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1 forms found in the DOM

Name: MVA Form New One — POST

<form class="elementor-form" method="post" id="mvaformdata" name="MVA Form New One">
  <input type="hidden" name="post_id" value="181">
  <input type="hidden" name="form_id" value="6901d6b">
  <input type="hidden" name="referer_title" value="">
  <input type="hidden" name="queried_id" value="181">
  <div class="elementor-form-fields-wrapper elementor-labels-above">
    <div class="elementor-field-type-step elementor-column elementor-field-group-field_a80cbeb elementor-col-100 e-form__step">
      <div class="e-field-step elementor-hidden" data-label="Step 1" data-previousbutton="" data-nextbutton="" data-iconurl="" data-iconlibrary="fas fa-star" data-icon=""></div>
      <div class="elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-Injuries elementor-col-100">
        <label for="form-field-Injuries" class="elementor-field-label"> What type of injuries you sustain in your accident? </label>
        <div class="elementor-field-subgroup  elementor-subgroup-inline"><span class="elementor-field-option"><input type="radio" value="Back Injury" id="form-field-Injuries-0" name="form_fields[Injuries]"> <label for="form-field-Injuries-0">Back
              Injury</label></span><span class="elementor-field-option"><input type="radio" value="Back or Neck Pain" id="form-field-Injuries-1" name="form_fields[Injuries]"> <label for="form-field-Injuries-1">Back or Neck Pain</label></span><span
            class="elementor-field-option"><input type="radio" value="Broken Bones" id="form-field-Injuries-2" name="form_fields[Injuries]"> <label for="form-field-Injuries-2">Broken Bones</label></span><span class="elementor-field-option"><input
              type="radio" value="Broken Limb" id="form-field-Injuries-3" name="form_fields[Injuries]"> <label for="form-field-Injuries-3">Broken Limb</label></span><span class="elementor-field-option"><input type="radio" value="Concussion"
              id="form-field-Injuries-4" name="form_fields[Injuries]"> <label for="form-field-Injuries-4">Concussion</label></span><span class="elementor-field-option"><input type="radio" value="Coma/Death" id="form-field-Injuries-5"
              name="form_fields[Injuries]"> <label for="form-field-Injuries-5">Coma/Death</label></span><span class="elementor-field-option"><input type="radio" value="Cuts &amp; Bruises" id="form-field-Injuries-6" name="form_fields[Injuries]">
            <label for="form-field-Injuries-6">Cuts &amp; Bruises</label></span><span class="elementor-field-option"><input type="radio" value="Headaches" id="form-field-Injuries-7" name="form_fields[Injuries]"> <label
              for="form-field-Injuries-7">Headaches</label></span><span class="elementor-field-option"><input type="radio" value="Internal Bleeding" id="form-field-Injuries-8" name="form_fields[Injuries]"> <label for="form-field-Injuries-8">Internal
              Bleeding</label></span><span class="elementor-field-option"><input type="radio" value="Loss of Limb" id="form-field-Injuries-9" name="form_fields[Injuries]"> <label for="form-field-Injuries-9">Loss of Limb</label></span><span
            class="elementor-field-option"><input type="radio" value="Memory Loss" id="form-field-Injuries-10" name="form_fields[Injuries]"> <label for="form-field-Injuries-10">Memory Loss</label></span><span class="elementor-field-option"><input
              type="radio" value="Soft Tissues" id="form-field-Injuries-11" name="form_fields[Injuries]"> <label for="form-field-Injuries-11">Soft Tissues</label></span><span class="elementor-field-option"><input type="radio" value="Whiplash"
              id="form-field-Injuries-12" name="form_fields[Injuries]"> <label for="form-field-Injuries-12">Whiplash</label></span><span class="elementor-field-option"><input type="radio" value="Other" id="form-field-Injuries-13"
              name="form_fields[Injuries]"> <label for="form-field-Injuries-13">Other</label></span></div>
      </div>
      <div class="e-form__buttons elementor-column elementor-col-100">
        <div class="elementor-field-group e-form__buttons__wrapper elementor-field-type-next"><button type="button" class="elementor-button elementor-size-sm e-form__buttons__wrapper__button e-form__buttons__wrapper__button-next">Next</button></div>
      </div>
    </div>
