_label\">Policy end date\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_26kov\" name=\"item_meta[76]\" value=\"\"  readonly=\"readonly\"  data-reqmsg=\"This field cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" autocomplete=\"off\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1017_container\" class=\"frm_form_field frm_section_heading frm_hidden frm_invisible_section form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing frm_trigger\" tabindex=\"0\" role=\"button\">Administrator - Override Policy Dates <svg  viewBox=\"0 0 20 20\" width=\"1em\" height=\"1em\" aria-expanded=\"false\" aria-label=\"Toggle fields\" class=\"frmsvg frm-svg-icon\">\n\t<path d=\"M5 6l5 5 5-5 2 1-7 7-7-7 2-1z\"><\/path>\n\n<\/svg><svg  viewBox=\"0 0 20 20\" width=\"1em\" height=\"1em\" aria-expanded=\"false\" aria-label=\"Toggle fields\" class=\"frmsvg frm-svg-icon\">\n\t<title>arrowup6<\/title>\n\t<path style=\"transform:rotate(180deg); transform-origin:center;\" d=\"M5 6l5 5 5-5 2 1-7 7-7-7 2-1z\"><\/path>\n<\/svg><\/h3>\r\n\r\n<div class=\"frm_toggle_container frm_grid_container\" style=\"display:none;\">\r\n<input type=\"hidden\" name=\"item_meta[1021]\" id=\"field_hu0aq\" value=\"\"  data-sectionid=\"1017\" data-invmsg=\"Show Policy Override Feature is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[1252]\" id=\"field_zoyis-0\" value=\"\"  data-sectionid=\"1017\" data-invmsg=\"Override Policy Dates is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[1019]\" id=\"field_c41at\" value=\"04\/27\/2024\"  data-sectionid=\"1017\" data-frmval=\"04\/27\/2024\" data-invmsg=\"Date is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[1020]\" id=\"field_sh14l\" value=\"04\/27\/2024\"  data-sectionid=\"1017\" data-frmval=\"04\/27\/2024\" data-invmsg=\"Date is invalid\"   \/>\n<\/div>\n<\/div>\n<div id=\"frm_field_78_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container cost vertical_radio\">\r\n    <label for=\"field_labum\" class=\"frm_primary_label\">Estimated gross annual sales\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\"> \t\t<div class=\"frm_radio\" id=\"frm_radio_78-1\"><label for=\"field_labum-1\">\t\t<input type=\"radio\" name=\"item_meta[78]\" id=\"field_labum-1\" value=\"250\"\n\t\t   data-reqmsg=\"Please enter your gross annual sales.\" data-invmsg=\"Estimated gross annual sales is invalid\" autocomplete=\"off\" aria-invalid=\"false\"  \/> Up to $25,000<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_78-2\"><label for=\"field_labum-2\">\t\t<input type=\"radio\" name=\"item_meta[78]\" id=\"field_labum-2\" value=\"300\"\n\t\t   data-reqmsg=\"Please enter your gross annual sales.\" data-invmsg=\"Estimated gross annual sales is invalid\" autocomplete=\"off\" aria-invalid=\"false\"  \/> $25,001 - $100,000<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_78-3\"><label for=\"field_labum-3\">\t\t<input type=\"radio\" name=\"item_meta[78]\" id=\"field_labum-3\" value=\"500\"\n\t\t   data-reqmsg=\"Please enter your gross annual sales.\" data-invmsg=\"Estimated gross annual sales is invalid\" autocomplete=\"off\" aria-invalid=\"false\"  \/> $100,001 - $250,000<\/label><\/div>\n<\/div>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_labum\">Over $250,000: We will contact you with a customized price quote<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_1234_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div  id=\"field_zut9q_label\" class=\"frm_primary_label\">Choose your limits of insurance\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_zut9q_label\" role=\"radiogroup\" aria-required=\"true\"> \t\t<div class=\"frm_radio\" id=\"frm_radio_1234-0\"><label for=\"field_zut9q-0\">\t\t<input type=\"radio\" name=\"item_meta[1234]\" id=\"field_zut9q-0\" value=\"0\"\n\t\t   data-reqmsg=\"This field cannot be blank.