{"id":38552,"date":"2023-11-25T16:48:59","date_gmt":"2023-11-25T21:48:59","guid":{"rendered":"https:\/\/www.sec.coop\/?page_id=38552"},"modified":"2023-12-05T00:20:40","modified_gmt":"2023-12-05T05:20:40","slug":"insurance-claim-form","status":"publish","type":"page","link":"https:\/\/www.sec.coop\/account-services\/insurance-claim-form\/","title":{"rendered":"Insurance Claim Form"},"content":{"rendered":"<h2>Interruption of Electric Service Claim for Damage or Loss<\/h2>\n<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_unknown gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_24' ><form method='post' enctype='multipart\/form-data'  id='gform_24'  action='\/wp-json\/wp\/v2\/pages\/38552' data-formid='24' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_24' class='gform_fields top_label form_sublabel_above description_above validation_below'><fieldset id=\"field_24_1\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_24_1\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Name of Account Holder<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 has_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_24_1'>\n                            \n                            <span id='input_24_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_24_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_1.3' id='input_24_1_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            <span id='input_24_1_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_24_1_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                    <input type='text' name='input_1.4' id='input_24_1_4' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            <span id='input_24_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_24_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_1.6' id='input_24_1_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            <span id='input_24_1_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                        <label for='input_24_1_8' class='gform-field-label gform-field-label--type-sub '>Suffix<\/label>\n                                                        <input type='text' name='input_1.8' id='input_24_1_8' value=''   aria-required='false'     \/>\n                                                    <\/span>\n                        <\/div><\/fieldset><div id=\"field_24_3\" class=\"gfield gfield--type-text gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_24_3\" ><label class='gfield_label gform-field-label' for='input_24_3'>SEC Account Number<\/label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_24_3' type='text' value='' class='large'      aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_24_4\" class=\"gfield gfield--type-email gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_24_4\" ><label class='gfield_label gform-field-label' for='input_24_4'>Email<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_4' id='input_24_4' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_24_5\" class=\"gfield gfield--type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_24_5\" ><label class='gfield_label gform-field-label' for='input_24_5'>Home Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_24_5' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_24_7\" class=\"gfield gfield--type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_24_7\" ><label class='gfield_label gform-field-label' for='input_24_7'>Cell Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_24_7' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_24_6\" class=\"gfield gfield--type-phone gfield--width-third field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_24_6\" ><label class='gfield_label gform-field-label' for='input_24_6'>Work Phone<\/label><div class='ginput_container ginput_container_phone'><input name='input_6' id='input_24_6' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_24_8\" class=\"gfield gfield--type-name gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_24_8\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Person Reporting Damage<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 has_middle_name has_last_name has_suffix gf_name_has_4 ginput_container_name gform-grid-row' id='input_24_8'>\n                            \n                            <span id='input_24_8_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_24_8_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_8.3' id='input_24_8_3' value=''   aria-required='true'     \/>\n                                                <\/span>\n                            <span id='input_24_8_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_24_8_4' class='gform-field-label gform-field-label--type-sub '>Middle<\/label>\n                                                    <input type='text' name='input_8.4' id='input_24_8_4' value=''   aria-required='false'     \/>\n                                                <\/span>\n                            <span id='input_24_8_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_24_8_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_8.6' id='input_24_8_6' value=''   aria-required='true'     \/>\n                                                        <\/span>\n                            <span id='input_24_8_8_container' class='name_suffix  gform-grid-col gform-grid-col--size-auto' >\n                                                        <label for='input_24_8_8' class='gform-field-label gform-field-label--type-sub '>Suffix<\/label>\n                                                        <input type='text' name='input_8.8' id='input_24_8_8' value=''   aria-required='false'     \/>\n                                                    <\/span>\n                        <\/div><\/fieldset><fieldset id=\"field_24_9\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_24_9\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Service Address<\/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_24_9' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_24_9_1_container' >\n                                        <label for='input_24_9_1' id='input_24_9_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_9.1' id='input_24_9_1' value=''    aria-required='false'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_24_9_2_container' >\n                                        <label for='input_24_9_2' id='input_24_9_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_9.2' id='input_24_9_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_24_9_3_container' >\n                                    <label for='input_24_9_3' id='input_24_9_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_9.3' id='input_24_9_3' value=''    