www.edoan.com
Open in
urlscan Pro
74.206.97.157
Public Scan
Submitted URL: https://r20.rs6.net/tn.jsp?f=001JukBduTYFc4KMms1urFchmtAo7sHn0cANivbv4O_aNK14staLRBgdCHjemcVp19buoQIqD4S4uPeaoJjiUze...
Effective URL: https://www.edoan.com/ClaimAssignment/NewWebUser?_authcn=eDoanWebuser
Submission: On August 04 via api from US — Scanned from DE
Effective URL: https://www.edoan.com/ClaimAssignment/NewWebUser?_authcn=eDoanWebuser
Submission: On August 04 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
POST /ClaimAssignment/NewWebUser
<form action="/ClaimAssignment/NewWebUser" data-ajax="false" data-ajax-success="ClaimAssignment.OnSuccess" data-default-work-mode="edit" data-overlay="true" data-timeout="60" id="form" method="post" role="form" novalidate="novalidate">
<script language="javascript" type="text/javascript">
$(document).ready(function() {
SetInvalidFormVSform('#form');
});
function SetInvalidFormVSform(formSelector) {
DisplayMsgPopupByDefault('', true);
$(formSelector).bind('invalid-form.validate2', function(event, validator) {
var errors = validator.numberOfInvalids();
if (errors) {
var msg = '';
if (validator.errorList.length > 1) {
msg += '<ul>';
$.each(validator.errorList, function() {
msg += '<li>' + this.message + '</li>';
});
msg += '</ul>';
} else {
$.each(validator.errorList, function() {
msg += this.message;
});
}
DisplayMsg(msg, 'exclm', 'VALIDATION FAILED', null, {
bDisplayIcon: true,
height: 0,
MsgDialogMode: 'popup'
});
}
});
}
</script>
<div class="clearfix form-horizontal ">
<input data-val="true" data-val-number="The field ClaimAssignmentID must be a number." data-val-required="The ClaimAssignmentID field is required." id="ClaimAssignmentID" name="ClaimAssignmentID" type="hidden" value="0">
<input data-val="true" data-val-number="The field SourceClaimAssignmentID must be a number." id="SourceClaimAssignmentID" name="SourceClaimAssignmentID" type="hidden" value="">
<input data-val="true" data-val-required="The IsLinkedCopy field is required." id="IsLinkedCopy" name="IsLinkedCopy" type="hidden" value="False">
<input data-val="true" data-val-required="The Mode field is required." id="Mode" name="Mode" type="hidden" value="NewWeb">
<input data-val="true" data-val-number="The field EMSImportQueueID must be a number." data-val-required="The EMSImportQueueID field is required." id="EMSImportQueueID" name="EMSImportQueueID" type="hidden" value="0">
<div class="col-xs-12 col-sm-12 col-md-10 col-lg-6 center-alignement">
<div class="clearfix">
</div>
<div class="">
<div class="border-bottom clearfix">
<h2 class="pull-left">Inspection Info</h2>
<button id="btnClearInspectionInfo" data-onclickconfirmjs="ClaimAssignment.ClearInspectionInfo" title="" data-prevent-default="true" class="jq-buttons btn-close btn btn-link pull-left skip-focus" data-original-title="Clear"
tabindex="-1">(Clear)</button>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="ClaimTypeID">Claim Type*</label><span class="field-validation-valid"
data-valmsg-for="ClaimTypeID" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9">
<div data-role="fieldcontain"><select id="ClaimTypeID" name="ClaimTypeID" class="bs-select show-tick" data-title="--Select--" data-width="100%" data-style=" btn-default" data-on-change="ClaimAssignment.ClaimTypeOnChange"
data-clear-btn="true" title="" data-val="true" data-val-required="Claim Type is required." data-original-title="--Select--" style="display: none;">
<option value=""></option>
<option value="31">Appraisal Clause</option>
<option value="27">ATV/Off Road</option>
<option value="17">Auction</option>
<option value="1">Auto</option>
<option value="18">Auto - Exceptional</option>
<option value="30">Auto - Specialty/Exotic</option>
<option value="19">CAT - Auto</option>
<option value="20">CAT - Property</option>
<option value="11">Classic Car</option>
<option value="6">Diminished Value</option>
<option value="13">DOI Re-inspection</option>
<option value="4">Estimate Review - Auto</option>
<option value="5">Estimate Review - Other</option>
<option value="28">Farm Equipment</option>
<option value="2">Heavy Equipment</option>
<option value="22">Heavy Equipment - Specialty</option>
<option value="24">Heavy Equipment - Trailer</option>
<option value="23">Marine/Watercraft</option>
<option value="9">Motorcycle</option>
<option value="99">Other</option>
<option value="21">Photos and Scope Only</option>
<option value="15">Photos Direct</option>
<option value="16">Photos Direct with Estimate</option>
<option value="10">Photos Only</option>
<option value="3">Property</option>
<option value="26">Property - Commercial</option>
<option value="32">Property - Farm/Ranch</option>
<option value="25">Property - Residential</option>
<option value="12">RV / Motorhome</option>
<option value="14">Scene Inspection</option>
<option value="7">Subrogation - Auto</option>
<option value="8">Subrogation - Other</option>
<option value="29">Virtual Estimate</option>
</select>
<div class="btn-group bootstrap-select bs-select show-tick" style="width: 100%;"><button type="button" class="btn dropdown-toggle selectpicker btn-default" data-toggle="dropdown" data-id="ClaimTypeID" title="--Select--"><span
class="filter-option pull-left">--Select--</span> <span class="caret"></span></button>
<div class="dropdown-menu open">
<ul class="dropdown-menu inner selectpicker" role="menu">
<li rel="0" class="selected"><a tabindex="0" class="" style=""><span class="text"></span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="1"><a tabindex="0" class="" style=""><span class="text">Appraisal Clause</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="2"><a tabindex="0" class="" style=""><span class="text">ATV/Off Road</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="3"><a tabindex="0" class="" style=""><span class="text">Auction</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="4"><a tabindex="0" class="" style=""><span class="text">Auto</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="5"><a tabindex="0" class="" style=""><span class="text">Auto - Exceptional</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="6"><a tabindex="0" class="" style=""><span class="text">Auto - Specialty/Exotic</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="7"><a tabindex="0" class="" style=""><span class="text">CAT - Auto</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="8"><a