\" data-invmsg=\"Choose your limits of insurance is invalid\" autocomplete=\"off\" aria-invalid=\"false\"  \/> $1,000,000 per occurrence \/ $2,000,000 aggregate limit<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_1234-1\"><label for=\"field_zut9q-1\">\t\t<input type=\"radio\" name=\"item_meta[1234]\" id=\"field_zut9q-1\" value=\"25\"\n\t\t   data-reqmsg=\"This field cannot be blank.\" data-invmsg=\"Choose your limits of insurance is invalid\" autocomplete=\"off\" aria-invalid=\"false\"  \/> $2,000,000 per occurrence \/ $4,000,000 aggregate limit<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<input type=\"hidden\" name=\"item_meta[727]\" id=\"field_3xo9h\" value=\"\"  data-invmsg=\"Text is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[1235]\" id=\"field_nvotn\" value=\"35\"  data-frmval=\"35\" data-invmsg=\"Text is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[1334]\" id=\"field_klqte\" value=\"\"  data-invmsg=\"Text is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[703]\" id=\"field_1hxun\" value=\"\"  data-invmsg=\"Text is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[584]\" id=\"field_qzhi4\" value=\"1M\/2M\"  data-frmval=\"1M\/2M\" data-invmsg=\"Text is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[585]\" id=\"field_mkl2c\" value=\"2M\/4M\"  data-frmval=\"2M\/4M\" data-invmsg=\"Text is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[734]\" id=\"field_6f0og\" value=\"$25,000\"  data-frmval=\"$25,000\" data-invmsg=\"Text is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[735]\" id=\"field_d2sy7\" value=\"$250,000\"  data-frmval=\"$250,000\" data-invmsg=\"Text is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[587]\" id=\"field_xs753\" value=\"\"  data-invmsg=\"Text is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[586]\" id=\"field_y451h\" value=\"\"  data-invmsg=\"Text is invalid\"   \/>\n<div id=\"frm_field_83_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h3>Policy Holder Information<\/h3>\n<\/div>\n<div id=\"frm_field_87_container\" class=\"frm_form_field frm_section_heading form-field  frm_half frm_first\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Contact & Mailing Information<\/h3>\r\n\r\n\r\n<div id=\"frm_field_89_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_41vle\" class=\"frm_primary_label\">First Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_41vle\" name=\"item_meta[89]\" value=\"\"  data-sectionid=\"87\" data-reqmsg=\"This field cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_90_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_mm81c\" class=\"frm_primary_label\">Last Name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_mm81c\" name=\"item_meta[90]\" value=\"\"  data-sectionid=\"87\" data-reqmsg=\"This field cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_879_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_nt6hm\" id=\"field_nt6hm_label\" class=\"frm_primary_label\">Street Address\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_nt6hm\" name=\"item_meta[879]\" value=\"\"  data-sectionid=\"87\" data-reqmsg=\"This field cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" autocomplete=\"street-address\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_880_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_ix2v0\" id=\"field_ix2v0_label\" class=\"frm_primary_label\">Address (Suite, Apt #)\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_ix2v0\" name=\"item_meta[880]\" value=\"\"  data-sectionid=\"87\" data-invmsg=\"Text is invalid\" autocomplete=\"address-line2\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_881_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_first frm_third\">\r\n    <label for=\"field_o9q4c\" id=\"field_o9q4c_label\" class=\"frm_primary_label\">City\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_o9q4c\" name=\"item_meta[881]\" value=\"\"  data-sectionid=\"87\" style=\"width:400px\" data-reqmsg=\"This field cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" class=\"auto_width\" autocomplete=\"city\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_882_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_8br7e\" id=\"field_8br7e_label\" class=\"frm_primary_label\">State\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[882]\" id=\"field_8br7e\"  data-sectionid=\"87\" data-reqmsg=\"This field cannot be blank.