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Sep 20th, 2019
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  1. ---
  2. FieldType: Button
  3. FieldName: undefined
  4. FieldNameAlt: undefined
  5. FieldFlags: 0
  6. FieldJustification: Left
  7. FieldStateOption: Off
  8. FieldStateOption: On
  9. ---
  10. FieldType: Button
  11. FieldName: undefined_2
  12. FieldNameAlt: undefined
  13. FieldFlags: 0
  14. FieldJustification: Left
  15. FieldStateOption: Off
  16. FieldStateOption: On
  17. ---
  18. FieldType: Button
  19. FieldName: undefined_3
  20. FieldNameAlt: undefined
  21. FieldFlags: 0
  22. FieldJustification: Left
  23. FieldStateOption: Off
  24. FieldStateOption: On
  25. ---
  26. FieldType: Button
  27. FieldName: South Dakota 1000
  28. FieldNameAlt: South Dakota ($10.00
  29. FieldFlags: 0
  30. FieldJustification: Left
  31. FieldStateOption: Off
  32. FieldStateOption: On
  33. ---
  34. FieldType: Button
  35. FieldName: undefined_4
  36. FieldNameAlt: undefined
  37. FieldFlags: 0
  38. FieldJustification: Left
  39. FieldStateOption: Off
  40. FieldStateOption: On
  41. ---
  42. FieldType: Button
  43. FieldName: Kentucky 4000
  44. FieldNameAlt: Kentucky ($40.00
  45. FieldFlags: 0
  46. FieldJustification: Left
  47. FieldStateOption: Off
  48. FieldStateOption: On
  49. ---
  50. FieldType: Button
  51. FieldName: undefined_5
  52. FieldNameAlt: undefined
  53. FieldFlags: 0
  54. FieldJustification: Left
  55. FieldStateOption: Off
  56. FieldStateOption: On
  57. ---
  58. FieldType: Button
  59. FieldName: undefined_6
  60. FieldNameAlt: undefined
  61. FieldFlags: 0
  62. FieldJustification: Left
  63. FieldStateOption: Off
  64. FieldStateOption: On
  65. ---
  66. FieldType: Button
  67. FieldName: undefined_7
  68. FieldNameAlt: undefined
  69. FieldFlags: 0
  70. FieldJustification: Left
  71. FieldStateOption: Off
  72. FieldStateOption: On
  73. ---
  74. FieldType: Button
  75. FieldName: undefined_8
  76. FieldNameAlt: undefined
  77. FieldFlags: 0
  78. FieldJustification: Left
  79. FieldStateOption: Off
  80. FieldStateOption: On
  81. ---
  82. FieldType: Button
  83. FieldName: undefined_9
  84. FieldNameAlt: undefined
  85. FieldFlags: 0
  86. FieldJustification: Left
  87. FieldStateOption: Off
  88. FieldStateOption: On
  89. ---
  90. FieldType: Button
  91. FieldName: undefined_10
  92. FieldNameAlt: undefined
  93. FieldFlags: 0
  94. FieldJustification: Left
  95. FieldStateOption: Off
  96. FieldStateOption: On
  97. ---
  98. FieldType: Button
  99. FieldName: undefined_11
  100. FieldNameAlt: undefined
  101. FieldFlags: 0
  102. FieldJustification: Left
  103. FieldStateOption: Off
  104. FieldStateOption: On
  105. ---
  106. FieldType: Button
  107. FieldName: undefined_12
  108. FieldNameAlt: undefined
  109. FieldFlags: 0
  110. FieldJustification: Left
  111. FieldStateOption: Off
  112. FieldStateOption: On
  113. ---
  114. FieldType: Button
  115. FieldName: North Carolina
  116. FieldNameAlt: North Carolina
  117. FieldFlags: 0
  118. FieldJustification: Left
  119. FieldStateOption: Off
  120. FieldStateOption: On
  121. ---
  122. FieldType: Button
