/* growform client2
bundle.url: https://assets.growform.co/06f828b-mhc46129/form.bundle.js
resolve.source: kv
resolve.at: 2025-11-03T14:31:44.789Z
form.source: kv
cache.age_ms: 0
kv.value_present: true
fallback_used: false
*/
;(function () {
var EMBED_TYPE = "iFrame";
var FORM_ID = "68654cb0cd5e7c000b6b3d07";
var FORM_BUNDLE_URL = "https://assets.growform.co/06f828b-mhc46129/form.bundle.js"; // injected by worker (KV/memory/fallback)
var FORM_DATA = {"data":{"form":{"_id":"68654cb0cd5e7c000b6b3d07","steps":[{"id":"acd45227cac332d443c4e1db","name":"Quote Form","sortOrder":1}],"isActive":true,"formName":"Lead Form with Jornaya","fields":{"Decorative Header_52363373085874":{"type":"Decorative Header","value":"Thank You!","width":12,"step":"complete","sortOrder":1,"fieldStyle":{"fontSize":{"value":19,"unit":"px"},"fontWeight":"Bold"},"margins":{"marginTop":20},"stepId":"complete"},"Decorative_Paragraph_194067845817258":{"type":"Decorative Paragraph","value":"Thanks for getting in touch. We'll be in contact soon.","width":12,"step":"complete","sortOrder":2,"margins":{"marginBottom":60},"stepId":"complete"},"name_122840883998954":{"type":"Name","label":"What is your name?","width":12,"hideLabel":false,"options":{"Firstname":{"value":null,"errorText":null,"validationRules":{"required":true}},"Lastname":{"value":null,"errorText":null,"validationRules":{"required":true}},"Prefix":{"value":null,"errorText":null}},"stepId":"acd45227cac332d443c4e1db","sortOrder":1,"hidePrefix":true},"phone_909480530422051":{"type":"Phone","label":"What is your phone number?","width":12,"stepId":"acd45227cac332d443c4e1db","sortOrder":2,"showCountryCode":false},"email_284785320924340":{"type":"Email","label":"What is your email address?","width":12,"stepId":"acd45227cac332d443c4e1db","sortOrder":3},"time_972514712361382":{"type":"Time","label":"Preferred Contact Time","width":12,"stepId":"acd45227cac332d443c4e1db","sortOrder":4},"dob_988337440449926":{"type":"DOB","label":"What is your date of birth?","width":12,"stepId":"acd45227cac332d443c4e1db","sortOrder":5},"single_select_958094143290924":{"type":"Single Select","width":12,"label":"Gender","options":[{"text":"Male","id":"62262bc86026d909ef2c6cb9"},{"text":"Female","id":"27b7b490c91eec6787f5f3b8"}],"helperText":null,"stepId":"acd45227cac332d443c4e1db","sortOrder":6,"validationRules":{"required":true}},"zipcode_463634374971898":{"type":"Zipcode","label":"What is your zip code?","zipcodeFieldFormat":"zipcode_usa","width":12,"stepId":"acd45227cac332d443c4e1db","sortOrder":7},"single_select_674049607263413":{"type":"Single Select","width":12,"label":"Citizenship Status","options":[{"text":"Yes (U.S Citizen or Legal Resident)","id":"62262bc86026d909ef2c6cb9"},{"text":"NO","id":"27b7b490c91eec6787f5f3b8"}],"helperText":null,"stepId":"acd45227cac332d443c4e1db","sortOrder":8},"single_select_549298254142246":{"type":"Single Select","width":12,"label":"Do you currently have Medicare A and Medicare B","options":[{"text":"Yes","id":"62262bc86026d909ef2c6cb9"},{"text":"No","id":"27b7b490c91eec6787f5f3b8"}],"helperText":null,"stepId":"acd45227cac332d443c4e1db","sortOrder":9},"number_257618340631978":{"type":"Number","label":"Number of People in Household","currencySymbol":"None","width":12,"stepId":"acd45227cac332d443c4e1db","sortOrder":10,"wholeNumbersOnly":true},"number_530279665396110":{"type":"Number","label":"Estimated Household Income (Annual)","currencySymbol":"$","width":12,"stepId":"acd45227cac332d443c4e1db","sortOrder":11,"wholeNumbersOnly":true},"single_select_339744544181434":{"type":"Single Select","width":12,"label":"Do you take any prescription medications?","options":[{"text":"Yes","id":"62262bc86026d909ef2c6cb9"},{"text":"No","id":"27b7b490c91eec6787f5f3b8"}],"helperText":null,"stepId":"acd45227cac332d443c4e1db","sortOrder":12},"text_857857014964697":{"type":"Text","label":"List any medications (If applicable)","width":12,"stepId":"acd45227cac332d443c4e1db","sortOrder":13,"multiline":true,"rows":5},"text_778059411962258":{"type":"Text","label":"Preferred Doctors or Facilities","width":12,"stepId":"acd45227cac332d443c4e1db","sortOrder":14,"multiline":true,"rows":5},"multi_select_739838845932338":{"type":"Multi Select","width":12,"label":"Additional Coverage Interested In.","options":[{"text":"Dental","id":"9240a13b72e2165a9128f564"},{"text":"Vision","id":"806f4bb425f189bd2d5f13c1"},{"text":"Hearing","id":"f1f0ae443c7cea6293dcd603"},{"text":"Not Sure","image":null,"id":"5545a1e32f62977624b25adb"}],"helperText":null,"stepId":"acd45227cac332d443c4e1db","sortOrder":15},"multi_select_101403422890311":{"type":"Multi Select","width":12,"label":"Medicare-Specific Section (If Age 65+)","options":[{"text":"I have my Medicare card","id":"9240a13b72e2165a9128f564"},{"text":"I qualify for a Special Enrollment Period (SEP)","id":"806f4bb425f189bd2d5f13c1"}],"helperText":null,"stepId":"acd45227cac332d443c4e1db","sortOrder":16},"toscheckbox_684275351059697":{"type":"TOSCheckbox","label":"Do you agree to the TCPA Disclaimer?","width":12,"stepId":"acd45227cac332d443c4e1db","sortOrder":17},"hidden_823153874830541":{"type":"Hidden","hiddenFieldName":"universal_leadid","width":12,"stepId":"acd45227cac332d443c4e1db","sortOrder":18,"customCssClasses":"leadid_token"},"hidden_832259378649234":{"type":"Hidden","hiddenFieldName":"LeadiD","width":12,"stepId":"acd45227cac332d443c4e1db","sortOrder":19},"jornayatcpadisclosure_211929732592363":{"type":"JornayaTCPADisclosure","value":"By submitting your name and contact information you are expressly consenting via electronic signature to receive calls, text messages and/or emails to