\" aria-required=\"true\" data-invmsg=\"State is invalid\" autocomplete=\"state\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"Alabama\">Alabama<\/option><option  value=\"Arizona\">Arizona<\/option><option  value=\"Arkansas\">Arkansas<\/option><option  value=\"California\">California<\/option><option  value=\"Colorado\">Colorado<\/option><option  value=\"Connecticut\">Connecticut<\/option><option  value=\"Delaware\">Delaware<\/option><option  value=\"District of Columbia\">District of Columbia<\/option><option  value=\"Florida\">Florida<\/option><option  value=\"Georgia\">Georgia<\/option><option  value=\"Hawaii\">Hawaii<\/option><option  value=\"Idaho\">Idaho<\/option><option  value=\"Illinois\">Illinois<\/option><option  value=\"Indiana\">Indiana<\/option><option  value=\"Iowa\">Iowa<\/option><option  value=\"Kansas\">Kansas<\/option><option  value=\"Kentucky\">Kentucky<\/option><option  value=\"Louisiana\">Louisiana<\/option><option  value=\"Maine\">Maine<\/option><option  value=\"Maryland\">Maryland<\/option><option  value=\"Massachusetts\">Massachusetts<\/option><option  value=\"Michigan\">Michigan<\/option><option  value=\"Minnesota\">Minnesota<\/option><option  value=\"Mississippi\">Mississippi<\/option><option  value=\"Missouri\">Missouri<\/option><option  value=\"Montana\">Montana<\/option><option  value=\"Nebraska\">Nebraska<\/option><option  value=\"Nevada\">Nevada<\/option><option  value=\"New Hampshire\">New Hampshire<\/option><option  value=\"New Jersey\">New Jersey<\/option><option  value=\"New Mexico\">New Mexico<\/option><option  value=\"New York\">New York<\/option><option  value=\"North Carolina\">North Carolina<\/option><option  value=\"North Dakota\">North Dakota<\/option><option  value=\"Ohio\">Ohio<\/option><option  value=\"Oklahoma\">Oklahoma<\/option><option  value=\"Oregon\">Oregon<\/option><option  value=\"Pennsylvania\">Pennsylvania<\/option><option  value=\"Rhode Island\">Rhode Island<\/option><option  value=\"South Carolina\">South Carolina<\/option><option  value=\"South Dakota\">South Dakota<\/option><option  value=\"Tennessee\">Tennessee<\/option><option  value=\"Texas\">Texas<\/option><option  value=\"Utah\">Utah<\/option><option  value=\"Vermont\">Vermont<\/option><option  value=\"Virginia\">Virginia<\/option><option  value=\"Washington\">Washington<\/option><option  value=\"West Virginia\">West Virginia<\/option><option  value=\"Wisconsin\">Wisconsin<\/option><option  value=\"Wyoming\">Wyoming<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_883_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_third\">\r\n    <label for=\"field_pzfwn\" id=\"field_pzfwn_label\" class=\"frm_primary_label\">Zip Code\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_pzfwn\" name=\"item_meta[883]\" value=\"\"  data-sectionid=\"87\" data-reqmsg=\"This field cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" autocomplete=\"zipcode\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_109_container\" class=\"frm_form_field frm_section_heading form-field  frm_half frm_alignright\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Business Information<\/h3>\r\n\r\n\r\n<div id=\"frm_field_111_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_kplmp\" class=\"frm_primary_label\">Select Business Type:\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[111]\" id=\"field_kplmp\"  data-sectionid=\"109\" data-reqmsg=\"This field cannot be blank.\" aria-required=\"true\" data-invmsg=\"Select Business Type: is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"Corporation\">Corporation<\/option><option  value=\"LLC\">LLC<\/option><option  value=\"Partnership or Joint Venture\">Partnership or Joint Venture<\/option><option  value=\"Individual\/Sole Proprietor\">Individual\/Sole Proprietor<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_112_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_v6zr\" class=\"frm_primary_label\">Vendor's Individual or Business Name (include DBA if applicable)\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_v6zr\" name=\"item_meta[112]\" value=\"\"  data-sectionid=\"109\" data-reqmsg=\"This field cannot be blank.