tabindex="0" class="" style=""><span class="text">CAT - Property</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="9"><a tabindex="0" class="" style=""><span class="text">Classic Car</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="10"><a tabindex="0" class="" style=""><span class="text">Diminished Value</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="11"><a tabindex="0" class="" style=""><span class="text">DOI Re-inspection</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="12"><a tabindex="0" class="" style=""><span class="text">Estimate Review - Auto</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="13"><a tabindex="0" class="" style=""><span class="text">Estimate Review - Other</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="14"><a tabindex="0" class="" style=""><span class="text">Farm Equipment</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="15"><a tabindex="0" class="" style=""><span class="text">Heavy Equipment</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="16"><a tabindex="0" class="" style=""><span class="text">Heavy Equipment - Specialty</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="17"><a tabindex="0" class="" style=""><span class="text">Heavy Equipment - Trailer</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="18"><a tabindex="0" class="" style=""><span class="text">Marine/Watercraft</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="19"><a tabindex="0" class="" style=""><span class="text">Motorcycle</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="20"><a tabindex="0" class="" style=""><span class="text">Other</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="21"><a tabindex="0" class="" style=""><span class="text">Photos and Scope Only</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="22"><a tabindex="0" class="" style=""><span class="text">Photos Direct</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="23"><a tabindex="0" class="" style=""><span class="text">Photos Direct with Estimate</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="24"><a tabindex="0" class="" style=""><span class="text">Photos Only</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="25"><a tabindex="0" class="" style=""><span class="text">Property</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="26"><a tabindex="0" class="" style=""><span class="text">Property - Commercial</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="27"><a tabindex="0" class="" style=""><span class="text">Property - Farm/Ranch</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="28"><a tabindex="0" class="" style=""><span class="text">Property - Residential</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="29"><a tabindex="0" class="" style=""><span class="text">RV / Motorhome</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="30"><a tabindex="0" class="" style=""><span class="text">Scene Inspection</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="31"><a tabindex="0" class="" style=""><span class="text">Subrogation - Auto</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="32"><a tabindex="0" class="" style=""><span class="text">Subrogation - Other</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="33"><a tabindex="0" class="" style=""><span class="text">Virtual Estimate</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
</ul>
</div>
</div>
</div>
</div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="InspectionLocationTypeID">Inspection Location*</label><span class="field-validation-valid"
data-valmsg-for="InspectionLocationTypeID" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9">
<div data-role="fieldcontain"><select id="InspectionLocationTypeID" name="InspectionLocationTypeID" class="bs-select show-tick" data-title="--Select--" data-width="100%" data-style=" btn-default"
data-on-change="ClaimAssignment.InspectionLocationTypeOnChange" data-clear-btn="true" title="" data-val="true" data-val-required="Inspection Location is required." data-original-title="--Select--" style="display: none;">
<option value=""></option>
<option value="1">With Owner</option>
<option value="2">Repair Facility</option>
<option value="3">Workplace</option>
<option value="4">Tow/Salvage Yard</option>
<option value="9">OTHER</option>
</select>
<div class="btn-group bootstrap-select bs-select show-tick" style="width: 100%;"><button type="button" class="btn dropdown-toggle selectpicker btn-default" data-toggle="dropdown" data-id="InspectionLocationTypeID"
title="--Select--"><span class="filter-option pull-left">--Select--</span> <span class="caret"></span></button>
<div class="dropdown-menu open">
<ul class="dropdown-menu inner selectpicker" role="menu">
<li rel="0" class="selected"><a tabindex="0" class="" style=""><span class="text"></span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="1"><a tabindex="0" class="" style=""><span class="text">With Owner</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="2"><a tabindex="0" class="" style=""><span class="text">Repair Facility</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="3"><a tabindex="0" class="" style=""><span class="text">Workplace</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="4"><a tabindex="0" class="" style=""><span class="text">Tow/Salvage Yard</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="5"><a tabindex="0" class="" style=""><span class="text">OTHER</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
</ul>
</div>
</div>
</div>
</div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="InspectionLocationName">Location Name</label><span class="field-validation-valid"
data-valmsg-for="InspectionLocationName" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" id="InspectionLocationName" maxlength="100" name="InspectionLocationName" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group" style="display: block;"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="InspectionLocationPhone">Location Phone</label><span
class="field-validation-valid" data-valmsg-for="InspectionLocationPhone" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-4 col-md-4 col-lg-4"><input class="form-control input-text inputmask" data-clear-btn="true" data-input-mask="(999) 999-9999" data-val="true" data-val-regex="Please enter valid Phone (Cell)."