    <div class="elementor-field-type-step elementor-column elementor-field-group-field_51216b5 elementor-col-100 e-form__step elementor-hidden">
      <div class="e-field-step elementor-hidden" data-label="Step 2" data-previousbutton="" data-nextbutton="" data-iconurl="" data-iconlibrary="fas fa-star" data-icon=""></div>
      <div class="elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_287af1a elementor-col-100">
        <p><span style="color: #000000; font-size: 25px; font-weight:600">Month and Year of your accident?</span></p>
      </div>
      <div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-Month elementor-col-50">
        <div class="elementor-field elementor-select-wrapper remove-before ">
          <div class="select-caret-down-wrapper">
            <i aria-hidden="true" class="eicon-caret-down"></i>
          </div>
          <select name="form_fields[Month]" id="form-field-Month" class="elementor-field-textual elementor-size-md">
            <option value="- Select Month -">- Select Month -</option>
            <option value="January">January</option>
            <option value="February">February</option>
            <option value="March">March</option>
            <option value="April">April</option>
            <option value="May">May</option>
            <option value="June">June</option>
            <option value="July">July</option>
            <option value="August">August</option>
            <option value="September">September</option>
            <option value="October">October</option>
            <option value="November">November</option>
            <option value="December">December</option>
          </select>
        </div>
      </div>
      <div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-Year elementor-col-50">
        <div class="elementor-field elementor-select-wrapper remove-before ">
          <div class="select-caret-down-wrapper">
            <i aria-hidden="true" class="eicon-caret-down"></i>
          </div>
          <select name="form_fields[Year]" id="form-field-Year" class="elementor-field-textual elementor-size-md">
            <option value="- Select Year -">- Select Year -</option>
            <option value="2022">2022</option>
            <option value="2023">2023</option>
            <option value="2024">2024</option>
          </select>
        </div>
      </div>
      <div class="e-form__buttons elementor-column elementor-col-100">
        <div class="elementor-field-group e-form__buttons__wrapper elementor-field-type-previous"><button type="button"
            class="elementor-button elementor-size-sm e-form__buttons__wrapper__button e-form__buttons__wrapper__button-previous">Back</button></div>
        <div class="elementor-field-group e-form__buttons__wrapper elementor-field-type-next"><button type="button" class="elementor-button elementor-size-sm e-form__buttons__wrapper__button e-form__buttons__wrapper__button-next">Next</button></div>
      </div>
    </div>
    <div class="elementor-field-type-step elementor-column elementor-field-group-field_93f3058 elementor-col-100 e-form__step elementor-hidden">
      <div class="e-field-step elementor-hidden" data-label="Step 3" data-previousbutton="" data-nextbutton="" data-iconurl="" data-iconlibrary="fas fa-star" data-icon=""></div>
      <div class="elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_3e9835a elementor-col-100">
        <label for="form-field-field_3e9835a" class="elementor-field-label"> Did this event occur due to someone else's fault? </label>
        <div class="elementor-field-subgroup  elementor-subgroup-inline"><span class="elementor-field-option"><input type="radio" value="Yes" id="form-field-field_3e9835a-0" name="form_fields[field_3e9835a]"> <label
              for="form-field-field_3e9835a-0">Yes</label></span><span class="elementor-field-option"><input type="radio" value="No" id="form-field-field_3e9835a-1" name="form_fields[field_3e9835a]"> <label
              for="form-field-field_3e9835a-1">No</label></span><span class="elementor-field-option"><input type="radio" value="Partially Fault" id="form-field-field_3e9835a-2" name="form_fields[field_3e9835a]"> <label
              for="form-field-field_3e9835a-2">Partially Fault</label></span></div>
      </div>
      <div class="e-form__buttons elementor-column elementor-col-100">