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_113_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_web0q\" class=\"frm_primary_label\">Email Address:\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_web0q\" name=\"item_meta[113]\" value=\"\"  data-sectionid=\"109\" data-reqmsg=\"This field cannot be blank and must be a properly formatted email address.\" aria-required=\"true\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_115_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_c1meq\" class=\"frm_primary_label\">Phone\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_c1meq\" name=\"item_meta[115]\" value=\"\"  data-sectionid=\"109\" data-frmmask=\"(999)999-9999\" data-reqmsg=\"This field cannot be blank.\" aria-required=\"true\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"\\(\\d\\d\\d\\)\\d\\d\\d-\\d\\d\\d\\d$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_116_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_pz5ey\" class=\"frm_primary_label\">Website\/URL (if applicable)\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_pz5ey\" name=\"item_meta[116]\" value=\"\"  data-sectionid=\"109\" data-invmsg=\"Website\/URL is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_117_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h3>CLAIMS HISTORY<\/h3>\n<\/div>\n<div id=\"frm_field_118_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <label for=\"field_p2rne\" class=\"frm_primary_label\">Have you had any liability insurance claims in the past 5 years?\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_118-0\"><label for=\"field_p2rne-0\">\t\t<input type=\"radio\" name=\"item_meta[118]\" id=\"field_p2rne-0\" value=\"Yes\"\n\t\t   data-reqmsg=\"This field cannot be blank.\" data-invmsg=\"Have you had any liability insurance claims in the past 5 years? is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_118-1\"><label for=\"field_p2rne-1\">\t\t<input type=\"radio\" name=\"item_meta[118]\" id=\"field_p2rne-1\" value=\"No\"\n\t\t   data-reqmsg=\"This field cannot be blank.\" data-invmsg=\"Have you had any liability insurance claims in the past 5 years? is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_691_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <label for=\"field_u4xzk\" id=\"field_u4xzk_label\" class=\"frm_primary_label\">Please provide claim details\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[691]\" id=\"field_u4xzk\" rows=\"5\"  data-invmsg=\"Please provide claim details is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_119_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <label for=\"field_43xld\" class=\"frm_primary_label\">Have there been any recent incidents that could result in a claim?\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_119-0\"><label for=\"field_43xld-0\">\t\t<input type=\"radio\" name=\"item_meta[119]\" id=\"field_43xld-0\" value=\"Yes\"\n\t\t   data-reqmsg=\"This field cannot be blank.\" data-invmsg=\"Have there been any recent incidents that could result in a claim? is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_119-1\"><label for=\"field_43xld-1\">\t\t<input type=\"radio\" name=\"item_meta[119]\" id=\"field_43xld-1\" value=\"No\"\n\t\t   data-reqmsg=\"This field cannot be blank.\" data-invmsg=\"Have there been any recent incidents that could result in a claim? is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_704_container\" class=\"frm_form_field  warning frm_html_container form-field\">\n<div id=\"warning\">\n<h5>We cannot process a new request for insurance while a potential claim is pending<\/p>\n<h5>\n<p>This form will not process if you continue. Please resolve your issues before attempting to take out a new policy.