{"id":1581,"date":"2023-10-23T07:43:57","date_gmt":"2023-10-23T05:43:57","guid":{"rendered":"https:\/\/www.previseguro.es\/accident-report\/"},"modified":"2023-11-10T16:20:51","modified_gmt":"2023-11-10T15:20:51","slug":"accident-report","status":"publish","type":"page","link":"https:\/\/www.previseguro.es\/en\/accident-report\/","title":{"rendered":"Accident report"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1581\" class=\"elementor elementor-1581 elementor-215\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-62ae412 e-flex e-con-boxed e-con e-parent\" data-id=\"62ae412\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b1ae35d elementor-widget elementor-widget-heading\" data-id=\"b1ae35d\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Accident report<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-51e09b0 e-con-full e-flex e-con e-child\" data-id=\"51e09b0\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-468d944 elementor-widget elementor-widget-heading\" data-id=\"468d944\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"elementor-heading-title elementor-size-default\">Select one of these three options:<\/div>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-cebe0ab elementor-icon-list--layout-traditional elementor-list-item-link-full_width elementor-widget elementor-widget-icon-list\" data-id=\"cebe0ab\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"icon-list.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<ul class=\"elementor-icon-list-items\">\n\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/www.previseguro.es\/wp-content\/uploads\/parte-de-accidente.pdf\" target=\"_blank\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-file-download\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">I want to download a vehicle accident report template in PDF for printing.<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"#part-accidents\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-arrow-circle-down\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">I want to fill out a vehicle accident report directly on the web.<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t\t\t<li class=\"elementor-icon-list-item\">\n\t\t\t\t\t\t\t\t\t\t\t<a href=\"https:\/\/www.previseguro.es\/en\/?page_id=1562\">\n\n\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-icon\">\n\t\t\t\t\t\t\t<i aria-hidden=\"true\" class=\"fas fa-arrow-circle-right\"><\/i>\t\t\t\t\t\t<\/span>\n\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-icon-list-text\">I want to report a different type of claim on the web.<\/span>\n\t\t\t\t\t\t\t\t\t\t\t<\/a>\n\t\t\t\t\t\t\t\t\t<\/li>\n\t\t\t\t\t\t<\/ul>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-c52b793 e-flex e-con-boxed e-con e-parent\" data-id=\"c52b793\" data-element_type=\"container\" data-e-type=\"container\" id=\"parte-accidentes\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-0324785 elementor-widget elementor-widget-heading\" data-id=\"0324785\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Friendly declaration of accident<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-cae33c6 e-flex e-con-boxed e-con e-parent\" data-id=\"cae33c6\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-f803092 elementor-button-align-start elementor-widget__width-initial elementor-widget elementor-widget-form\" data-id=\"f803092\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;step_next_label&quot;:&quot;Next&quot;,&quot;step_previous_label&quot;:&quot;Previous&quot;,&quot;button_width&quot;:&quot;100&quot;,&quot;step_type&quot;:&quot;number_text&quot;,&quot;step_icon_shape&quot;:&quot;circle&quot;}\" data-widget_type=\"form.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<form class=\"elementor-form\" method=\"post\" name=\"Part accidents\" aria-label=\"Part accidents\">\n\t\t\t<input type=\"hidden\" name=\"post_id\" value=\"1581\"\/>\n\t\t\t<input type=\"hidden\" name=\"form_id\" value=\"f803092\"\/>\n\t\t\t<input type=\"hidden\" name=\"referer_title\" value=\"Previseguro\" \/>\n\n\t\t\t\n\t\t\t<div class=\"elementor-form-fields-wrapper elementor-labels-above\">\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_0566368 elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Contact information\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_2368c44 elementor-col-100\">\n\t\t\t\t\t<b>ALL FIELDS MARKED WITH * ARE REQUIRED<\/b>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_f891bca elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f891bca\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTAX ID\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_f891bca]\" id=\"form-field-field_f891bca\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-field_7c293a7 elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7c293a7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPhone\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input size=\"1\" type=\"tel\" name=\"form_fields[field_7c293a7]\" id=\"form-field-field_7c293a7\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" pattern=\"[0-9()#&amp;+*-=.]+\" title=\"Only numbers and phone characters (#, -, *, etc) are accepted.\">\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-email elementor-field-group elementor-column elementor-field-group-email elementor-col-33 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-email\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tE-mail address\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"email\" name=\"form_fields[email]\" id=\"form-field-email\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_9146361 elementor-col-70 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9146361\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t1. DATE OF ACCIDENT\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_9146361]\" id=\"form-field-field_9146361\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" required=\"required\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-time elementor-field-group elementor-column elementor-field-group-field_6ff4db5 elementor-col-30 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6ff4db5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAccident time\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<input type=\"time\" name=\"form_fields[field_6ff4db5]\" id=\"form-field-field_6ff4db5\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-time-field\" required=\"required\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_bccfcaa elementor-col-70 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bccfcaa\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t2. LOCATION (town, street, road, etc...)