{"id":2,"date":"2026-03-04T20:01:49","date_gmt":"2026-03-04T20:01:49","guid":{"rendered":"https:\/\/leads.acera.ca\/?page_id=2"},"modified":"2026-04-01T11:48:22","modified_gmt":"2026-04-01T18:48:22","slug":"sample-page","status":"publish","type":"page","link":"https:\/\/leads.acera.ca\/","title":{"rendered":"National Referral Program &amp; Internal Lead Routing"},"content":{"rendered":"\n<p>Please fill out the form below if you are referring new business or an existing client from a different line of business.<\/p>\n\n\n\n<div style=\"height:40px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n<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 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<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gform-theme gform-theme--foundation gform-theme--framework gform-theme--orbital' data-form-theme='orbital' data-form-index='0' id='gform_wrapper_1' style='display:none'><style>#gform_wrapper_1[data-form-index=\"0\"].gform-theme,[data-parent-form=\"1_0\"]{--gf-color-primary: 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><form method='post' enctype='multipart\/form-data'  id='gform_1'  action='\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F2' data-formid='1' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_1' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_1_7\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_1_7'>Your Full Name<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_7' id='input_1_7' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_7\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_7'>Provide your full name (the person submitting the referral and who will receive the referral bonus).<\/div><\/div><div id=\"field_1_6\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half 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_1_6'>Your Acera Insurance Email 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_6' id='input_1_6' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_1_6\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_1_6'>Please provide your Acera Insurance (@acera.ca) email address.<\/div><\/div><fieldset id=\"field_1_8\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label screen-reader-text gfield_label_before_complex' ><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_1_8'><div class='gchoice gchoice_1_8_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_8.1' type='checkbox'  value='Please check this box if you are sending this referral on behalf of your Client Executive'  id='choice_1_8_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_1_8_1' id='label_1_8_1' class='gform-field-label gform-field-label--type-inline'>Please check this box if you are sending this referral on behalf of your Client Executive<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_1_35\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Was this lead generated by you?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_1_35'>\n\t\t\t<div class='gchoice gchoice_1_35_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='Yes'  id='choice_1_35_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_35_0' id='label_1_35_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_1_35_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_35' type='radio' value='No'  id='choice_1_35_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_1_35_1' id='label_1_35_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_1_25\" 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\"><\/h3><\/div><div id=\"field_1_9\" 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_visible\"  ><h2>About Your Referral<\/h2>\nPlease provide the following information about your referral.<\/div><div id=\"field_1_34\" class=\"gfield gfield--type-select gfield--input-type-select 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_1_34'>Client Type<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_34' id='input_1_34' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='New Client' >New Client<\/option><option value='Business Development Manager' >Business Development Manager<\/option><option value='Existing Client Home' >Existing Client Home<\/option><option value='Existing Client Auto' >Existing Client Auto<\/option><option value='Existing Client Business' >Existing Client Business<\/option><\/select><\/div><\/div><div id=\"field_1_10\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full 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_1_10'>Name<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_10' id='input_1_10' type='text' value='' class='large'  aria-describedby=\"gfield_description_1_10\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_1_10'>Name of the person you are referring.<\/div><\/div><div id=\"field_1_11\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half 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_1_11'>Phone<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_11' id='input_1_11' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_1_11\"  \/><\/div><div class='gfield_description' id='gfield_description_1_11'>Phone number of the person you are referring.<\/div><\/div><div id=\"field_1_12\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half 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_1_12'>Email<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_12' id='input_1_12' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_description_1_12\" \/>\n                        <\/div><div class='gfield_description' id='gfield_description_1_12'>Email address of the person you are referring.