data-val-regex-pattern="^\(\d{3}\)\s\d{3}-\d{4}$" id="InspectionLocationPhone" maxlength="100" name="InspectionLocationPhone" type="text" value=""></div>
</div>
<div class="form-group" data-role="fieldcontain">
<div data-role="fieldcontain" class="field-container"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="InspectionZipCode">Zip*</label><span class="field-validation-valid"
data-valmsg-for="InspectionZipCode" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-3 col-md-3 col-lg-3"><input class="form-control input-text" data-clear-btn="true" data-val="true" data-val-regex="Please enter valid Inspection Zip" data-val-regex-pattern="^\d{5}(-\d{4})?$"
data-val-required="Inspection Zip is required." id="InspectionZipCode" maxlength="10" name="InspectionZipCode" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container"><label class="col-xs-12 col-sm-1 col-md-2 col-lg-2 control-label control-label" for="InspectionStateID">State*</label><span class="field-validation-valid"
data-valmsg-for="InspectionStateID" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-4 col-md-4 col-lg-4">
<div data-role="fieldcontain"><select id="InspectionStateID" name="InspectionStateID" class="bs-select show-tick" data-title="--Select--" data-width="100%" data-style=" btn-default"
data-on-change="ClaimAssignment.InspectionStateOnChange" data-clear-btn="true" title="" data-val="true" data-val-required="Inspection State is required." data-original-title="--Select--" style="display: none;">
<option value=""></option>
<option value="AL">AL</option>
<option value="AK">AK</option>
<option value="AZ">AZ</option>
<option value="AR">AR</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DE">DE</option>
<option value="DC">DC</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="IA">IA</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="ME">ME</option>
<option value="MD">MD</option>
<option value="MA">MA</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MS">MS</option>
<option value="MO">MO</option>
<option value="MT">MT</option>
<option value="NE">NE</option>
<option value="NV">NV</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NY">NY</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="PR">PR</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VT">VT</option>
<option value="VA">VA</option>
<option value="WA">WA</option>
<option value="WV">WV</option>
<option value="WI">WI</option>
<option value="WY">WY</option>
</select>
<div class="btn-group bootstrap-select bs-select show-tick" style="width: 100%;"><button type="button" class="btn dropdown-toggle selectpicker btn-default" data-toggle="dropdown" data-id="InspectionStateID" title="--Select--"><span
class="filter-option pull-left">--Select--</span> <span class="caret"></span></button>
<div class="dropdown-menu open">
<ul class="dropdown-menu inner selectpicker" role="menu">
<li rel="0" class="selected"><a tabindex="0" class="" style=""><span class="text"></span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="1"><a tabindex="0" class="" style=""><span class="text">AL</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="2"><a tabindex="0" class="" style=""><span class="text">AK</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="3"><a tabindex="0" class="" style=""><span class="text">AZ</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="4"><a tabindex="0" class="" style=""><span class="text">AR</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="5"><a tabindex="0" class="" style=""><span class="text">CA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="6"><a tabindex="0" class="" style=""><span class="text">CO</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="7"><a tabindex="0" class="" style=""><span class="text">CT</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="8"><a tabindex="0" class="" style=""><span class="text">DE</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="9"><a tabindex="0" class="" style=""><span class="text">DC</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="10"><a tabindex="0" class="" style=""><span class="text">FL</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="11"><a tabindex="0" class="" style=""><span class="text">GA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="12"><a tabindex="0" class="" style=""><span class="text">HI</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="13"><a tabindex="0" class="" style=""><span class="text">ID</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="14"><a tabindex="0" class="" style=""><span class="text">IL</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="15"><a tabindex="0" class="" style=""><span class="text">IN</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="16"><a tabindex="0" class="" style=""><span class="text">IA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="17"><a tabindex="0" class="" style=""><span class="text">KS</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="18"><a tabindex="0" class="" style=""><span class="text">KY</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="19"><a tabindex="0" class="" style=""><span class="text">LA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="20"><a tabindex="0" class="" style=""><span class="text">ME</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="21"><a tabindex="0" class="" style=""><span class="text">MD</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="22"><a tabindex="0" class="" style=""><span class="text">MA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="23"><a tabindex="0" class="" style=""><span class="text">MI</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="24"><a tabindex="0" class="" style=""><span class="text">MN</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="25"><a tabindex="0" class="" style=""><span class="text">MS</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="26"><a tabindex="0" class="" style=""><span class="text">MO</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="27"><a tabindex="0" class="" style=""><span class="text">MT</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="28"><a tabindex="0" class="" style=""><span