{"id":3781,"date":"2026-01-23T10:04:55","date_gmt":"2026-01-23T18:04:55","guid":{"rendered":"https:\/\/todayna.org\/todaynawp\/?page_id=3781"},"modified":"2026-01-23T10:09:20","modified_gmt":"2026-01-23T18:09:20","slug":"insurance-application","status":"publish","type":"page","link":"https:\/\/todayna.org\/todaynawp\/insurance-application\/","title":{"rendered":"Insurance Application"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_10' >\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Application for Event Insurance<\/h2>\n                            <p class='gform_description'>For your event to be posted you must fill out the application form and purchase event insurance. After you complete the form and submit it, the special worker will call you at the number you have provided during regular office hours and will go over any entries you were uncertain of or, are incomplete, and take your payment over the phone. We offer this as a convenience with the alternative method of doing it in person at the Regional Service Office in Monrovia.<br>\ud83e\udd14If you choose to secure event insurance from an outside source, you must provide your Certificate of Insurance prior to your event being posted.<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_10'  action='\/todaynawp\/wp-json\/wp\/v2\/pages\/3781' data-formid='10' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_10' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_10_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_10_1'>\n                            \n                            <span id='input_10_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_10_1_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_10_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                <\/span>\n                            \n                            <span id='input_10_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_10_1_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_10_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_10_3\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_3'>Today&#039;s Date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_3' id='input_10_3' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_10_3_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_10_3_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_10_3' class='gform_hidden' value='https:\/\/todayna.org\/todaynawp\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_10_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_4'>Your Phone Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_10_4' type='tel' value='' class='small'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_10_6\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Information for Certificate<\/h3><\/div><div id=\"field_10_5\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_5'>Certificate Holder<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_10_5' type='text' value='' class='large'  aria-describedby=\"gfield_description_10_5\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_10_5'>The name of your venue.<\/div><\/div><fieldset id=\"field_10_7\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_10_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_10_7_1_container' >\n                                        <input type='text' name='input_7.1' id='input_10_7_1' value=''    aria-required='true'    \/>\n                                        <label for='input_10_7_1' id='input_10_7_1_label' class='gform-field-label gform-field-label--type-sub '>the address of your venue<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_10_7_2_container' >\n                                        <input type='text' name='input_7.2' id='input_10_7_2' value=''     aria-required='false'   \/>\n                                        <label for='input_10_7_2' id='input_10_7_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_10_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_10_7_3' value=''    aria-required='true'    \/>\n                                    <label for='input_10_7_3' id='input_10_7_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_10_7_4_container' >\n                                        <select name='input_7.4' id='input_10_7_4'     aria-required='true'    ><option value='' ><\/option><option value='Alabama' >Alabama<\/option><option value='Alaska' >Alaska<\/option><option value='American Samoa' >American Samoa<\/option><option value='Arizona' >Arizona<\/option><option value='Arkansas' >Arkansas<\/option><option value='California' selected='selected'>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='Guam' >Guam<\/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='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Ohio' >Ohio<\/option><option value='Oklahoma' >Oklahoma<\/option><option value='Oregon' >Oregon<\/option><option value='Pennsylvania' >Pennsylvania<\/option><option value='Puerto Rico' >Puerto Rico<\/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='U.S. Virgin Islands' >U.S. Virgin Islands<\/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><option value='Armed Forces Americas' >Armed Forces Americas<\/option><option value='Armed Forces Europe' >Armed Forces Europe<\/option><option value='Armed Forces Pacific' >Armed Forces Pacific<\/option><\/select>\n                                        <label for='input_10_7_4' id='input_10_7_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_10_7_5_container' >\n                                    <input type='text' name='input_7.5' id='input_10_7_5' value=''    aria-required='true'    \/>\n                                    <label for='input_10_7_5' id='input_10_7_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_7.6' id='input_10_7_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><div class='gfield_description' id='gfield_description_10_7'>The address of your venue.<\/div><\/fieldset><div id=\"field_10_9\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_9'>Attention:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_9' id='input_10_9' type='email' value='' class='small'     aria-invalid=\"false\" aria-describedby=\"gfield_description_10_9\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_10_9'>Add email address if there is someone you were directed to provide this to.<\/div><\/div><fieldset id=\"field_10_10\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Required Coverage<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_10'><div class='gchoice gchoice_10_10_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_10.1' type='checkbox'  value='General  Aggregate Liability (2,000,000)'  id='choice_10_10_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_10_10_1' id='label_10_10_1' class='gform-field-label gform-field-label--type-inline'>General  Aggregate Liability (2,000,000)<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_10_11\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Special Endorsement<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_11'><div class='gchoice gchoice_10_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='Additional Insured'  id='choice_10_11_1'   aria-describedby=\"gfield_description_10_11\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_10_11_1' id='label_10_11_1' class='gform-field-label gform-field-label--type-inline'>Additional Insured<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_10_11'>If you have additional insured needs (uncommon).<\/div><\/fieldset><div id=\"field_10_12\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Handling Instructions<\/h3><\/div><div id=\"field_10_14\" class=\"gfield gfield--type-email gfield--input-type-email field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_14'>Certificate Holder Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_14' id='input_10_14' type='email' value='' class='large'     aria-invalid=\"false\" aria-describedby=\"gfield_description_10_14\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_10_14'>Email to certificate holder here<\/div><\/div><div id=\"field_10_15\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_15'>Email to Me<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_15' id='input_10_15' type='email' value='' class='medium'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_10_15\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_10_15'>Put in your email address.<\/div><\/div><div id=\"field_10_16\" class=\"gfield gfield--type-textarea gfield--input-type-textarea field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_16'>Comments\/Specific Additional Insured Requirements<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_16' id='input_10_16' class='textarea large'  aria-describedby=\"gfield_description_10_16\"  placeholder='Here is where you can tell us if there is any special day or time that you are available to get a phone call to discuss payment arrangements or any issues with your application. The RSO is closed on Mondays and Tuesdays, as well as Holidays.'  aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_10_16'>If your venue requires any additional needs you probably already know.<\/div><\/div><fieldset id=\"field_10_17\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Payment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_10_17'><div class='gchoice gchoice_10_17_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_17.1' type='checkbox'  value='I will call the RSO  (626.359.0084) and make payment arrangements'  id='choice_10_17_1'   aria-describedby=\"gfield_description_10_17\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_10_17_1' id='label_10_17_1' class='gform-field-label gform-field-label--type-inline'>I will call the RSO  (626.359.0084) and make payment arrangements<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_10_17'>Call during office hours and speak to the special worker.<\/div><\/fieldset><div id=\"field_10_19\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >Use this link to call the special worker now. You will be able to finalize your insurance application and provide payment at this time to avoid having to follow up later.\n<a href=\"tel:16263590084\">Call Us Now<\/a><\/div><div id=\"field_10_18\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_10_18'>CAPTCHA<\/label><div id='input_10_18' class='ginput_container ginput_recaptcha' data-sitekey='6Lc5RTAUAAAAAOXs8NnLrdgN4cxUId9IwR9nyJWZ'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_10' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' 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