<\/p>\n<p>If you have questions, you can reach us here: 317-848-9075.<\/p>\n<\/div>\n<\/div>\n<div id=\"frm_field_123_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <label for=\"field_5878e\" class=\"frm_primary_label\">Are you in compliance with all County, State, and Federal Food and Safety Regulations?\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_123-0\"><label for=\"field_5878e-0\">\t\t<input type=\"radio\" name=\"item_meta[123]\" id=\"field_5878e-0\" value=\"Yes\"\n\t\t   data-reqmsg=\"This field cannot be blank.\" data-invmsg=\"Are you in compliance with all County, State, and Federal Food and Safety Regulations? is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_123-1\"><label for=\"field_5878e-1\">\t\t<input type=\"radio\" name=\"item_meta[123]\" id=\"field_5878e-1\" value=\"No\"\n\t\t   data-reqmsg=\"This field cannot be blank.\" data-invmsg=\"Are you in compliance with all County, State, and Federal Food and Safety Regulations? is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_705_container\" class=\"frm_form_field  warning frm_html_container form-field\">\n<div id=\"warning\">\n<h5>We cannot process a new request for insurance if you are not in compliance.<\/p>\n<h5>\n<p>This form will not process if you continue. Please resolve any issues before attempting to take out a new policy.<\/p>\n<p>If you have questions, you can reach us here: 317-848-9075.<\/p>\n<\/div>\n<\/div>\n<div id=\"frm_field_120_container\" class=\"frm_form_field  frm_html_container form-field\">\n<h3>Product Information<\/h3>\n<\/div>\n<div id=\"frm_field_122_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label for=\"field_mzi72\" class=\"frm_primary_label\">Please list types of products sold (if you are making bath or body products please list the ingredients as well):\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n       <textarea name=\"item_meta[122]\" id=\"field_mzi72\" rows=\"5\"  data-reqmsg=\"This field cannot be blank.\" aria-required=\"true\" data-invmsg=\"Please list types of products sold (if you are making bath or body products please list the ingredients as well): is invalid\" autocomplete=\"section-nothing\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_126_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <label for=\"field_ubmjh\" class=\"frm_primary_label\">Do you sell any of the following? Finished products that are directly imported,  herbal remedies,  items targeted toward infants,  children's toy's or children's furniture,  Liquid raw milk, Alcoholic beverages,  Tobacco related products including e-cigarettes or smokeless products,  Marijuana or products containing THC, Herbal remedies or medicinal products claiming healing properties.\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_radio\" id=\"frm_radio_126-0\"><label for=\"field_ubmjh-0\">\t\t<input type=\"radio\" name=\"item_meta[126]\" id=\"field_ubmjh-0\" value=\"Yes\"\n\t\t   data-reqmsg=\"This field cannot be blank.\" data-invmsg=\"Do you sell any of the following? Finished products that are directly imported,  herbal remedies,  items targeted toward infants,  children&#039;s toy&#039;s or children&#039;s furniture,  Liquid raw milk, Alcoholic beverages,  Tobacco related products including e-cigarettes or smokeless products,  Marijuana or products containing THC, Herbal remedies or medicinal products claiming healing properties. is invalid\" aria-invalid=\"false\"  \/> Yes<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_126-1\"><label for=\"field_ubmjh-1\">\t\t<input type=\"radio\" name=\"item_meta[126]\" id=\"field_ubmjh-1\" value=\"No\"\n\t\t   data-reqmsg=\"This field cannot be blank.