aria-required='false'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_24_9_4_container' >\n                                        <label for='input_24_9_4' id='input_24_9_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                        <select name='input_9.4' id='input_24_9_4'     aria-required='false'    ><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' >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' selected='selected'>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                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_24_9_5_container' >\n                                    <label for='input_24_9_5' id='input_24_9_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                    <input type='text' name='input_9.5' id='input_24_9_5' value=''    aria-required='false'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_9.6' id='input_24_9_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_24_10\" class=\"gfield gfield--type-address gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_24_10\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Mailing Address<\/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_24_10' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_24_10_1_container' >\n                                        <label for='input_24_10_1' id='input_24_10_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                        <input type='text' name='input_10.1' id='input_24_10_1' value=''    aria-required='false'    \/>\n                                   <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_24_10_2_container' >\n                                        <label for='input_24_10_2' id='input_24_10_2_label' class='gform-field-label gform-field-label--type-sub '>Address Line 2<\/label>\n                                        <input type='text' name='input_10.2' id='input_24_10_2' value=''     aria-required='false'   \/>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_24_10_3_container' >\n                                    <label for='input_24_10_3' id='input_24_10_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                    <input type='text' name='input_10.3' id='input_24_10_3' value=''    aria-required='false'    \/>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_24_10_4_container' >\n                                        <label for='input_24_10_4' id='input_24_10_4_label' class='gform-field-label gform-field-label--type-sub '>State<\/label>\n                                        <select name='input_10.4' id='input_24_10_4'     aria-required='false'    ><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' >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' selected='selected'>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                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_24_10_5_container' >\n                                    <label for='input_24_10_5' id='input_24_10_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP Code<\/label>\n                                    <input type='text' name='input_10.5' id='input_24_10_5' value=''    aria-required='false'    \/>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_10.6' id='input_24_10_6' value='United States' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_24_11\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_24_11\" ><label class='gfield_label gform-field-label' for='input_24_11'>Description<\/label><div class='gfield_description' id='gfield_description_24_11'>Description of the incident:<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_11' id='input_24_11' class='textarea medium'  aria-describedby=\"gfield_description_24_11\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_24_12\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--width-full gf_list_3col field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_24_12\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Other Observations<\/legend><div class='gfield_description' id='gfield_description_24_12'>Check all that apply:<\/div><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox' id='input_24_12'><div class='gchoice gchoice_24_12_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.1' type='checkbox'  value='Power Outage'  id='choice_24_12_1'   aria-describedby=\"gfield_description_24_12\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_24_12_1' id='label_24_12_1' class='gform-field-label gform-field-label--type-inline'>Power Outage<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_12_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.2' type='checkbox'  value='Partial Power'  id='choice_24_12_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_12_2' id='label_24_12_2' class='gform-field-label gform-field-label--type-inline'>Partial Power<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_12_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.3' type='checkbox'  value='Flickering Lights'  id='choice_24_12_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_12_3' id='label_24_12_3' class='gform-field-label gform-field-label--type-inline'>Flickering Lights<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_12_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.4' type='checkbox'  value='Line Sparking'  id='choice_24_12_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_12_4' id='label_24_12_4' class='gform-field-label gform-field-label--type-inline'>Line Sparking<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_12_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.5' type='checkbox'  value='Loud Noise'  id='choice_24_12_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_12_5' id='label_24_12_5' class='gform-field-label gform-field-label--type-inline'>Loud Noise<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_24_12_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_12.6' type='checkbox'  value='Burning Smell'  id='choice_24_12_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_24_12_6' id='label_24_12_6' class='gform-field-label gform-field-label--type-inline'>Burning Smell<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_24_13\" class=\"gfield gfield--type-textarea gfield--width-full field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_24_13\" ><label class='gfield_label gform-field-label' for='input_24_13'>Damaged Electrical Appliances<\/label><div class='gfield_description' id='gfield_description_24_13'>List damaged electric appliances (include make, model, serial number, year purchased \u2013 for food or other items include description of items and amounts):<\/div><div class='ginput_container ginput_container_textarea'><textarea name='input_13' id='input_24_13' class='textarea large'  