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_bccfcaa]\" id=\"form-field-field_bccfcaa\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_bbf8f90 elementor-col-25 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bbf8f90\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t3. VICTIMS\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_bbf8f90]\" id=\"form-field-field_bbf8f90\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_e6fc38b elementor-col-100\">\n\t\t\t\t\t4. PROPERTY DAMAGE\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_052a9b9 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_052a9b9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tVehicles other than A and B  \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_052a9b9-0\" name=\"form_fields[field_052a9b9]\" required=\"required\"> <label for=\"form-field-field_052a9b9-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_052a9b9-1\" name=\"form_fields[field_052a9b9]\" required=\"required\"> <label for=\"form-field-field_052a9b9-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_283304b elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_283304b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tObjects other than the vehicle\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  \"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_283304b-0\" name=\"form_fields[field_283304b]\" required=\"required\"> <label for=\"form-field-field_283304b-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_283304b-1\" name=\"form_fields[field_283304b]\" required=\"required\"> <label for=\"form-field-field_283304b-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_8c029e8 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8c029e8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t5. WITNESSES: Name, address and telephone number. Specify if they are A or B occupants\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_8c029e8]\" id=\"form-field-field_8c029e8\" rows=\"4\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_86d6f0b elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Vehicle A (own)\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-name elementor-col-100\">\n\t\t\t\t\t<h3><b>VEHICLE A (OWN)<\/b><\/h3>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_1b7433c elementor-col-100\">\n\t\t\t\t\t6. INSURED (See Insurance Policy)\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_c2472c5 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c2472c5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_c2472c5]\" id=\"form-field-field_c2472c5\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_11895c4 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_11895c4\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSurname\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_11895c4]\" id=\"form-field-field_11895c4\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_bb30ecd elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_bb30ecd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_bb30ecd]\" id=\"form-field-field_bb30ecd\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-number elementor-field-group elementor-column elementor-field-group-field_5139b9f elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5139b9f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t<input type=\"number\" name=\"form_fields[field_5139b9f]\" id=\"form-field-field_5139b9f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\" min=\"\" max=\"\" >\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_35d933b elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_35d933b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCountry\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_35d933b]\" id=\"form-field-field_35d933b\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_3b365cb elementor-col-100\">\n\t\t\t\t\t7. VEHICLE\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_36ea156 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_36ea156\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMake, model\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_36ea156]\" id=\"form-field-field_36ea156\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ddbf92d elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ddbf92d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRegistration\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ddbf92d]\" id=\"form-field-field_ddbf92d\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_2ca0438 elementor-col-50\">\n\t\t\t\t\t8. INSURANCE\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_7c80bf1 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_7c80bf1\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_7c80bf1]\" id=\"form-field-field_7c80bf1\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_57b1d56 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_57b1d56\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPolicy No.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_57b1d56]\" id=\"form-field-field_57b1d56\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_50f482d elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_50f482d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGreen Card No.