\" data-invmsg=\"Do you sell any of the following? Finished products that are directly imported,  herbal remedies,  items targeted toward infants,  children&#039;s toy&#039;s or children&#039;s furniture,  Liquid raw milk, Alcoholic beverages,  Tobacco related products including e-cigarettes or smokeless products,  Marijuana or products containing THC, Herbal remedies or medicinal products claiming healing properties. is invalid\" aria-invalid=\"false\"  \/> No<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_706_container\" class=\"frm_form_field  warning frm_html_container form-field\">\n<div id=\"warning\">\n<h5>Thank you for you interest in this insurance program. Due to the nature of your products we are unable to offer a quote at this time.<\/p>\n<h5>\n<p>This form will not process if you continue.<\/p>\n<p>If you have questions, you can reach us here: 317-848-9075<\/p>\n<\/div>\n<\/div>\n<input type=\"hidden\" name=\"item_meta[593]\" id=\"field_l9dad\" value=\"\"  data-invmsg=\"Specific Certificate Holder is invalid\"   \/>\n<div id=\"frm_field_1570_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Please Select Source of Referral<\/h3>\r\n\r\n\r\n<div id=\"frm_field_1572_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm_other_container\">\r\n    <label for=\"field_yiqh\" id=\"field_yiqh_label\" class=\"frm_primary_label\">Source\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[1572]\" id=\"field_yiqh\"  data-sectionid=\"1570\" data-placeholder=\"Please Select Referral Source\"  placeholder=\"Please Select Referral Source\" data-reqmsg=\"Please check all required fields.  This field cannot be blank.\" aria-required=\"true\" data-invmsg=\"Source is invalid\" aria-invalid=\"false\"  >\n\t\t\t\t\t<option class=\"frm-select-placeholder\" value=\"\">\n\t\t\t\tPlease Select Referral Source\t\t\t<\/option>\n\t\t\t<option  value=\"Google\">Google<\/option><option  value=\"Bing\">Bing<\/option><option  value=\"Internet Search Engine\">Internet Search Engine<\/option><option  value=\"Referral from a Market Manager\">Referral from a Market Manager<\/option><option  value=\"Referral from a Vendor\">Referral from a Vendor<\/option><option  value=\"Referral from a friend\">Referral from a friend<\/option><option  value=\"Referral from Facebook\">Referral from Facebook<\/option><option  value=\"Referral from another website\">Referral from another website<\/option><option  value=\"Television Advertisement\">Television Advertisement<\/option><option  value=\"Other\" class=\"frm_other_trigger\">Other<\/option>\t<\/select>\n\t<label for=\"field_yiqh-otext\" class=\"frm_screen_reader frm_hidden\">Source<\/label><input type=\"text\" id=\"field_yiqh-otext\" class=\"frm_other_input frm_pos_none\"  name=\"item_meta[other][1572]\" value=\"\" \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_129_container\" class=\"frm_form_field  frm_html_container form-field\">\n<div class=\"form-tc\">\n<h4>Terms & Conditions<\/h4>\n<p>By filling out the preceding form, any farmers market or vendor is eligible to become a member of the FM&V RPG, managed by Campbell Risk Management.<\/p>\n<p><\/p>\n<p>The FM&V RPG has worked with the Hanover Insurance Company which is rated  \"A\" Excellent by A.M. Best & Co. to make this program available.<\/p>\n<p><\/p>\n<p>RISK PURCHASING GROUP NOTICE<br \/>\nThis policy is issued to the FM&V risk purchase group. Risk purchasing groups may not be subject to all of the insurance laws and regulations of your state of domicile.<\/p>\n<p>By filling out the preceding form you agree to receive occasional marketing-related or promotional emails from us. You may unsubscribe from this list at any time.\n<\/p>\n<p><\/p>\n<p>IMPORTANT NOTICE REGARDING RISK PURCHASING GROUPS<br \/>\nDisclosure Pursuant to Federal Law Regarding Purchasing Groups [15 U.S.C. SEC. 3901, et seq] FM&V purchasing group is a \"Risk Purchasing Group\", as defined under Federal law, formed to purchase liability insurance on a group basis for its Members to cover the similar or related liability exposure(s) to which the Members of the Risk Purchasing Group are exposed by virtue of their related, similar, or common businesses or services. Members do not share limits and each member is provided with its own policy and\/or evidence of insurance.