class="text">NE</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="29"><a tabindex="0" class="" style=""><span class="text">NV</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="30"><a tabindex="0" class="" style=""><span class="text">NH</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="31"><a tabindex="0" class="" style=""><span class="text">NJ</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="32"><a tabindex="0" class="" style=""><span class="text">NM</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="33"><a tabindex="0" class="" style=""><span class="text">NY</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="34"><a tabindex="0" class="" style=""><span class="text">NC</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="35"><a tabindex="0" class="" style=""><span class="text">ND</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="36"><a tabindex="0" class="" style=""><span class="text">OH</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="37"><a tabindex="0" class="" style=""><span class="text">OK</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="38"><a tabindex="0" class="" style=""><span class="text">OR</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="39"><a tabindex="0" class="" style=""><span class="text">PA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="40"><a tabindex="0" class="" style=""><span class="text">PR</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="41"><a tabindex="0" class="" style=""><span class="text">RI</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="42"><a tabindex="0" class="" style=""><span class="text">SC</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="43"><a tabindex="0" class="" style=""><span class="text">SD</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="44"><a tabindex="0" class="" style=""><span class="text">TN</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="45"><a tabindex="0" class="" style=""><span class="text">TX</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="46"><a tabindex="0" class="" style=""><span class="text">UT</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="47"><a tabindex="0" class="" style=""><span class="text">VT</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="48"><a tabindex="0" class="" style=""><span class="text">VA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="49"><a tabindex="0" class="" style=""><span class="text">WA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="50"><a tabindex="0" class="" style=""><span class="text">WV</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="51"><a tabindex="0" class="" style=""><span class="text">WI</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="52"><a tabindex="0" class="" style=""><span class="text">WY</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
</ul>
</div>
</div>
</div>
</div>
</div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="InspectionCity">City*</label><span class="field-validation-valid"
data-valmsg-for="InspectionCity" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" data-val="true" data-val-required="Inspection City is required." id="InspectionCity" maxlength="100" name="InspectionCity"
type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="InspectionAddress">Inspection Address*</label><span class="field-validation-valid"
data-valmsg-for="InspectionAddress" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" data-val="true" data-val-required="Inspection Address is required." id="InspectionAddress" maxlength="200"
name="InspectionAddress" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group" style="display:none;"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="InspectionSuiteUnitNumber">Suite/Unit Number</label><span
class="field-validation-valid" data-valmsg-for="InspectionSuiteUnitNumber" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" id="InspectionSuiteUnitNumber" maxlength="25" name="InspectionSuiteUnitNumber" type="text" value=""></div>
</div>
</div>
<div class="">
<div class="border-bottom clearfix">
<div class="clearfix">
<h2 class="pull-left"> Claim Info</h2>
<button id="btnClearClaimInfo" data-onclickconfirmjs="ClaimAssignment.ClearClaimInfo" title="" data-prevent-default="true" class="jq-buttons btn-close btn btn-link pull-left skip-focus" data-original-title="Clear"
tabindex="-1">(Clear)</button>
</div>
<div class="clearfix">
<p style="color:red">If you are new to Doan, welcome! Please feel free to contact us at 877-411-DOAN to get set up. To continue with assignment entry now, please enter ‘New’ under Client, Branch, and Adjuster. Please provide your name,
company name, phone, and email in the ‘Instructions’ field below.</p>
</div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="ClientName">Client*</label><span class="field-validation-valid" data-valmsg-for="ClientName"
data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input autocomplete="off" class="autocomplete form-control" data-clear-btn="true" data-createhiddenfield="1" data-delay="700" data-displayfield="DisplayText" data-items="-1"
data-on-change="ClaimAssignment.ClientOnChange" data-param-name="query" data-textcontrolid="ClientName" data-url="https://www.edoan.com:443/ClaimAssignment/GetClients?itemCount=5" data-val="true" data-val-required="Client is required."
data-value="0" data-valuecontrolid="ClientID" data-valuefield="Value" id="ClientName" name="ClientName" type="text" value=""><input type="hidden" id="ClientID" name="ClientID" value="0"></div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="BranchName">Branch*</label><span class="field-validation-valid" data-valmsg-for="BranchName"
data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input autocomplete="off" class="autocomplete form-control" data-clear-btn="true" data-createhiddenfield="1" data-delay="700" data-displayfield="DisplayText"
data-function="ClaimAssignment.AutoCompleteParamsBranch" data-items="-1" data-on-change="ClaimAssignment.BranchOnChange" data-param-name="query" data-textcontrolid="BranchName"