  123. FieldName: Cancer Plan 1000
  124. FieldNameAlt: Cancer Plan ($10.00
  125. FieldFlags: 0
  126. FieldJustification: Left
  127. FieldStateOption: Off
  128. FieldStateOption: On
  129. ---
  130. FieldType: Button
  131. FieldName: Health 1000
  132. FieldNameAlt: Health ($10.00
  133. FieldFlags: 0
  134. FieldJustification: Left
  135. FieldStateOption: Off
  136. FieldStateOption: On
  137. ---
  138. FieldType: Button
  139. FieldName: Life 1000
  140. FieldNameAlt: Life ($10.00
  141. FieldFlags: 0
  142. FieldJustification: Left
  143. FieldStateOption: Off
  144. FieldStateOption: On
  145. ---
  146. FieldType: Button
  147. FieldName: Utah 000_2
  148. FieldNameAlt: Utah ($0.00
  149. FieldFlags: 0
  150. FieldJustification: Left
  151. FieldStateOption: Off
  152. FieldStateOption: On
  153. ---
  154. FieldType: Button
  155. FieldName: Connecticut 8000
  156. FieldNameAlt: Connecticut ($80.00
  157. FieldFlags: 0
  158. FieldJustification: Left
  159. FieldStateOption: Off
  160. FieldStateOption: On
  161. ---
  162. FieldType: Button
  163. FieldName: Maryland 000
  164. FieldNameAlt: Maryland ($0.00
  165. FieldFlags: 0
  166. FieldJustification: Left
  167. FieldStateOption: Off
  168. FieldStateOption: On
  169. ---
  170. FieldType: Button
  171. FieldName: North Dakota 1000
  172. FieldNameAlt: North Dakota ($10.00
  173. FieldFlags: 0
  174. FieldJustification: Left
  175. FieldStateOption: Off
  176. FieldStateOption: On
  177. ---
  178. FieldType: Button
  179. FieldName: Vermont 6000
  180. FieldNameAlt: Vermont ($60.00
  181. FieldFlags: 0
  182. FieldJustification: Left
  183. FieldStateOption: Off
  184. FieldStateOption: On
  185. ---
  186. FieldType: Button
  187. FieldName: undefined_13
  188. FieldNameAlt: undefined
  189. FieldFlags: 0
  190. FieldJustification: Left
  191. FieldStateOption: Off
  192. FieldStateOption: On
  193. ---
  194. FieldType: Button
  195. FieldName: undefined_14
  196. FieldNameAlt: undefined
  197. FieldFlags: 0
  198. FieldJustification: Left
  199. FieldStateOption: Off
  200. FieldStateOption: On
  201. ---
  202. FieldType: Button
  203. FieldName: Ohio 000
  204. FieldNameAlt: Ohio** ($0.00
  205. FieldFlags: 0
  206. FieldJustification: Left
  207. FieldStateOption: Off
  208. FieldStateOption: On
  209. ---
  210. FieldType: Button
  211. FieldName: Health 1500
  212. FieldNameAlt: Health ($15.00
  213. FieldFlags: 0
  214. FieldJustification: Left
  215. FieldStateOption: Off
  216. FieldStateOption: On
  217. ---
  218. FieldType: Button
  219. FieldName: Life 1500
  220. FieldNameAlt: Life ($15.00
  221. FieldFlags: 0
  222. FieldJustification: Left
  223. FieldStateOption: Off
  224. FieldStateOption: On
  225. ---
  226. FieldType: Button
  227. FieldName: undefined_15
  228. FieldNameAlt: undefined
  229. FieldFlags: 0
  230. FieldJustification: Left
  231. FieldStateOption: Off
  232. FieldStateOption: On
  233. ---
  234. FieldType: Button
  235. FieldName: Georgia 1000
  236. FieldNameAlt: Georgia ($10.00
  237. FieldFlags: 0
  238. FieldJustification: Left
  239. FieldStateOption: Off
  240. FieldStateOption: On
  241. ---
  242. FieldType: Button