<\/p>\n<p><a href=\"\/terms-and-conditions\/\" target=\"_blank\">Read Terms & Conditions<\/a>\n<\/div>\n<\/div>\n<div id=\"frm_field_128_container\" class=\"frm_form_field form-field  frm_required_field frm_none_container vertical_radio\">\r\n    <label for=\"field_iawip\" class=\"frm_primary_label\">Terms & Conditions\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <div class=\"frm_opt_container\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_128-0\"><label for=\"field_iawip-0\"><input type=\"checkbox\" name=\"item_meta[128][]\" id=\"field_iawip-0\" value=\"By checking this box I accept the Terms &amp; Conditions\"  data-reqmsg=\"Terms and Conditions must be accepted.\" data-invmsg=\"Terms &amp; Conditions is invalid\" aria-invalid=\"false\"   \/> By checking this box I accept the Terms &amp; Conditions<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<input type=\"hidden\" name=\"item_meta[598]\" id=\"field_1qot6\" value=\"\"  data-invmsg=\"Insured Info is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[925]\" id=\"field_rocnh\" value=\"Those usual to the Insured&#039;s operation. Blanket additional Insured applies per coverage form 421-2015 06 15. Certificate holder, if any, is hereby an additional insured.\"  data-frmval=\"Those usual to the Insured&#039;s operation. Blanket additional Insured applies per coverage form 421-2015 06 15. Certificate holder, if any, is hereby an additional insured.\" data-invmsg=\"Description of Operations is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[472]\" id=\"field_g6o00\" value=\"\" data-frmval=\"\"\/>\n<input type=\"hidden\" name=\"item_meta[1265]\" id=\"field_k3sdg\" value=\"10441 \"  data-frmval=\"10441 \" data-invmsg=\"Text is invalid\"   \/>\n<div id=\"frm_field_470_container\" class=\"frm_form_field frm_section_heading form-field  totals\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">Total<\/h3>\r\n\r\n\r\n<input type=\"hidden\" name=\"item_meta[406]\" id=\"field_j3gf2\" value=\"Surcharge\"  data-sectionid=\"470\" data-frmval=\"Surcharge\" data-invmsg=\"Text is invalid\"   \/>\n<div id=\"frm_field_131_container\" class=\"frm_form_field form-field  frm_top_container policy-total\">\r\n    <label for=\"field_apdn3\" class=\"frm_primary_label\">Total Amount($)\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_apdn3\" name=\"item_meta[131]\" value=\"Order Total\"  readonly=\"readonly\"  data-sectionid=\"470\" data-frmval=\"Order Total\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_1236_container\" class=\"frm_form_field form-field  frm_top_container policy-total\">\r\n    <label for=\"field_98f0o\" class=\"frm_primary_label\">Total Amount($)\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_98f0o\" name=\"item_meta[1236]\" value=\"Order Total\"  readonly=\"readonly\"  data-sectionid=\"470\" data-frmval=\"Order Total\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<input type=\"hidden\" name=\"frm_page_order_7\" id=\"frm_page_order_7\" value=\"124\" \/><input type=\"hidden\" name=\"item_meta[786]\" id=\"field_du6r4\" value=\"\"  data-invmsg=\"Text is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[784]\" id=\"field_pay0a\" value=\"\"  data-invmsg=\"User Registration is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[473]\" id=\"field_i1d8j\" value=\"\"  data-sectionid=\"784\" data-reqmsg=\"This field cannot be blank.\" aria-required=\"true\" data-invmsg=\"Email is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[474]\" id=\"field_pourt\" value=\"\"  data-sectionid=\"784\" data-reqmsg=\"This field cannot be blank.