data-url="https://www.edoan.com:443/ClaimAssignment/GetBranches?itemCount=5" data-val="true" data-val-required="Branch is required." data-value="0" data-valuecontrolid="BranchID" data-valuefield="Value" id="BranchName" name="BranchName"
placeholder="…start typing to see available Branches, or hit [SPACE] to see all Branches…" type="text" value="" readonly=""><input type="hidden" id="BranchID" name="BranchID" value="0"></div>
</div>
<div class="form-group">
<div data-role="fieldcontain" class="field-container"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="AdjusterUserName">Adjuster*</label><span class="field-validation-valid"
data-valmsg-for="AdjusterUserName" data-valmsg-replace="false">*</span>
<div class="col-xs-10 col-sm-6 col-md-7 col-lg-7"><input autocomplete="off" class="autocomplete form-control" data-clear-btn="true" data-createhiddenfield="1" data-delay="700" data-displayfield="DisplayText"
data-function="ClaimAssignment.AutoCompleteParamsAdjuster" data-items="-1" data-param-name="query" data-textcontrolid="AdjusterUserName" data-url="https://www.edoan.com:443/ClaimAssignment/GetAdjusterUsers?itemCount=5" data-val="true"
data-val-required="Adjuster is required." data-value="0" data-valuecontrolid="AdjusterUserID" data-valuefield="Value" id="AdjusterUserName" name="AdjusterUserName" type="text" value="" readonly=""><input type="hidden"
id="AdjusterUserID" name="AdjusterUserID" value="0"></div>
</div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="ClaimNumber">Claim #*</label><span class="field-validation-valid"
data-valmsg-for="ClaimNumber" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-6 col-lg-6"><input class="form-control input-text" data-clear-btn="true" data-val="true" data-val-required="Claim # is required." id="ClaimNumber" maxlength="50" name="ClaimNumber" type="text" value="">
</div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="LossTypeID">Type of Loss*</label><span class="field-validation-valid"
data-valmsg-for="LossTypeID" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-5 col-lg-4">
<div data-role="fieldcontain"><select id="LossTypeID" name="LossTypeID" class="bs-select show-tick" data-title="--Select--" data-width="100%" data-style=" btn-default" data-clear-btn="true" title="" data-val="true"
data-val-required="Type of Loss is required." data-original-title="--Select--" style="display: none;">
<option value=""></option>
<option value="1">Comprehensive</option>
<option value="2">Collision</option>
<option value="3">Liability</option>
<option value="4">Theft</option>
<option value="5">Property Damage</option>
<option value="98">Unknown</option>
<option value="99">Other</option>
</select>
<div class="btn-group bootstrap-select bs-select show-tick" style="width: 100%;"><button type="button" class="btn dropdown-toggle selectpicker btn-default" data-toggle="dropdown" data-id="LossTypeID" title="--Select--"><span
class="filter-option pull-left">--Select--</span> <span class="caret"></span></button>
<div class="dropdown-menu open">
<ul class="dropdown-menu inner selectpicker" role="menu">
<li rel="0" class="selected"><a tabindex="0" class="" style=""><span class="text"></span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="1"><a tabindex="0" class="" style=""><span class="text">Comprehensive</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="2"><a tabindex="0" class="" style=""><span class="text">Collision</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="3"><a tabindex="0" class="" style=""><span class="text">Liability</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="4"><a tabindex="0" class="" style=""><span class="text">Theft</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="5"><a tabindex="0" class="" style=""><span class="text">Property Damage</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="6"><a tabindex="0" class="" style=""><span class="text">Unknown</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="7"><a tabindex="0" class="" style=""><span class="text">Other</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
</ul>
</div>
</div>
</div>
</div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="DateOfLoss">Date of Loss*</label><span class="field-validation-valid"
data-valmsg-for="DateOfLoss" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-6 col-md-4 col-lg-4">
<div class="input-group">
<input class="form-control date inputmask" data-clear-btn="true" data-date-format="MM/DD/YYYY" data-val="true" data-val-date="The field Date of Loss* must be a date." data-val-required="Date of Loss is required." id="DateOfLoss"
name="DateOfLoss" type="text" value="">
<span class="input-group-addon add-on"><i data-date-icon="glyphicon glyphicon-calendar" class="glyphicon glyphicon-calendar"></i></span>
</div>
</div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="PolicyNumber">Policy #</label><span class="field-validation-valid"
data-valmsg-for="PolicyNumber" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-6 col-md-5 col-lg-4"><input class="form-control input-text" data-clear-btn="true" id="PolicyNumber" maxlength="50" name="PolicyNumber" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group" style="display:none;"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="ClaimPolicyEffectiveDates">Policy Effective Dates</label><span
class="field-validation-valid" data-valmsg-for="ClaimPolicyEffectiveDates" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" id="ClaimPolicyEffectiveDates" maxlength="100" name="ClaimPolicyEffectiveDates" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group" style="display:none;"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="ClaimMortgageCompany">Mortgage Company</label><span
class="field-validation-valid" data-valmsg-for="ClaimMortgageCompany" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" id="ClaimMortgageCompany" maxlength="200" name="ClaimMortgageCompany" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="DeductibleAmount">Deductible</label><span class="field-validation-valid"
data-valmsg-for="DeductibleAmount" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-6 col-md-5 col-lg-4"><input class="form-control input-text" data-clear-btn="true" data-val="true" data-val-number="The field Deductible must be a number."