  243. FieldName: Michigan 1000
  244. FieldNameAlt: Michigan ($10.00
  245. FieldFlags: 0
  246. FieldJustification: Left
  247. FieldStateOption: Off
  248. FieldStateOption: On
  249. ---
  250. FieldType: Button
  251. FieldName: Oklahoma 3000
  252. FieldNameAlt: Oklahoma ($30.00
  253. FieldFlags: 0
  254. FieldJustification: Left
  255. FieldStateOption: Off
  256. FieldStateOption: On
  257. ---
  258. FieldType: Button
  259. FieldName: Washington 2000
  260. FieldNameAlt: Washington ($20.00
  261. FieldFlags: 0
  262. FieldJustification: Left
  263. FieldStateOption: Off
  264. FieldStateOption: On
  265. ---
  266. FieldType: Button
  267. FieldName: undefined_16
  268. FieldNameAlt: undefined
  269. FieldFlags: 0
  270. FieldJustification: Left
  271. FieldStateOption: Off
  272. FieldStateOption: On
  273. ---
  274. FieldType: Button
  275. FieldName: Mississippi 2500
  276. FieldNameAlt: Mississippi ($25.00
  277. FieldFlags: 0
  278. FieldJustification: Left
  279. FieldStateOption: Off
  280. FieldStateOption: On
  281. ---
  282. FieldType: Button
  283. FieldName: undefined_17
  284. FieldNameAlt: undefined
  285. FieldFlags: 0
  286. FieldJustification: Left
  287. FieldStateOption: Off
  288. FieldStateOption: On
  289. ---
  290. FieldType: Button
  291. FieldName: West Virginia 2500
  292. FieldNameAlt: West Virginia ($ 25.00
  293. FieldFlags: 0
  294. FieldJustification: Left
  295. FieldStateOption: Off
  296. FieldStateOption: On
  297. ---
  298. FieldType: Button
  299. FieldName: undefined_18
  300. FieldNameAlt: undefined
  301. FieldFlags: 0
  302. FieldJustification: Left
  303. FieldStateOption: Off
  304. FieldStateOption: On
  305. ---
  306. FieldType: Button
  307. FieldName: undefined_19
  308. FieldNameAlt: undefined
  309. FieldFlags: 0
  310. FieldJustification: Left
  311. FieldStateOption: Off
  312. FieldStateOption: On
  313. ---
  314. FieldType: Button
  315. FieldName: undefined_20
  316. FieldNameAlt: undefined
  317. FieldFlags: 0
  318. FieldJustification: Left
  319. FieldStateOption: Off
  320. FieldStateOption: On
  321. ---
  322. FieldType: Button
  323. FieldName: Wisconsin 1600
  324. FieldNameAlt: Wisconsin ($16.00
  325. FieldFlags: 0
  326. FieldJustification: Left
  327. FieldStateOption: Off
  328. FieldStateOption: On
  329. ---
  330. FieldType: Button
  331. FieldName: Indiana 000
  332. FieldNameAlt: Indiana ($0.00
  333. FieldFlags: 0
  334. FieldJustification: Left
  335. FieldStateOption: Off
  336. FieldStateOption: On
  337. ---
  338. FieldType: Button
  339. FieldName: Montana 000
  340. FieldNameAlt: Montana ($0.00
  341. FieldFlags: 0
  342. FieldJustification: Left
  343. FieldStateOption: Off
  344. FieldStateOption: On
  345. ---
  346. FieldType: Button
  347. FieldName: Rhode Island 000
  348. FieldNameAlt: Rhode Island ($0.00
  349. FieldFlags: 0
  350. FieldJustification: Left
  351. FieldStateOption: Off
  352. FieldStateOption: On
  353. ---
  354. FieldType: Button
  355. FieldName: Wyoming 1500
  356. FieldNameAlt: Wyoming ($ 15.00
  357. FieldFlags: 0
  358. FieldJustification: Left
  359. FieldStateOption: Off
  360. FieldStateOption: On