\" aria-required=\"true\" data-invmsg=\"Password is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[785]\" id=\"field_fdij3\" value=\"\"  data-invmsg=\"End Section is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[694]\" id=\"field_87gtd\" value=\"\"  data-invmsg=\"Text is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[1291]\" id=\"field_m0wds\" value=\"\"  data-invmsg=\"Text is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[887]\" id=\"field_rt5v5\" value=\"\"  data-invmsg=\"Hidden Field Street Address is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[888]\" id=\"field_dvxcd\" value=\"\"  data-invmsg=\"Hidden Field Address Line 2 is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[889]\" id=\"field_9iyu5\" value=\"\"  data-invmsg=\"Hidden Field City is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[890]\" id=\"field_uh52r\" value=\"\"  data-invmsg=\"Hidden Field State is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[891]\" id=\"field_f9twe\" value=\"\"  data-invmsg=\"Hidden Field Zip is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[1029]\" id=\"field_ear5h\" value=\"No\"  data-frmval=\"No\" data-invmsg=\"Administrator - Override Payment is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[1238]\" id=\"field_iay59\" value=\"Yes\"  data-frmval=\"Yes\" data-invmsg=\"Send Updated PDF To Customer? is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[1030]\" id=\"field_ouo14\" value=\"\"  data-invmsg=\"Text is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[482]\" id=\"field_re5sv\" value=\"authnet_aim\"  data-frmval=\"authnet_aim\" data-reqmsg=\"This field cannot be blank.\" aria-required=\"true\" data-invmsg=\"Payment Method is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[884]\" id=\"field_ad3w8\" value=\"\"  data-invmsg=\"Payment Information is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[860]\" id=\"field_sdai9\" value=\"\"  data-sectionid=\"884\" data-reqmsg=\"This field cannot be blank.\" aria-required=\"true\" data-invmsg=\"Credit Card Billing Address is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[886]\" id=\"field_1fdrg\" value=\"\"  data-sectionid=\"884\" data-reqmsg=\"This field cannot be blank.\" aria-required=\"true\" data-invmsg=\"Credit Card Information is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[895]\" id=\"field_xefh7\" value=\"\"  data-sectionid=\"884\" data-invmsg=\"Text is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[893]\" id=\"field_uld9a\" value=\"\"  data-sectionid=\"884\" data-invmsg=\"Text is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[894]\" id=\"field_ghxhg\" value=\"\"  data-sectionid=\"884\" data-invmsg=\"Text is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[885]\" id=\"field_ozksg\" value=\"\"  data-invmsg=\"End Section is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[767]\" id=\"field_ctgks\" value=\"\"  data-invmsg=\"vexTotal is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[1461]\" id=\"field_7vb5w\" value=\"48670\"  data-frmval=\"48670\" data-invmsg=\"Text is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[1470]\" id=\"field_tk0m4\" value=\"1I79uzINXeHqJAF\"  data-frmval=\"1I79uzINXeHqJAF\" data-invmsg=\"cID is invalid\"   \/>\n<input type=\"hidden\" name=\"item_meta[1475]\" id=\"field_xzami\" value=\"\"  data-invmsg=\"Archive is invalid\"   \/>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t\t<div class=\"frm__65f9f06bd0e02\" aria-hidden=\"true\">\n\t\t\t\t<label for=\"frm_email_7\" >\n\t\t\t\t\tIf you are human, leave this field blank.\t\t\t\t<\/label>\n\t\t\t\t<input  id=\"frm_email_7\" type=\"text\" class=\"frm_verify\" name=\"frm__65f9f06bd0e02\" value=\"\" autocomplete=\"false\"  \/>\n\t\t\t<\/div>\n\t\t<input type=\"hidden\" name=\"frm_register[email]\" value=\"473\"\/><input type=\"hidden\" name=\"frm_register[username]\" value=\"-1\"\/><input type=\"hidden\" name=\"frm_register[password]\" value=\"474\"\/><input type=\"hidden\" name=\"frm_register[subsite_title]\" value=\"username\"\/><input type=\"hidden\" name=\"frm_register[subsite_domain]\" value=\"blog_title\"\/><input name=\"frm_state\" type=\"hidden\" value=\"0NpaHQzpRTWQkc8yoP4lUGNOaQPwMcTKioUjyXX6wd4=\" \/><div class=\"frm_submit\">\r\n\r\n<button id=\"buttonsubmit\" class=\"frm_button_submit\" type=\"submit\"   formnovalidate=\"formnovalidate\">Purchase This Insurance<\/button>\r\n\r\n<\/div>\r\n\r\n<h5>After 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