data-val-range="The field Deductible must be between 0 and 999999999.99." data-val-range-max="999999999.99" data-val-range-min="0" data-val-regex="Deductible Amount is invalid" data-val-regex-pattern="^\d+([.]\d{0,2})?$"
id="DeductibleAmount" maxlength="12" name="DeductibleAmount" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="InsuredName">Insured Name</label><span class="field-validation-valid"
data-valmsg-for="InsuredName" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-6 col-lg-6"><input class="form-control input-text" data-clear-btn="true" id="InsuredName" maxlength="200" name="InsuredName" type="text" value=""></div>
</div>
</div>
<div class="">
<div class="border-bottom clearfix">
<h2 class="pull-left"> Owner Info</h2>
<button id="btnClearOwnerInfo" data-onclickconfirmjs="ClaimAssignment.ClearOwnerInfo" title="" data-prevent-default="true" class="jq-buttons btn-close btn btn-link pull-left skip-focus" data-original-title="Clear"
tabindex="-1">(Clear)</button>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="OwnerFirstName">First Name</label><span class="field-validation-valid"
data-valmsg-for="OwnerFirstName" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" id="OwnerFirstName" maxlength="50" name="OwnerFirstName" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="OwnerLastName">Last Name</label><span class="field-validation-valid"
data-valmsg-for="OwnerLastName" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" id="OwnerLastName" maxlength="50" name="OwnerLastName" type="text" value=""></div>
</div>
<div class="form-group" data-role="fieldcontain">
<div data-role="fieldcontain" class="field-container"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="OwnerZipCode">Zip</label><span class="field-validation-valid" data-valmsg-for="OwnerZipCode"
data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-3 col-md-3 col-lg-3"><input class="form-control input-text" data-clear-btn="true" data-val="true" data-val-regex="Please enter valid Owner Zip" data-val-regex-pattern="^\d{5}(-\d{4})?$" id="OwnerZipCode"
maxlength="10" name="OwnerZipCode" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container"><label class="col-xs-12 col-sm-1 col-md-2 col-lg-2 control-label control-label" for="OwnerStateID">State</label><span class="field-validation-valid" data-valmsg-for="OwnerStateID"
data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-4 col-md-4 col-lg-4">
<div data-role="fieldcontain"><select id="OwnerStateID" name="OwnerStateID" class="bs-select show-tick" data-title="--Select--" data-width="100%" data-style=" btn-default" data-clear-btn="true" title="" data-original-title="--Select--"
style="display: none;">
<option value=""></option>
<option value="AL">AL</option>
<option value="AK">AK</option>
<option value="AZ">AZ</option>
<option value="AR">AR</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DE">DE</option>
<option value="DC">DC</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="IA">IA</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="ME">ME</option>
<option value="MD">MD</option>
<option value="MA">MA</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MS">MS</option>
<option value="MO">MO</option>
<option value="MT">MT</option>
<option value="NE">NE</option>
<option value="NV">NV</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NY">NY</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="PR">PR</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VT">VT</option>
<option value="VA">VA</option>
<option value="WA">WA</option>
<option value="WV">WV</option>
<option value="WI">WI</option>
<option value="WY">WY</option>
</select>
<div class="btn-group bootstrap-select bs-select show-tick" style="width: 100%;"><button type="button" class="btn dropdown-toggle selectpicker btn-default" data-toggle="dropdown" data-id="OwnerStateID" title="--Select--"><span
class="filter-option pull-left">--Select--</span> <span class="caret"></span></button>
<div class="dropdown-menu open">
<ul class="dropdown-menu inner selectpicker" role="menu">
<li rel="0" class="selected"><a tabindex="0" class="" style=""><span class="text"></span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="1"><a tabindex="0" class="" style=""><span class="text">AL</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="2"><a tabindex="0" class="" style=""><span class="text">AK</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="3"><a tabindex="0" class="" style=""><span class="text">AZ</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="4"><a tabindex="0" class="" style=""><span class="text">AR</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="5"><a tabindex="0" class="" style=""><span class="text">CA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="6"><a tabindex="0" class="" style=""><span class="text">CO</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="7"><a tabindex="0" class="" style=""><span class="text">CT</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="8"><a tabindex="0" class="" style=""><span class="text">DE</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="9"><a tabindex="0" class="" style=""><span class="text">DC</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="10"><a tabindex="0" class="" style=""><span class="text">FL</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="11"><a tabindex="0" class="" style=""><span class="text">GA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="12"><a tabindex="0" class="" style=""><span class="text">HI</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="13"><a tabindex="0" class="" style=""><span class="text">ID</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="14"><a tabindex="0" class="" style=""><span class="text">IL</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="15"><a tabindex="0" class="" style=""><span class="text">IN</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="16"><a tabindex="0" class="" style=""><span class="text">IA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="17"><a tabindex="0" class="" style=""><span class="text">KS</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="18"><a tabindex="0" class="" style=""><span class="text">KY</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="19"><a tabindex="0" class="" style=""><span class="text">LA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="20"><a tabindex="0" class="" style=""><span class="text">ME</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="21"><a tabindex="0" class="" style=""><span class="text">MD</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="22"><a tabindex="0" class="" style=""><span class="text">MA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="23"><a tabindex="0" class="" style=""><span class="text">MI</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="24"><a tabindex="0" class="" style=""><span class="text">MN</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="25"><a tabindex="0" class="" style=""><span class="text">MS</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="26"><a tabindex="0" class="" style=""><span class="text">MO</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="27"><a tabindex="0" class="" style=""><span class="text">MT</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="28"><a tabindex="0" class="" style=""><span class="text">NE</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="29"><a tabindex="0" class="" style=""><span class="text">NV</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="30"><a tabindex="0" class="" style=""><span class="text">NH</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="31"><a tabindex="0" class="" style=""><span class="text">NJ</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="32"><a tabindex="0" class="" style=""><span class="text">NM</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="33"><a tabindex="0" class="" style=""><span class="text">NY</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="34"><a tabindex="0" class="" style=""><span class="text">NC</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="35"><a tabindex="0" class="" style=""><span class="text">ND</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="36"><a tabindex="0" class="" style=""><span class="text">OH</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="37"><a tabindex="0" class="" style=""><span class="text">OK</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="38"><a tabindex="0" class="" style=""><span class="text">OR</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="39"><a tabindex="0" class="" style=""><span class="text">PA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="40"><a tabindex="0" class="" style=""><span class="text">PR</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="41"><a tabindex="0" class="" style=""><span class="text">RI</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="42"><a tabindex="0" class="" style=""><span class="text">SC</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="43"><a tabindex="0" class="" style=""><span class="text">SD</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="44"><a tabindex="0" class="" style=""><span class="text">TN</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="45"><a tabindex="0" class="" style=""><span class="text">TX</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="46"><a tabindex="0" class="" style=""><span class="text">UT</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="47"><a tabindex="0" class="" style=""><span class="text">VT</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="48"><a tabindex="0" class="" style=""><span class="text">VA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="49"><a tabindex="0" class="" style=""><span class="text">WA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="50"><a tabindex="0" class="" style=""><span class="text">WV</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="51"><a tabindex="0" class="" style=""><span class="text">WI</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="52"><a tabindex="0" class="" style=""><span class="text">WY</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
</ul>
</div>
</div>
</div>
</div>
</div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="OwnerCity">City</label><span class="field-validation-valid" data-valmsg-for="OwnerCity"
data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" id="OwnerCity" maxlength="100" name="OwnerCity" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="OwnerAddress">Address</label><span class="field-validation-valid"
data-valmsg-for="OwnerAddress" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" id="OwnerAddress" maxlength="200" name="OwnerAddress" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group" style="display:none;"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="OwnerSuiteUnitNumber">Suite/Unit Number</label><span
class="field-validation-valid" data-valmsg-for="OwnerSuiteUnitNumber" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" id="OwnerSuiteUnitNumber" maxlength="25" name="OwnerSuiteUnitNumber" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="OwnerEmailAddress">Email</label><span class="field-validation-valid"
data-valmsg-for="OwnerEmailAddress" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" data-val="true" data-val-regex="The field Email is invalid email address format."