  361. ---
  362. FieldType: Button
  363. FieldName: undefined_21
  364. FieldNameAlt: undefined
  365. FieldFlags: 0
  366. FieldJustification: Left
  367. FieldStateOption: Off
  368. FieldStateOption: On
  369. ---
  370. FieldType: Button
  371. FieldName: Nebraska 800
  372. FieldNameAlt: Nebraska ($8.00
  373. FieldFlags: 0
  374. FieldJustification: Left
  375. FieldStateOption: Off
  376. FieldStateOption: On
  377. ---
  378. FieldType: Button
  379. FieldName: South Carolina 000
  380. FieldNameAlt: South Carolina ($0.00
  381. FieldFlags: 0
  382. FieldJustification: Left
  383. FieldStateOption: Off
  384. FieldStateOption: On
  385. ---
  386. FieldType: Text
  387. FieldName: How did you hear about Equitable
  388. FieldNameAlt: How did you hear about Equitable
  389. FieldFlags: 0
  390. FieldJustification: Left
  391. ---
  392. FieldType: Text
  393. FieldName: Please Explain
  394. FieldNameAlt: Please Explain
  395. FieldFlags: 0
  396. FieldJustification: Left
  397. ---
  398. FieldType: Text
  399. FieldName: State Appointment Type AmountRow1
  400. FieldNameAlt: State Appointment Type Amount_Row_1
  401. FieldFlags: 0
  402. FieldJustification: Center
  403. ---
  404. FieldType: Text
  405. FieldName: State Appointment Type AmountRow2
  406. FieldNameAlt: State Appointment Type Amount_Row_2
  407. FieldFlags: 0
  408. FieldJustification: Center
  409. ---
  410. FieldType: Text
  411. FieldName: State Appointment Type AmountRow3
  412. FieldNameAlt: State Appointment Type Amount_Row_3
  413. FieldFlags: 0
  414. FieldJustification: Center
  415. ---
  416. FieldType: Text
  417. FieldName: Text1
  418. FieldFlags: 0
  419. FieldJustification: Left
  420. ---
  421. FieldType: Text
  422. FieldName: The total amount of
  423. FieldNameAlt: The total amount of
  424. FieldFlags: 0
  425. FieldJustification: Left
  426. ---
  427. FieldType: Text
  428. FieldName: will be electronically transferred from your checking account ending in
  429. FieldNameAlt: will be electronically transferred from your checking account ending in
  430. FieldFlags: 0
  431. FieldJustification: Left
  432. ---
  433. FieldType: Text
  434. FieldName: as a onetime payment for appointment fees
  435. FieldNameAlt: as a one-time payment for appointment fees
  436. FieldFlags: 0
  437. FieldJustification: Left
  438. ---
  439. FieldType: Text
  440. FieldName: Upon appointment I
  441. FieldNameAlt: Upon appointment, I
  442. FieldFlags: 0
  443. FieldJustification: Left
  444. ---
  445. FieldType: Text
  446. FieldName: Above account as a onetime payment of appointment fees in the amountof
  447. FieldNameAlt: Above account as a one-time payment of appointment fees in the amountof
  448. FieldFlags: 0
  449. FieldJustification: Left
  450. ---
  451. FieldType: Text
  452. FieldName: undefined_22
  453. FieldNameAlt: undefined
  454. FieldFlags: 0
  455. FieldJustification: Left
  456. ---
  457. FieldType: Button
  458. FieldName: I Agree
  459. FieldNameAlt: I Agree
  460. FieldFlags: 0
  461. FieldJustification: Left
  462. FieldStateOption: Off
  463. FieldStateOption: On
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