        <div class="elementor-field-group e-form__buttons__wrapper elementor-field-type-previous"><button type="button"
            class="elementor-button elementor-size-sm e-form__buttons__wrapper__button e-form__buttons__wrapper__button-previous">Back</button></div>
        <div class="elementor-field-group e-form__buttons__wrapper elementor-field-type-next"><button type="button" class="elementor-button elementor-size-sm e-form__buttons__wrapper__button e-form__buttons__wrapper__button-next">Next</button></div>
      </div>
    </div>
    <div class="elementor-field-type-step elementor-column elementor-field-group-field_1ca8f62 elementor-col-100 e-form__step elementor-hidden">
      <div class="e-field-step elementor-hidden" data-label="Step 4" data-previousbutton="" data-nextbutton="" data-iconurl="" data-iconlibrary="fas fa-star" data-icon=""></div>
      <div class="elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_4493200 elementor-col-100">
        <label for="form-field-field_4493200" class="elementor-field-label"> Type of medical treatment you seek at the time of the accident? </label>
        <div class="elementor-field-subgroup  elementor-subgroup-inline"><span class="elementor-field-option"><input type="radio" value="No Treatment" id="form-field-field_4493200-0" name="form_fields[field_4493200]"> <label
              for="form-field-field_4493200-0">No Treatment</label></span><span class="elementor-field-option"><input type="radio" value="Doctor Visit" id="form-field-field_4493200-1" name="form_fields[field_4493200]"> <label
              for="form-field-field_4493200-1">Doctor Visit</label></span><span class="elementor-field-option"><input type="radio" value="Hospital" id="form-field-field_4493200-2" name="form_fields[field_4493200]"> <label
              for="form-field-field_4493200-2">Hospital</label></span><span class="elementor-field-option"><input type="radio" value="Emergency Room" id="form-field-field_4493200-3" name="form_fields[field_4493200]"> <label
              for="form-field-field_4493200-3">Emergency Room</label></span><span class="elementor-field-option"><input type="radio" value="Surgery" id="form-field-field_4493200-4" name="form_fields[field_4493200]"> <label
              for="form-field-field_4493200-4">Surgery</label></span><span class="elementor-field-option"><input type="radio" value="Health Clinic" id="form-field-field_4493200-5" name="form_fields[field_4493200]"> <label
              for="form-field-field_4493200-5">Health Clinic</label></span><span class="elementor-field-option"><input type="radio" value="Physiotherapy" id="form-field-field_4493200-6" name="form_fields[field_4493200]"> <label
              for="form-field-field_4493200-6">Physiotherapy</label></span><span class="elementor-field-option"><input type="radio" value="Other" id="form-field-field_4493200-7" name="form_fields[field_4493200]"> <label
              for="form-field-field_4493200-7">Other</label></span></div>
      </div>
      <div class="e-form__buttons elementor-column elementor-col-100">
        <div class="elementor-field-group e-form__buttons__wrapper elementor-field-type-previous"><button type="button"
            class="elementor-button elementor-size-sm e-form__buttons__wrapper__button e-form__buttons__wrapper__button-previous">Back</button></div>
        <div class="elementor-field-group e-form__buttons__wrapper elementor-field-type-next"><button type="button" class="elementor-button elementor-size-sm e-form__buttons__wrapper__button e-form__buttons__wrapper__button-next">Next</button></div>
      </div>
    </div>
    <div class="elementor-field-type-step elementor-column elementor-field-group-field_6945624 elementor-col-100 e-form__step elementor-hidden">
      <div class="e-field-step elementor-hidden" data-label="Step 5" data-previousbutton="" data-nextbutton="" data-iconurl="" data-iconlibrary="fas fa-star" data-icon=""></div>
      <div class="elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_cf1dc21 elementor-col-100">
        <label for="form-field-field_cf1dc21" class="elementor-field-label"> Have You Hired a Lawyer to Represent You in Your Car Accident Injury Claim? </label>
        <div class="elementor-field-subgroup  elementor-subgroup-inline"><span class="elementor-field-option"><input type="radio" value="Yes" id="form-field-field_cf1dc21-0" name="form_fields[field_cf1dc21]"> <label