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_50f482d]\" id=\"form-field-field_50f482d\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_b613156 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b613156\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tValid until\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_b613156]\" id=\"form-field-field_b613156\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d89a727 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d89a727\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCovers own damages\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d89a727]\" id=\"form-field-field_d89a727\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_1e8792e elementor-col-100\">\n\t\t\t\t\t9. DRIVER (see driver's license)\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_9c9940b elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_9c9940b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName and surname\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_9c9940b]\" id=\"form-field-field_9c9940b\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_4eaba59 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4eaba59\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_4eaba59]\" id=\"form-field-field_4eaba59\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ab4ec4f elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ab4ec4f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDriving license No.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ab4ec4f]\" id=\"form-field-field_ab4ec4f\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_120f59e elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_120f59e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCategory (A, B,...)  \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_120f59e]\" id=\"form-field-field_120f59e\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_96cf065 elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_96cf065\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIssued\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_96cf065]\" id=\"form-field-field_96cf065\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_68288dd elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_68288dd\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\ta\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_68288dd]\" id=\"form-field-field_68288dd\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_d59ae48 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d59ae48\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t11. DAMAGE ASSESSED\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_d59ae48]\" id=\"form-field-field_d59ae48\" rows=\"4\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_9f8626c elementor-col-100\">\n\t\t\t\t\t12. CIRCUMSTANCES. INDICATE \"YES\" IN EACH BOX AS APPROPRIATE\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_b95bd91 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b95bd91\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tI was parked\/stopped\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_b95bd91-0\" name=\"form_fields[field_b95bd91]\"> <label for=\"form-field-field_b95bd91-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_b95bd91-1\" name=\"form_fields[field_b95bd91]\"> <label for=\"form-field-field_b95bd91-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_b967635 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b967635\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tComing out of a parking lot\/ opening door\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_b967635-0\" name=\"form_fields[field_b967635]\"> <label for=\"form-field-field_b967635-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_b967635-1\" name=\"form_fields[field_b967635]\"> <label for=\"form-field-field_b967635-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_1c21ee2 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1c21ee2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tI was going to park\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_1c21ee2-0\" name=\"form_fields[field_1c21ee2]\"> <label for=\"form-field-field_1c21ee2-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_1c21ee2-1\" name=\"form_fields[field_1c21ee2]\"> <label for=\"form-field-field_1c21ee2-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_a731b79 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a731b79\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIt came out of a parking lot, a private place, a dirt road.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_a731b79-0\" name=\"form_fields[field_a731b79]\"> <label for=\"form-field-field_a731b79-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_a731b79-1\" name=\"form_fields[field_a731b79]\"> <label for=\"form-field-field_a731b79-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_3566089 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3566089\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tI was entering a parking lot, a private place, a dirt road.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_3566089-0\" name=\"form_fields[field_3566089]\"> <label for=\"form-field-field_3566089-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_3566089-1\" name=\"form_fields[field_3566089]\"> <label for=\"form-field-field_3566089-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_651bf81 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_651bf81\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEntered a rotating direction square\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_651bf81-0\" name=\"form_fields[field_651bf81]\"> <label for=\"form-field-field_651bf81-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_651bf81-1\" name=\"form_fields[field_651bf81]\"> <label for=\"form-field-field_651bf81-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_41781f9 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_41781f9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tI was driving in a square in a rotating direction.