aria-describedby=\"gfield_description_24_13\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_24_14\" class=\"gfield gfield--type-fileupload gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_24_14\" ><label class='gfield_label gform-field-label' for='input_24_14'>Supporting Images<\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='104857600' \/><input name='input_14' id='input_24_14' type='file' class='large' aria-describedby=\"gfield_upload_rules_24_14\" onchange='javascript:gformValidateFileSize( this, 104857600 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_24_14'>Max. file size: 100 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_24_14'><\/div><\/div><\/div><div id=\"field_24_15\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_24_15\" ><label class='gfield_label gform-field-label' for='input_24_15'>Date of Loss<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_15' id='input_24_15' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_24_15_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_24_15_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_24_15' class='gform_hidden' value='https:\/\/www.sec.coop\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_24_16\" class=\"gfield gfield--type-time gfield--width-half field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_24_16\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Time of Loss<\/legend><div class=\"ginput_container ginput_complex gform-grid-row\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_24_16'>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_24_16_1'>Hours<\/label>\n                            <input type='number' maxlength='2' name='input_16[]' id='input_24_16_1' value=''  min='0' max='12' step='1'  placeholder='HH' aria-required='false'   \/> \n                        <\/div>\n                        <div class=\"below hour_minute_colon gform-grid-col\">:<\/div>\n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_24_16_2'>Minutes<\/label>\n                            <input type='number' maxlength='2' name='input_16[]' id='input_24_16_2' value=''  min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                        <\/div>\n                        <div class='gfield_time_ampm ginput_container ginput_container_time below gform-grid-col' >\n                                \n                                <select name='input_16[]' id='input_24_16_3'  >\n                                    <option value='am' >AM<\/option>\n                                    <option value='pm' >PM<\/option>\n                                <\/select> \n                                <label class='gform-field-label gform-field-label--type-sub am_pm_label screen-reader-text' for='input_24_16_3'>AM\/PM<\/label>                                \n                           <\/div>\n                    <\/div><\/fieldset><fieldset id=\"field_24_17\" class=\"gfield gfield--type-radio gfield--type-choice gfield--width-full field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_24_17\" ><legend class='gfield_label gform-field-label' >Did you place a trouble call with SEC at the time of the incident?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_24_17'>\n\t\t\t<div class='gchoice gchoice_24_17_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='Yes'  id='choice_24_17_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_17_0' id='label_24_17_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_24_17_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_17' type='radio' value='No'  id='choice_24_17_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_24_17_1' id='label_24_17_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_24_18\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_24_18\" ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Member Consent<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='gfield_description gfield_consent_description' id='gfield_consent_description_24_18'><span style=\"font-size: 120%;\"> It is the member's responsibility to provide protection for his\/her electric motors, apparatus, wiring and other equipment from the effects of unavoidable interruption or abnormal service supply conditions,  such as low voltage, high voltage, single-phasing, lightning damage or frequency change. The Cooperative will not be held responsible for losses experienced by the member due to his\/her failure to provide such protection.<\/span><\/div><div class='ginput_container ginput_container_consent'><input name='input_18.1' id='input_24_18_1' type='checkbox' value='1'  aria-describedby=\"gfield_consent_description_24_18\" aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_24_18_1' >I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today\u2019s date and authorized by me as if I had signed my signature.<\/label><input type='hidden' name='input_18.2' value='I hereby verify the information to be true and complete and agree to the terms and conditions. I understand that by typing my full name and pressing the Submit button, this form submission will be stamped with today\u2019s date and authorized by me as if I had signed my signature.' class='gform_hidden' \/><input type='hidden' name='input_18.3' value='10' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_24_19\" class=\"gfield gfield--type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_24_19\" ><label class='gfield_label gform-field-label' for='input_24_19'>Member Electronic Signature<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_19' id='input_24_19' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/div><div id=\"field_24_20\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_above gfield--has-description field_description_above field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_24_20\" ><label class='gfield_label gform-field-label' for='input_24_20'>Email<\/label><div class='gfield_description' id='gfield_description_24_20'>This field is for validation purposes and should be left unchanged.<\/div><div class='ginput_container'><input name='input_20' id='input_24_20' type='text' value='' autocomplete='new-password'\/><\/div><\/div><\/div><\/div>\n        <div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_24' class='gform_button button' value='Submit'  onclick='if(window[\"gf_submitting_24\"]){return false;}  if( !jQuery(\"#gform_24\")[0].checkValidity || jQuery(\"#gform_24\")[0].checkValidity()){window[\"gf_submitting_24\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_24\"]){return false;} if( !jQuery(\"#gform_24\")[0].checkValidity || jQuery(\"#gform_24\")[0].checkValidity()){window[\"gf_submitting_24\"]=true;}  jQuery(\"#gform_24\").trigger(\"submit\",[true]); 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