{"id":6667,"date":"2024-05-06T09:09:27","date_gmt":"2024-05-06T09:09:27","guid":{"rendered":"https:\/\/swflinsurance.com\/?page_id=6667"},"modified":"2024-05-09T13:15:47","modified_gmt":"2024-05-09T13:15:47","slug":"prescription-drug-insurance-request","status":"publish","type":"page","link":"https:\/\/swflinsurance.com\/prescription-drug-insurance-request\/","title":{"rendered":"Prescription Drug Insurance Request"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"6667\" class=\"elementor elementor-6667\" data-elementor-post-type=\"page\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-top-section elementor-element elementor-element-1c397a6 elementor-section-boxed elementor-section-height-default elementor-section-height-default wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no\" data-id=\"1c397a6\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-efb9a00\" data-id=\"efb9a00\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-0413265 elementor-widget elementor-widget-heading\" data-id=\"0413265\" data-element_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\">Prescription Drug Insurance Request\n<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-4a08f27 elementor-section-boxed elementor-section-height-default elementor-section-height-default wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no\" data-id=\"4a08f27\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-1925a59\" data-id=\"1925a59\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-5cdbb01 elementor-section-boxed elementor-section-height-default elementor-section-height-default wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no\" data-id=\"5cdbb01\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-c1f6db0\" data-id=\"c1f6db0\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-d3f8b09 elementor-widget elementor-widget-heading\" data-id=\"d3f8b09\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">Fill out the following form as completely as possible.<\/h4>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-2561646\" data-id=\"2561646\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-46547d6 elementor-widget elementor-widget-heading\" data-id=\"46547d6\" data-element_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\">01<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-57c6452 elementor-section-boxed elementor-section-height-default elementor-section-height-default wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no\" data-id=\"57c6452\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t\t<div class=\"elementor-background-overlay\"><\/div>\n\t\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-d5903c4\" data-id=\"d5903c4\" data-element_type=\"column\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-31b96b6 elementor-section-boxed elementor-section-height-default elementor-section-height-default wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no\" data-id=\"31b96b6\" data-element_type=\"section\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-e32b200\" data-id=\"e32b200\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-c9c8963 elementor-widget elementor-widget-heading\" data-id=\"c9c8963\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h4 class=\"elementor-heading-title elementor-size-default\">Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.<\/h4>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-inner-column elementor-element elementor-element-2d46bd1\" data-id=\"2d46bd1\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-0e5e336 elementor-widget elementor-widget-heading\" data-id=\"0e5e336\" data-element_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\">02<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/section>\n\t\t\t\t<div class=\"elementor-element elementor-element-76c9cfe elementor-widget elementor-widget-text-editor\" data-id=\"76c9cfe\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p style=\"margin-bottom: 5px;font-size: 13px;\">Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to <a style=\" font-weight: 700;\" href=\"\/contact-us\/\" > contact us<\/a>.<\/p>\n\n<p style=\"margin-bottom: 5px;font-size: 13px;\">Per the terms of our <a style=\"margin-bottom:0px; font-weight: 700;\" href=\"\/privacy\/\" >online privacy policy<\/a> we will not resell your information to any third-party.<\/p>\n\n<p style=\"margin-bottom: 5px;font-size: 13px;\"><span style=\"font-weight: 700;\">Note<\/span>: verify the URL<\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t<\/div>\n\t\t\t\t<div class=\"elementor-column elementor-col-50 elementor-top-column elementor-element elementor-element-c76043d\" data-id=\"c76043d\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<section class=\"elementor-section elementor-inner-section elementor-element elementor-element-8b31185 elementor-section-boxed elementor-section-height-default elementor-section-height-default wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no\" data-id=\"8b31185\" data-element_type=\"section\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t\t<div class=\"elementor-container elementor-column-gap-default\">\n\t\t\t\t\t<div class=\"elementor-column elementor-col-100 elementor-inner-column elementor-element elementor-element-6215d64\" data-id=\"6215d64\" data-element_type=\"column\">\n\t\t\t<div class=\"elementor-widget-wrap elementor-element-populated\">\n\t\t\t\t\t\t<div class=\"elementor-element elementor-element-885222f elementor-widget elementor-widget-heading\" data-id=\"885222f\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h3 class=\"elementor-heading-title elementor-size-default\">Personal Information<\/h3>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-65631d1 uael-gf-ajax-true uael-gf-style-box uael-gf-input-size-sm uael-gf-enable-classes-no uael-gf-button-left uael-gf-btn-size-sm elementor-widget elementor-widget-uael-gf-styler\" data-id=\"65631d1\" data-element_type=\"widget\" data-widget_type=\"uael-gf-styler.