<\/div><\/div><fieldset id=\"field_1_37\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full 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' >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_1_37' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_1_37_1_container' >\n                                        <input type='text' name='input_37.1' id='input_1_37_1' value=''    aria-required='true'   autocomplete=\"address-line1\" \/>\n                                        <label for='input_1_37_1' id='input_1_37_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_1_37_2_container' >\n                                        <input type='text' name='input_37.2' id='input_1_37_2' value=''    autocomplete=\"address-line2\" aria-required='false'   \/>\n                                        <label for='input_1_37_2' id='input_1_37_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_1_37_3_container' >\n                                    <input type='text' name='input_37.3' id='input_1_37_3' value=''    aria-required='true'   autocomplete=\"address-level2\" \/>\n                                    <label for='input_1_37_3' id='input_1_37_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_1_37_4_container' >\n                                        <input type='text' name='input_37.4' id='input_1_37_4' value=''      aria-required='true'   autocomplete=\"address-level1\" \/>\n                                        <label for='input_1_37_4' id='input_1_37_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_1_37_5_container' >\n                                    <input type='text' name='input_37.5' id='input_1_37_5' value=''    aria-required='true'   autocomplete=\"postal-code\" \/>\n                                    <label for='input_1_37_5' id='input_1_37_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_37.6' id='input_1_37_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_1_15\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_15'>Expiry Date of Policy<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_15' id='input_1_15' type='text' value='' class='datepicker gform-datepicker mdy datepicker_with_icon gdatepicker_with_icon'   placeholder='mm\/dd\/yyyy' aria-describedby=\"input_1_15_date_format gfield_description_1_15\" aria-invalid=\"false\" \/>\n                            <span id='input_1_15_date_format' class='screen-reader-text'>MM slash DD slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_1_15' class='gform_hidden' value='https:\/\/leads.acera.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_1_15'>If you have the expiry date of the policy you are referring for, please provide it here.<\/div><\/div><div id=\"field_1_16\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half 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_1_16'>Type of insurance<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_16' id='input_1_16' class='large gfield_select'  aria-describedby=\"gfield_description_1_16\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Type of Insurance<\/option><option value='Personal' >Personal<\/option><option value='Commercial' >Commercial<\/option><option value='Group Benefits' >Group Benefits<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_16'>What line of business is your referral looking for?<\/div><\/div><div id=\"field_1_17\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full 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_1_17'>Insurance Product &#8211; Personal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_1_17' class='large gfield_select'  aria-describedby=\"gfield_description_1_17\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Insurance Product &#8211; Personal<\/option><option value='Auto &amp; Recreational' >Auto &amp; Recreational<\/option><option value='Home &amp; Property' >Home &amp; Property<\/option><option value='Life &amp; Travel' >Life &amp; Travel<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_17'>Which personal insurance product is your referral looking for?<\/div><\/div><div id=\"field_1_18\" class=\"gfield gfield--type-select gfield--input-type-select 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_1_18'>Sub-Product you\u2019d like a quote for (Auto &amp; Recreational)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_18' id='input_1_18' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Sub-Product you\u2019d like a quote for (Auto &amp; Recreational)<\/option><option value='Car Insurance' >Car Insurance<\/option><option value='Luxury Auto Insurance' >Luxury Auto Insurance<\/option><option value='Motorcycle Insurance' >Motorcycle Insurance<\/option><option value='Boat Insurance' >Boat Insurance<\/option><option value='Off-Road Vehicle Insurance' >Off-Road Vehicle Insurance<\/option><option value='RV, Motorhome &amp; Trailer Insurance' >RV, Motorhome &amp; Trailer Insurance<\/option><\/select><\/div><\/div><div id=\"field_1_20\" class=\"gfield gfield--type-select gfield--input-type-select 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_1_20'>Sub-Product you\u2019d like a quote for (Home &amp; Property)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_20' id='input_1_20' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Sub-Product