              for="form-field-field_cf1dc21-0">Yes</label></span><span class="elementor-field-option"><input type="radio" value="No" id="form-field-field_cf1dc21-1" name="form_fields[field_cf1dc21]"> <label
              for="form-field-field_cf1dc21-1">No</label></span><span class="elementor-field-option"><input type="radio" value="I was but no anymore" id="form-field-field_cf1dc21-2" name="form_fields[field_cf1dc21]"> <label
              for="form-field-field_cf1dc21-2">I was but no anymore</label></span></div>
      </div>
      <div class="e-form__buttons elementor-column elementor-col-100">
        <div class="elementor-field-group e-form__buttons__wrapper elementor-field-type-previous"><button type="button"
            class="elementor-button elementor-size-sm e-form__buttons__wrapper__button e-form__buttons__wrapper__button-previous">Back</button></div>
        <div class="elementor-field-group e-form__buttons__wrapper elementor-field-type-next"><button type="button" class="elementor-button elementor-size-sm e-form__buttons__wrapper__button e-form__buttons__wrapper__button-next">Next</button></div>
      </div>
    </div>
    <div class="elementor-field-type-step elementor-column elementor-field-group-field_b77b810 elementor-col-100 e-form__step elementor-hidden">
      <div class="e-field-step elementor-hidden" data-label="Step 6" data-previousbutton="" data-nextbutton="" data-iconurl="" data-iconlibrary="fas fa-star" data-icon=""></div>
      <div class="elementor-field-type-radio elementor-field-group elementor-column elementor-field-group-field_80b56e1 elementor-col-100">
        <label for="form-field-field_80b56e1" class="elementor-field-label"> Where were you in the Car? </label>
        <div class="elementor-field-subgroup  elementor-subgroup-inline"><span class="elementor-field-option"><input type="radio" value="Driver" id="form-field-field_80b56e1-0" name="form_fields[field_80b56e1]"> <label
              for="form-field-field_80b56e1-0">Driver</label></span><span class="elementor-field-option"><input type="radio" value="Passenger" id="form-field-field_80b56e1-1" name="form_fields[field_80b56e1]"> <label
              for="form-field-field_80b56e1-1">Passenger</label></span><span class="elementor-field-option"><input type="radio" value="Pedestrian" id="form-field-field_80b56e1-2" name="form_fields[field_80b56e1]"> <label
              for="form-field-field_80b56e1-2">Pedestrian</label></span></div>
      </div>
      <div class="e-form__buttons elementor-column elementor-col-100">
        <div class="elementor-field-group e-form__buttons__wrapper elementor-field-type-previous"><button type="button"
            class="elementor-button elementor-size-sm e-form__buttons__wrapper__button e-form__buttons__wrapper__button-previous">Back</button></div>
        <div class="elementor-field-group e-form__buttons__wrapper elementor-field-type-next"><button type="button" class="elementor-button elementor-size-sm e-form__buttons__wrapper__button e-form__buttons__wrapper__button-next">Next</button></div>
      </div>
    </div>
    <div class="elementor-field-type-step elementor-column elementor-field-group-field_b0e4570 elementor-col-100 e-form__step elementor-hidden">
      <div class="e-field-step elementor-hidden" data-label="Step 7" data-previousbutton="" data-nextbutton="" data-iconurl="" data-iconlibrary="fas fa-star" data-icon=""></div>
      <div class="elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_52534c7 elementor-col-100">
        <p><span style="color: #000000; font-size: 25px; font-weight:600">Personal Information</span></p>
      </div>
      <div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-First_Name elementor-col-50">
        <input size="1" type="text" name="form_fields[First_Name]" id="form-field-First_Name" class="elementor-field elementor-size-md  elementor-field-textual" placeholder="First Name">
      </div>
      <div class="elementor-field-type-text elementor-field-group elementor-column elementor-field-group-Last_Name elementor-col-50">
        <input size="1" type="text" name="form_fields[Last_Name]" id="form-field-Last_Name" class="elementor-field elementor-size-md  elementor-field-textual" placeholder="Last Name">
      </div>
      <div class="elementor-field-type-tel elementor-field-group elementor-column elementor-field-group-Phone elementor-col-50">