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_41781f9-0\" name=\"form_fields[field_41781f9]\"> <label for=\"form-field-field_41781f9-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_41781f9-1\" name=\"form_fields[field_41781f9]\"> <label for=\"form-field-field_41781f9-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_3d4e1ca elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3d4e1ca\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRear-end collision with the other vehicle traveling in the same direction and in the same lane.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_3d4e1ca-0\" name=\"form_fields[field_3d4e1ca]\"> <label for=\"form-field-field_3d4e1ca-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_3d4e1ca-1\" name=\"form_fields[field_3d4e1ca]\"> <label for=\"form-field-field_3d4e1ca-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_5596442 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5596442\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHe was driving in the same direction and in a different lane.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_5596442-0\" name=\"form_fields[field_5596442]\"> <label for=\"form-field-field_5596442-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_5596442-1\" name=\"form_fields[field_5596442]\"> <label for=\"form-field-field_5596442-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_998da3a elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_998da3a\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tChanging lanes\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_998da3a-0\" name=\"form_fields[field_998da3a]\"> <label for=\"form-field-field_998da3a-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_998da3a-1\" name=\"form_fields[field_998da3a]\"> <label for=\"form-field-field_998da3a-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_e8f07b9 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e8f07b9\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tForward\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_e8f07b9-0\" name=\"form_fields[field_e8f07b9]\"> <label for=\"form-field-field_e8f07b9-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_e8f07b9-1\" name=\"form_fields[field_e8f07b9]\"> <label for=\"form-field-field_e8f07b9-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_61b787b elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_61b787b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTurned right\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_61b787b-0\" name=\"form_fields[field_61b787b]\"> <label for=\"form-field-field_61b787b-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_61b787b-1\" name=\"form_fields[field_61b787b]\"> <label for=\"form-field-field_61b787b-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_c51f53c elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c51f53c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTurned left\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_c51f53c-0\" name=\"form_fields[field_c51f53c]\"> <label for=\"form-field-field_c51f53c-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_c51f53c-1\" name=\"form_fields[field_c51f53c]\"> <label for=\"form-field-field_c51f53c-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_0812a68 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_0812a68\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tReversed\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_0812a68-0\" name=\"form_fields[field_0812a68]\"> <label for=\"form-field-field_0812a68-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_0812a68-1\" name=\"form_fields[field_0812a68]\"> <label for=\"form-field-field_0812a68-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_834de69 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_834de69\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInvaded the area reserved for traffic in the opposite direction\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_834de69-0\" name=\"form_fields[field_834de69]\"> <label for=\"form-field-field_834de69-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_834de69-1\" name=\"form_fields[field_834de69]\"> <label for=\"form-field-field_834de69-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_511a8e2 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_511a8e2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tComing from the right (at a crossroads)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_511a8e2-0\" name=\"form_fields[field_511a8e2]\"> <label for=\"form-field-field_511a8e2-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_511a8e2-1\" name=\"form_fields[field_511a8e2]\"> <label for=\"form-field-field_511a8e2-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_c78cde2 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_c78cde2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFailure to obey a red light or red traffic signal\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_c78cde2-0\" name=\"form_fields[field_c78cde2]\"> <label for=\"form-field-field_c78cde2-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_c78cde2-1\" name=\"form_fields[field_c78cde2]\"> <label for=\"form-field-field_c78cde2-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_6fa105b elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Vehicle B (opposite)\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_0272be1 elementor-col-100\">\n\t\t\t\t\t<h3><b>VEHICLE B (OPPOSITE)<\/b><\/h3>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_2e5cf4d elementor-col-100\">\n\t\t\t\t\t6. INSURED (See Insurance Policy)\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_ac8d158 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ac8d158\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_ac8d158]\" id=\"form-field-field_ac8d158\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_10e6c52 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_10e6c52\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tSurname\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_10e6c52]\" id=\"form-field-field_10e6c52\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_40041df elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_40041df\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_40041df]\" id=\"form-field-field_40041df\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_41ab6a2 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_41ab6a2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCP\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_41ab6a2]\" id=\"form-field-field_41ab6a2\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_643cd4c elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_643cd4c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCountry\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_643cd4c]\" id=\"form-field-field_643cd4c\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_bdc8c13 elementor-col-100\">\n\t\t\t\t\t7. VEHICLE\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_e9c7a46 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_e9c7a46\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tMake, model\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_e9c7a46]\" id=\"form-field-field_e9c7a46\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_27d8d0e elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_27d8d0e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRegistration\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_27d8d0e]\" id=\"form-field-field_27d8d0e\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_2d50fdd elementor-col-100\">\n\t\t\t\t\t8. INSURANCE\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_fb8b1a8 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_fb8b1a8\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_fb8b1a8]\" id=\"form-field-field_fb8b1a8\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_67f1a16 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_67f1a16\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tPolicy No.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_67f1a16]\" id=\"form-field-field_67f1a16\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a9e3466 elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a9e3466\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tGreen Card No.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a9e3466]\" id=\"form-field-field_a9e3466\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-date elementor-field-group elementor-column elementor-field-group-field_97d63cb elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_97d63cb\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tValid until\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\n\t\t<input type=\"date\" name=\"form_fields[field_97d63cb]\" id=\"form-field-field_97d63cb\" class=\"elementor-field elementor-size-sm  elementor-field-textual elementor-date-field\" pattern=\"[0-9]{4}-[0-9]{2}-[0-9]{2}\">\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_637854b elementor-col-50\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_637854b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCovers own damages\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_637854b]\" id=\"form-field-field_637854b\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_a6b8c4a elementor-col-100\">\n\t\t\t\t\t9. DRIVER (see driver's license)\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_d7e7b82 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d7e7b82\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tName and surname\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_d7e7b82]\" id=\"form-field-field_d7e7b82\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_b1ff698 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_b1ff698\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tAddress\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_b1ff698]\" id=\"form-field-field_b1ff698\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_a8ad499 elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_a8ad499\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tDriving license No.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_a8ad499]\" id=\"form-field-field_a8ad499\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_6c4464e elementor-col-50 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6c4464e\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tCategory (A, B,...)  \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_6c4464e]\" id=\"form-field-field_6c4464e\" class=\"elementor-field elementor-size-sm  elementor-field-textual\" required=\"required\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_aeb1a6d elementor-col-30\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_aeb1a6d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIssued\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_aeb1a6d]\" id=\"form-field-field_aeb1a6d\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-text elementor-field-group elementor-column elementor-field-group-field_38e06df elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_38e06df\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\ta\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t<input size=\"1\" type=\"text\" name=\"form_fields[field_38e06df]\" id=\"form-field-field_38e06df\" class=\"elementor-field elementor-size-sm  elementor-field-textual\">\n\t\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_2dad2b7 elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2dad2b7\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\t11. DAMAGE ASSESSED\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_2dad2b7]\" id=\"form-field-field_2dad2b7\" rows=\"4\" required=\"required\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_83e7c72 elementor-col-100\">\n\t\t\t\t\t12. CIRCUMSTANCES. INDICATE \"YES\" IN EACH BOX AS APPROPRIATE\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_1f280c2 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1f280c2\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tI was parked\/stopped\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_1f280c2-0\" name=\"form_fields[field_1f280c2]\"> <label