you\u2019d like a quote for (Home &amp; Property)<\/option><option value='Home Insurance' >Home Insurance<\/option><option value='Condo Insurance' >Condo Insurance<\/option><option value='Course of Construction Insurance' >Course of Construction Insurance<\/option><option value='Luxury Home Insurance' >Luxury Home Insurance<\/option><option value='Strata Deductible Insurance' >Strata Deductible Insurance<\/option><option value='Tenant Insurance' >Tenant Insurance<\/option><option value='Equine Insurance' >Equine Insurance<\/option><option value='Farm Insurance' >Farm Insurance<\/option><option value='Valuables &amp; Collections Insurance' >Valuables &amp; Collections Insurance<\/option><\/select><\/div><\/div><div id=\"field_1_21\" class=\"gfield gfield--type-select gfield--input-type-select 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_1_21'>Sub-Product you\u2019d like a quote for (Life &amp; Travel)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_21' id='input_1_21' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Sub-Product you\u2019d like a quote for (Life &amp; Travel)<\/option><option value='Life Insurance' >Life Insurance<\/option><option value='Critical Illness Insurance' >Critical Illness Insurance<\/option><option value='Disability Insurance' >Disability Insurance<\/option><option value='Travel Insurance' >Travel Insurance<\/option><option value='Adventure Travel Insurance' >Adventure Travel Insurance<\/option><\/select><\/div><\/div><div id=\"field_1_43\" class=\"gfield gfield--type-select gfield--input-type-select 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_1_43'>Insurance Product &#8211; Commercial<\/label><div class='ginput_container ginput_container_select'><select name='input_43' id='input_1_43' class='large gfield_select'     aria-invalid=\"false\" ><option value='Not Identified' >Not Identified<\/option><option value='Bonding &amp; Surety' >Bonding &amp; Surety<\/option><option value='Commercial Auto' >Commercial Auto<\/option><option value='Commercial General Liability' >Commercial General Liability<\/option><option value='Commercial Property' >Commercial Property<\/option><option value='Hole in One \/ Special Events' >Hole in One \/ Special Events<\/option><option value='Professional Liability\/E&amp;O Insurance' >Professional Liability\/E&amp;O Insurance<\/option><\/select><\/div><\/div><div id=\"field_1_19\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full 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_1_19'>Insurance Product &#8211; Benefits<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_19' id='input_1_19' class='large gfield_select'  aria-describedby=\"gfield_description_1_19\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Insurance Product &#8211; Benefits<\/option><option value='Group Benefits' >Group Benefits<\/option><option value='Group Savings &amp; Retirement' >Group Savings &amp; Retirement<\/option><option value='Key Person Insurance' >Key Person Insurance<\/option><option value='Critical Illness Insurance' >Critical Illness Insurance<\/option><option value='Disability Insurance' >Disability Insurance<\/option><option value='Life Insurance' >Life Insurance<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_19'>What benefits product is your referral looking for?<\/div><\/div><div id=\"field_1_27\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third 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_1_27'>Industry<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_27' id='input_1_27' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Industry<\/option><option value='Agriculture' >Agriculture<\/option><option value='Aviation' >Aviation<\/option><option value='Construction \/ Bonding &amp; Surety' >Construction \/ Bonding &amp; Surety<\/option><option value='Education' >Education<\/option><option value='Energy, Oil &amp; Gas' >Energy, Oil &amp; Gas<\/option><option value='Environmental' >Environmental<\/option><option value='Equine Business' >Equine Business<\/option><option value='Financial Services' >Financial Services<\/option><option value='Fine Art &amp; Jewelry' >Fine Art &amp; Jewelry<\/option><option value='Firearms' >Firearms<\/option><option value='Forestry' >Forestry<\/option><option value='Healthcare' >Healthcare<\/option><option value='Hospitality' >Hospitality<\/option><option value='Manufacturing' >Manufacturing<\/option><option value='Non-Profit' >Non-Profit<\/option><option value='Real Estate' >Real Estate<\/option><option value='Small Business' >Small Business<\/option><option value='Technology' >Technology<\/option><option value='Transportation \/ Fleet \/ Garage' >Transportation \/ Fleet \/ Garage<\/option><option value='Other' >Other<\/option><\/select><\/div><\/div><div id=\"field_1_26\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third 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_1_26'>Annual Revenue<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_1_26' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Annual Revenue<\/option><option value='0 \u2013 1,000,000' >0 \u2013 1,000,000<\/option><option value='1,000,001 \u2013 2,500,000' >1,000,001 \u2013 2,500,000<\/option><option value='2,500,001 \u2013 5,000,000' >2,500,001 \u2013 5,000,000<\/option><option value='5,000,001 \u2013 10,000,000' >5,000,001 \u2013 10,000,000<\/option><option value='10,000,001 \u2013 