data-val-regex-pattern="^[\w-']+(\.[\w-']+)*@([a-zA-Z0-9-]+(\.[a-zA-Z0-9-]+)*?\.[a-zA-Z]{2,6}|(\d{1,3}\.){3}\d{1,3})(:\d{4})?$" id="OwnerEmailAddress" maxlength="150" name="OwnerEmailAddress" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="OwnerPhoneNumberCell">Phone (cell)</label><span class="field-validation-valid"
data-valmsg-for="OwnerPhoneNumberCell" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-5 col-md-5 col-lg-4"><input class="form-control input-text inputmask" data-clear-btn="true" data-input-mask="(999) 999-9999" data-val="true" data-val-regex="Please enter valid Phone (Cell)."
data-val-regex-pattern="^\(\d{3}\)\s\d{3}-\d{4}$" id="OwnerPhoneNumberCell" maxlength="35" name="OwnerPhoneNumberCell" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="OwnerPhoneNumberHome">Phone (home)</label><span class="field-validation-valid"
data-valmsg-for="OwnerPhoneNumberHome" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-5 col-md-5 col-lg-4"><input class="form-control input-text inputmask" data-clear-btn="true" data-input-mask="(999) 999-9999" data-val="true" data-val-regex="Please enter valid Phone (home)."
data-val-regex-pattern="^\(\d{3}\)\s\d{3}-\d{4}$" id="OwnerPhoneNumberHome" maxlength="35" name="OwnerPhoneNumberHome" type="text" value=""></div>
</div>
<div class="form-group" data-role="fieldcontain">
<div data-role="fieldcontain" class="field-container"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="OwnerPhoneNumberOffice">Phone (office)</label><span class="field-validation-valid"
data-valmsg-for="OwnerPhoneNumberOffice" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-5 col-md-5 col-lg-4"><input class="form-control input-text inputmask" data-clear-btn="true" data-input-mask="(999) 999-9999" data-val="true" data-val-regex="Please enter valid Phone (office)."
data-val-regex-pattern="^\(\d{3}\)\s\d{3}-\d{4}$" id="OwnerPhoneNumberOffice" maxlength="35" name="OwnerPhoneNumberOffice" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container"><label class="col-xs-12 col-sm-1 col-md-1 col-lg-1 control-label control-label" for="OwnerPhoneNumberOfficeExt">Ext</label><span class="field-validation-valid"
data-valmsg-for="OwnerPhoneNumberOfficeExt" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-2 col-md-3 col-lg-2"><input class="form-control input-text" data-clear-btn="true" id="OwnerPhoneNumberOfficeExt" maxlength="10" name="OwnerPhoneNumberOfficeExt" type="text" value=""></div>
</div>
</div>
</div>
<div class="">
<div class="border-bottom clearfix">
<h2 class="pull-left">Vehicle Info</h2>
<button id="btnClearVehicleInfo" data-onclickconfirmjs="ClaimAssignment.ClearVehicleInfo" title="" data-prevent-default="true" class="jq-buttons btn-close btn btn-link pull-left skip-focus" data-original-title="Clear"
tabindex="-1">(Clear)</button>
</div>
<div data-role="fieldcontain" class="field-container form-group" style="display: block;"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="VehicleYear">Year</label><span class="field-validation-valid"
data-valmsg-for="VehicleYear" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-3 col-md-2 col-lg-2"><input class="form-control input-text" data-clear-btn="true" data-val="true" data-val-number="The field Year must be a number." id="VehicleYear" maxlength="4" name="VehicleYear" type="text"
value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group" style="display:none;"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="TypeOfPropertyID">Type of Property</label><span
class="field-validation-valid" data-valmsg-for="TypeOfPropertyID" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9">
<div data-role="fieldcontain"><select id="TypeOfPropertyID" name="TypeOfPropertyID" class="bs-select show-tick" data-title="--Select--" data-width="100%" data-style=" btn-default" data-clear-btn="true" title=""
data-original-title="--Select--" style="display: none;">
<option value=""></option>
<option value="1">Residential</option>
<option value="2">Commercial</option>
<option value="3">Other</option>
</select>
<div class="btn-group bootstrap-select bs-select show-tick" style="width: 100%;"><button type="button" class="btn dropdown-toggle selectpicker btn-default" data-toggle="dropdown" data-id="TypeOfPropertyID" title="--Select--"><span
class="filter-option pull-left">--Select--</span> <span class="caret"></span></button>
<div class="dropdown-menu open">
<ul class="dropdown-menu inner selectpicker" role="menu">
<li rel="0"><a tabindex="0" class="" style=""><span class="text"></span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="1"><a tabindex="0" class="" style=""><span class="text">Residential</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="2"><a tabindex="0" class="" style=""><span class="text">Commercial</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="3"><a tabindex="0" class="" style=""><span class="text">Other</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
</ul>
</div>
</div>
</div>
</div>
</div>
<div data-role="fieldcontain" class="field-container form-group" style="display:none;"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="PropertyBuildingDescription">Building Description</label><span
class="field-validation-valid" data-valmsg-for="PropertyBuildingDescription" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" id="PropertyBuildingDescription" maxlength="250" name="PropertyBuildingDescription"
placeholder="…briefly describe type of unit and appearance" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group" style="display:none;"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="PropertyNumberOfBuildings">Number of Buildings</label><span