for=\"form-field-field_1f280c2-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_1f280c2-1\" name=\"form_fields[field_1f280c2]\"> <label for=\"form-field-field_1f280c2-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_926b1bf elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_926b1bf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tComing out of a parking lot\/ opening door\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_926b1bf-0\" name=\"form_fields[field_926b1bf]\"> <label for=\"form-field-field_926b1bf-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_926b1bf-1\" name=\"form_fields[field_926b1bf]\"> <label for=\"form-field-field_926b1bf-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_f656dcf elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_f656dcf\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tI was going to park\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_f656dcf-0\" name=\"form_fields[field_f656dcf]\"> <label for=\"form-field-field_f656dcf-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_f656dcf-1\" name=\"form_fields[field_f656dcf]\"> <label for=\"form-field-field_f656dcf-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_580a5e6 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_580a5e6\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIt came out of a parking lot, a private place, a dirt road.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_580a5e6-0\" name=\"form_fields[field_580a5e6]\"> <label for=\"form-field-field_580a5e6-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_580a5e6-1\" name=\"form_fields[field_580a5e6]\"> <label for=\"form-field-field_580a5e6-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_99722ff elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_99722ff\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tI was entering a parking lot, a private place, a dirt road.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_99722ff-0\" name=\"form_fields[field_99722ff]\"> <label for=\"form-field-field_99722ff-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_99722ff-1\" name=\"form_fields[field_99722ff]\"> <label for=\"form-field-field_99722ff-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_2c2cb97 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_2c2cb97\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tEntering a rotating direction square\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_2c2cb97-0\" name=\"form_fields[field_2c2cb97]\"> <label for=\"form-field-field_2c2cb97-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_2c2cb97-1\" name=\"form_fields[field_2c2cb97]\"> <label for=\"form-field-field_2c2cb97-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_ca72806 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_ca72806\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tI was driving in a square in a rotating direction.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_ca72806-0\" name=\"form_fields[field_ca72806]\"> <label for=\"form-field-field_ca72806-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_ca72806-1\" name=\"form_fields[field_ca72806]\"> <label for=\"form-field-field_ca72806-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_1f3d956 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_1f3d956\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tRear-end collision with another vehicle traveling in the same direction and in the same lane.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_1f3d956-0\" name=\"form_fields[field_1f3d956]\"> <label for=\"form-field-field_1f3d956-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_1f3d956-1\" name=\"form_fields[field_1f3d956]\"> <label for=\"form-field-field_1f3d956-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_5017750 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5017750\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tHe was driving in the same direction and in a different lane.\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_5017750-0\" name=\"form_fields[field_5017750]\"> <label for=\"form-field-field_5017750-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_5017750-1\" name=\"form_fields[field_5017750]\"> <label for=\"form-field-field_5017750-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_74f6c6f elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_74f6c6f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tChanging lanes\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_74f6c6f-0\" name=\"form_fields[field_74f6c6f]\"> <label for=\"form-field-field_74f6c6f-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_74f6c6f-1\" name=\"form_fields[field_74f6c6f]\"> <label for=\"form-field-field_74f6c6f-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_3d897be elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_3d897be\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tForward\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_3d897be-0\" name=\"form_fields[field_3d897be]\"> <label for=\"form-field-field_3d897be-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_3d897be-1\" name=\"form_fields[field_3d897be]\"> <label for=\"form-field-field_3d897be-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_8299e1f elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_8299e1f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTurned right\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_8299e1f-0\" name=\"form_fields[field_8299e1f]\"> <label for=\"form-field-field_8299e1f-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_8299e1f-1\" name=\"form_fields[field_8299e1f]\"> <label for=\"form-field-field_8299e1f-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_35312d5 elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_35312d5\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tTurned left\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_35312d5-0\" name=\"form_fields[field_35312d5]\"> <label for=\"form-field-field_35312d5-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_35312d5-1\" name=\"form_fields[field_35312d5]\"> <label