20,000,000' >10,000,001 \u2013 20,000,000<\/option><option value='20,000,000+' >20,000,000+<\/option><\/select><\/div><\/div><div id=\"field_1_28\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third 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_1_28'>Number of Employees<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_28' id='input_1_28' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Number of Employees<\/option><option value='1 \u2013 5' >1 \u2013 5<\/option><option value='6 \u2013 10' >6 \u2013 10<\/option><option value='11 \u2013 20' >11 \u2013 20<\/option><option value='21 \u2013 50' >21 \u2013 50<\/option><option value='51 \u2013 100' >51 \u2013 100<\/option><option value='101+' >101+<\/option><\/select><\/div><\/div><div id=\"field_1_22\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third 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_1_22'>Please provide the make of the vehicle:<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_22' id='input_1_22' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_23\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third 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_1_23'>Please provide the model of the vehicle:<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_23' id='input_1_23' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_24\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third 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_1_24'>Please provide the year of the vehicle:<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_24' id='input_1_24' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_1_29\" 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\"><\/h3><\/div><div id=\"field_1_30\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full 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_1_30'>Would you like to refer your lead to a specific individual?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_30' id='input_1_30' class='large gfield_select'  aria-describedby=\"gfield_description_1_30\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_30'>We will automatically route your lead to the most appropriate person or team but if you&#8217;d like to send this lead to someone specific, please select &#8220;Yes.&#8221; Please ensure the person you are referring to is not out of office and note that it is not guaranteed this person will handle the lead.<\/div><\/div><div id=\"field_1_31\" class=\"gfield gfield--type-email gfield--input-type-email 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_1_31'>Please provide the Acera Insurance email address of the person you&#039;d like to send the lead to:<\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_31' id='input_1_31' type='email' value='' class='large'     aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_1_38\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_1_38'>Select a Location<\/label><div class='ginput_container ginput_container_select'><select name='input_38' id='input_1_38' class='large gfield_select'  aria-describedby=\"gfield_description_1_38\"   aria-invalid=\"false\" ><option value='Calgary' >Calgary<\/option><option value='Edmonton' >Edmonton<\/option><option value='Fort McMurray' >Fort McMurray<\/option><option value='Red Deer' >Red Deer<\/option><option value='Stettler' >Stettler<\/option><option value='Sylvan Lake' >Sylvan Lake<\/option><option value='Brampton' >Brampton<\/option><option value='Ottawa' >Ottawa<\/option><option value='Richmond Hill' >Richmond Hill<\/option><option value='BC - Greater Vancouver' >BC &#8211; Greater Vancouver<\/option><option value='BC - Interior' >BC &#8211; Interior<\/option><option value='BC - Vancouver Island' >BC &#8211; Vancouver Island<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_1_38'>This field will appear only if the lead doesn&#8217;t qualify for the NRP<\/div><\/div><div id=\"field_1_32\" class=\"gfield gfield--type-textarea gfield--input-type-textarea 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_1_32'>Additional Comments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_32' id='input_1_32' class='textarea medium'      aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_1_33\" class=\"gfield gfield--type-hidden gfield--input-type-hidden gfield--width-full gform_hidden field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><div class='ginput_container ginput_container_text'><input name='input_33' id='input_1_33' type='hidden' class='gform_hidden'  aria-invalid=\"false\" value='National Referral Program' \/><\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <input type='submit' id='gform_submit_button_1' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Submit'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_1' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_1' id='gform_theme_1' value='orbital' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_1' id='gform_style_settings_1' value='{&quot;inputPrimaryColor&quot;:&quot;#204ce5&quot;}' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_1' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='1' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='CAD' value='hEMdn24C\/d4R8db1pKpuJbL2P8RvAUXEj\/gVTgSuy1RBK3wsqCT5Hn5IQXkq3uhwtN8K+9Bt4IzmhlOdDB9i7BlAI1iIIq8d2kdgx\/am3mceCTo=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_1' 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