        <input size="1" type="tel" name="form_fields[Phone]" id="form-field-Phone" class="elementor-field elementor-size-md  elementor-field-textual" placeholder="Phone" pattern="[0-9()#&amp;+*-=.]+"
          title="Only numbers and phone characters (#, -, *, etc) are accepted.">
      </div>
      <div class="elementor-field-type-email elementor-field-group elementor-column elementor-field-group-Email elementor-col-50">
        <input size="1" type="email" name="form_fields[Email]" id="form-field-Email" class="elementor-field elementor-size-md  elementor-field-textual" placeholder="Email (Optional)">
      </div>
      <div class="elementor-field-type-select elementor-field-group elementor-column elementor-field-group-State elementor-col-50">
        <div class="elementor-field elementor-select-wrapper remove-before ">
          <div class="select-caret-down-wrapper">
            <i aria-hidden="true" class="eicon-caret-down"></i>
          </div>
          <select name="form_fields[State]" id="form-field-State" class="elementor-field-textual elementor-size-md">
            <option value="- State -">- State -</option>
            <option value="Alabama">Alabama</option>
            <option value="Alaska">Alaska</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="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="Ohio">Ohio</option>
            <option value="Oklahoma">Oklahoma</option>
            <option value="Oregon">Oregon</option>
            <option value="Pennsylvania">Pennsylvania</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="Vermont">Vermont</option>
            <option value="Virginia">Virginia</option>
            <option value="Washington">Washington</option>
            <option value="West Virginia">West Virginia</option>
            <option value="Wisconsin">Wisconsin</option>
            <option value="Wyoming">Wyoming</option>
            <option value="Armed Forces Americas">Armed Forces Americas</option>
            <option value="Armed Forces Europe">Armed Forces Europe</option>
            <option value="Armed Forces Pacific">Armed Forces Pacific</option>
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      <div class="elementor-field-type-html elementor-field-group elementor-column elementor-field-group-field_5961c4e elementor-col-100">
        <span style="color: #000000; font-size: 16px !important;"><input id="leadid_tcpa_disclosure" type="hidden"><label>By clicking the Button below, you represent that you are 18+ years of age and agree to the
            <a style="color: #000000;" href="/privacy-policy/"><span style="color: #0000ff;">privacy policy</span></a> and <a style="color: #000000;" href="/terms-and-conditions/"><span style="color: #0000ff;">terms &amp; conditions</span></a> and
            you consent and request to be contacted by <a style="color: #000000;" href="https://claimtoday.us"><span style="color: #0000ff;">claimtoday.us</span></a> -
            <a style="color: #000000;" href="https://claimtoday.us/marketing-partners/"><span style="color: #0000ff;">Marketing Partners</span></a> , third parties working on our behalf, and the law firm you are matched with by phone, email, and
            text/SMS to the home or mobile number(s) you provided even if your provided number is on a National or State Do Not Call List. In some cases, pre-recorded messages and automated technology may be used to contact you for marketing
            purposes. There is no requirement that you provide consent as a condition of any purchase.</label></span>
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      <div class="e-form__buttons elementor-column elementor-col-100">
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            class="elementor-button elementor-size-sm e-form__buttons__wrapper__button e-form__buttons__wrapper__button-previous">Back</button></div>
        <div class="elementor-field-group elementor-field-type-submit e-form__buttons__wrapper">
          <button type="submit" class="elementor-button elementor-size-sm e-form__buttons__wrapper__button">
            <span>
              <span class=" elementor-button-icon">
              </span>
              <span class="elementor-button-text">Submit</span>
            </span>
          </button>
        </div>
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