for=\"form-field-field_35312d5-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_4827e5f elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_4827e5f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tReversed\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_4827e5f-0\" name=\"form_fields[field_4827e5f]\"> <label for=\"form-field-field_4827e5f-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_4827e5f-1\" name=\"form_fields[field_4827e5f]\"> <label for=\"form-field-field_4827e5f-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_820e8df elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_820e8df\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tInvaded the part reserved for traffic in the opposite direction\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_820e8df-0\" name=\"form_fields[field_820e8df]\"> <label for=\"form-field-field_820e8df-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_820e8df-1\" name=\"form_fields[field_820e8df]\"> <label for=\"form-field-field_820e8df-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_6136b0d elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6136b0d\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tComing from the right (at a crossroads)\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_6136b0d-0\" name=\"form_fields[field_6136b0d]\"> <label for=\"form-field-field_6136b0d-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_6136b0d-1\" name=\"form_fields[field_6136b0d]\"> <label for=\"form-field-field_6136b0d-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_34e1d9b elementor-col-20\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_34e1d9b\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tFailure to obey a red light or red traffic signal\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_34e1d9b-0\" name=\"form_fields[field_34e1d9b]\"> <label for=\"form-field-field_34e1d9b-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_34e1d9b-1\" name=\"form_fields[field_34e1d9b]\"> <label for=\"form-field-field_34e1d9b-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-step elementor-field-group elementor-column elementor-field-group-field_2f26b8b elementor-col-100\">\n\t\t\t\t\t\t\t<div class=\"e-field-step elementor-hidden\" data-label=\"Send to\" data-previousButton=\"\" data-nextButton=\"\" data-iconUrl=\"\" data-iconLibrary=\"fas fa-star\" data-icon=\"\" ><\/div>\n\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_8d012d8 elementor-col-100\">\n\t\t\t\t\t<h3><b>SEND<\/b><\/h3>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_6033242 elementor-col-20 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_6033242\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tIs it signed by both of you?  \t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<div class=\"elementor-field-subgroup  elementor-subgroup-inline\"><span class=\"elementor-field-option\"><input type=\"radio\" value=\"Yes\" id=\"form-field-field_6033242-0\" name=\"form_fields[field_6033242]\" required=\"required\"> <label for=\"form-field-field_6033242-0\">Yes<\/label><\/span><span class=\"elementor-field-option\"><input type=\"radio\" value=\"No\" id=\"form-field-field_6033242-1\" name=\"form_fields[field_6033242]\" required=\"required\"> <label for=\"form-field-field_6033242-1\">No<\/label><\/span><\/div>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-textarea elementor-field-group elementor-column elementor-field-group-field_d89935c elementor-col-100\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_d89935c\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tComments to the brokerage\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t<textarea class=\"elementor-field-textual elementor-field  elementor-size-sm\" name=\"form_fields[field_d89935c]\" id=\"form-field-field_d89935c\" rows=\"4\"><\/textarea>\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-type-acceptance elementor-field-group elementor-column elementor-field-group-field_5c7279f elementor-col-100 elementor-field-required elementor-mark-required\">\n\t\t\t\t\t\t\t\t\t\t\t\t<label for=\"form-field-field_5c7279f\" class=\"elementor-field-label\">\n\t\t\t\t\t\t\t\tData protection\t\t\t\t\t\t\t<\/label>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-subgroup\">\n\t\t\t<span class=\"elementor-field-option\">\n\t\t\t\t<input type=\"checkbox\" name=\"form_fields[field_5c7279f]\" id=\"form-field-field_5c7279f\" class=\"elementor-field elementor-size-sm  elementor-acceptance-field\" required=\"required\" checked=\"checked\">\n\t\t\t\t<label for=\"form-field-field_5c7279f\">I have read and accept the <a href=\"https:\/\/www.previseguro.es\/en\/?page_id=1559\">Privacy Policy<\/a><\/label>\t\t\t<\/span>\n\t\t<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t<div class=\"elementor-field-group elementor-column elementor-field-type-submit elementor-col-100 e-form__buttons\">\n\t\t\t\t\t<button class=\"elementor-button elementor-size-sm\" type=\"submit\">\n\t\t\t\t\t\t<span class=\"elementor-button-content-wrapper\">\n\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t\t<span class=\"elementor-button-text\">Send part<\/span>\n\t\t\t\t\t\t\t\t\t\t\t\t\t<\/span>\n\t\t\t\t\t<\/button>\n\t\t\t\t<\/div>\n\t\t\t<\/div>\n\t\t<\/form>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Accident report Select one of these three options: I want to download a vehicle accident report template in PDF for printing. I want to fill out a vehicle accident report directly on the web. I want to report a different type of claim on the web. Friendly declaration of accident<\/p>\n","protected":false},"author":3,"featured_media":1482,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_joinchat":[],"footnotes":""},"class_list":["post-1581","page","type-page","status-publish","has-post-thumbnail","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Accident report -% Previseguro% - Insurance Brokerage<\/title>\n<meta name=\"description\" content=\"Online accident report. 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