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"uael-gf-style uael-gf-check-style elementor-clickable\">\n\t<script>\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 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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<\/script>\n\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_12' ><form method='post' enctype='multipart\/form-data'  id='gform_12'  action='\/wp-json\/wp\/v2\/pages\/6667' data-formid='12' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_12' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_12_11\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_11'>Comments<\/label><div class='ginput_container'><input name='input_11' id='input_12_11' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_12_11'>This field is for validation purposes and should be left unchanged.<\/div><\/div><fieldset id=\"field_12_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Full 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 no_last_name no_suffix gf_name_has_1 ginput_container_name gform-grid-row' id='input_12_1'>\n                            \n                            <span id='input_12_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_12_1_3' value='' tabindex='2'  aria-required='true'   placeholder='Full Name*'  \/>\n                                                    <label for='input_12_1_3' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>First<\/label>\n                                                <\/span>\n                            \n                            \n                            \n                        <\/div><\/fieldset><fieldset id=\"field_12_9\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_hidden_label gfield--no-description field_description_below hidden_label 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_city has_state has_zip ginput_container_address gform-grid-row' id='input_12_9' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_12_9_1_container' >\n                                        <input type='text' name='input_9.1' id='input_12_9_1' value='' tabindex='6'  placeholder='Street*' aria-required='true'    \/>\n                                        <label for='input_12_9_1' id='input_12_9_1_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_12_9_3_container' >\n                                    <input type='text' name='input_9.3' id='input_12_9_3' value='' tabindex='7'  placeholder='City*' aria-required='true'    \/>\n                                    <label for='input_12_9_3' id='input_12_9_3_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>City<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_12_9_4_container' >\n                                        <input type='text' name='input_9.4' id='input_12_9_4' value='' tabindex='9'    placeholder='State*' aria-required='true'    \/>\n                                        <label for='input_12_9_4' id='input_12_9_4_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>State \/ Province \/ Region<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_12_9_5_container' >\n                                    <input type='text' name='input_9.5' id='input_12_9_5' value='' tabindex='10'  placeholder='ZIP \/ Postal Code*' aria-required='true'    \/>\n                                    <label for='input_12_9_5' id='input_12_9_5_label' class='gform-field-label gform-field-label--type-sub hidden_sub_label screen-reader-text'>ZIP \/ Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_9.6' id='input_12_9_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_12_4\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_4'>Primary 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_12_4' type='tel' value='' class='large' tabindex='11' placeholder='Primary Phone Number*' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_3\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_3'>E-Mail Address<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_3' id='input_12_3' type='email' value='' class='large' tabindex='12'  placeholder='E-Mail Address*' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_12_10\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_10'>How did you hear about us?<\/label><div class='ginput_container ginput_container_select'><select name='input_10' id='input_12_10' class='large gfield_select' tabindex='13'    aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder' disabled>How did you hear about us?<\/option><option value='Current Customer' >Current Customer<\/option><option value='Friend' >Friend<\/option><option value='Advertisement' >Advertisement<\/option><option value='Direct Mail' >Direct Mail<\/option><option value='Email' >Email<\/option><option value='Internet Ad' >Internet Ad<\/option><option value='Radio Ad' >Radio Ad<\/option><option value='Television Ad' >Television Ad<\/option><option value='Yellow Page Listing' >Yellow Page Listing<\/option><option value='Online' >Online<\/option><option value='Online Vlog' >Online Vlog<\/option><option value='Internet Search Engine' >Internet Search Engine<\/option><option value='Bing\/Live Search Engine' >Bing\/Live Search Engine<\/option><option value='Google Search Engine' >Google Search Engine<\/option><option value='Yahoo! Search Engine' >Yahoo! Search Engine<\/option><option value='Other' >Other<\/option><option value='Driving By The Office' >Driving By The Office<\/option><option value='Business Card' >Business Card<\/option><option value='Flyer' >Flyer<\/option><\/select><\/div><\/div><div id=\"field_12_7\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><p style=\"margin-bottom: 10px;color: #fff;\">Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to <a style=\"color: #fff; font-weight: 600;\" href=\"\/contact\" > contact us<\/a>.<\/p>\n\n<p style=\"color: #fff;\">Per the terms of our <a style=\"margin-bottom:0px;color: #fff; font-weight: 600;\" href=\"\/privacy\" >online privacy policy<\/a> we will not resell your information to any third-party.<\/p><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <div class=\"gf-turnstile-container\"> <div id=\"cf-turnstile-gf-12\" class=\"cf-turnstile\" data-sitekey=\"0x4AAAAAAANbNB5wZ8PydWYr\" data-theme=\"light\" data-language=\"auto\" data-size=\"\" data-retry=\"auto\" data-retry-interval=\"1000\" data-action=\"gravity-form-12\" data-appearance=\"always\"><\/div> <script>document.addEventListener(\"DOMContentLoaded\", function() { setTimeout(function(){ var e=document.getElementById(\"cf-turnstile-gf-12\"); e&&!e.innerHTML.trim()&&(turnstile.remove(\"#cf-turnstile-gf-12\"), turnstile.render(\"#cf-turnstile-gf-12\", 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