class="field-validation-valid" data-valmsg-for="PropertyNumberOfBuildings" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" id="PropertyNumberOfBuildings" maxlength="100" name="PropertyNumberOfBuildings" type="text" value=""></div>
</div>
<div class="form-group" data-role="fieldcontain" style="display: block;">
<div data-role="fieldcontain" class="field-container"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="VehicleMake">Make</label><span class="field-validation-valid" data-valmsg-for="VehicleMake"
data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-4 col-md-4 col-lg-4"><input class="form-control input-text" data-clear-btn="true" id="VehicleMake" maxlength="50" name="VehicleMake" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container"><label class="col-xs-12 col-sm-1 col-md-1 col-lg-1 control-label control-label" for="VehicleModel">Model</label><span class="field-validation-valid" data-valmsg-for="VehicleModel"
data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-3 col-md-4 col-lg-4"><input class="form-control input-text" data-clear-btn="true" id="VehicleModel" maxlength="50" name="VehicleModel" type="text" value=""></div>
</div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="VehicleColor">Color</label><span class="field-validation-valid"
data-valmsg-for="VehicleColor" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" id="VehicleColor" maxlength="50" name="VehicleColor" type="text" value=""></div>
</div>
<div class="form-group" data-role="fieldcontain" style="display: block;">
<div data-role="fieldcontain" class="field-container"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="VehicleLicenseStateID">License State</label><span class="field-validation-valid"
data-valmsg-for="VehicleLicenseStateID" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-2 col-md-2 col-lg-2">
<div data-role="fieldcontain"><select id="VehicleLicenseStateID" name="VehicleLicenseStateID" class="bs-select show-tick" data-title="--Select--" data-width="100%" data-style=" btn-default" data-clear-btn="true" title=""
data-original-title="--Select--" style="display: none;">
<option value=""></option>
<option value="AL">AL</option>
<option value="AK">AK</option>
<option value="AZ">AZ</option>
<option value="AR">AR</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DE">DE</option>
<option value="DC">DC</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="IA">IA</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="ME">ME</option>
<option value="MD">MD</option>
<option value="MA">MA</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MS">MS</option>
<option value="MO">MO</option>
<option value="MT">MT</option>
<option value="NE">NE</option>
<option value="NV">NV</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NY">NY</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="PR">PR</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VT">VT</option>
<option value="VA">VA</option>
<option value="WA">WA</option>
<option value="WV">WV</option>
<option value="WI">WI</option>
<option value="WY">WY</option>
</select>
<div class="btn-group bootstrap-select bs-select show-tick" style="width: 100%;"><button type="button" class="btn dropdown-toggle selectpicker btn-default" data-toggle="dropdown" data-id="VehicleLicenseStateID"
title="--Select--"><span class="filter-option pull-left">--Select--</span> <span class="caret"></span></button>
<div class="dropdown-menu open">
<ul class="dropdown-menu inner selectpicker" role="menu">
<li rel="0" class="selected"><a tabindex="0" class="" style=""><span class="text"></span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="1"><a tabindex="0" class="" style=""><span class="text">AL</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="2"><a tabindex="0" class="" style=""><span class="text">AK</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="3"><a tabindex="0" class="" style=""><span class="text">AZ</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="4"><a tabindex="0" class="" style=""><span class="text">AR</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="5"><a tabindex="0" class="" style=""><span class="text">CA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="6"><a tabindex="0" class="" style=""><span class="text">CO</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="7"><a tabindex="0" class="" style=""><span class="text">CT</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="8"><a tabindex="0" class="" style=""><span class="text">DE</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="9"><a tabindex="0" class="" style=""><span class="text">DC</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="10"><a tabindex="0" class="" style=""><span class="text">FL</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="11"><a tabindex="0" class="" style=""><span class="text">GA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="12"><a tabindex="0" class="" style=""><span class="text">HI</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="13"><a tabindex="0" class="" style=""><span class="text">ID</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="14"><a tabindex="0" class="" style=""><span class="text">IL</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="15"><a tabindex="0" class="" style=""><span class="text">IN</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="16"><a tabindex="0" class="" style=""><span class="text">IA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="17"><a tabindex="0" class="" style=""><span class="text">KS</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="18"><a tabindex="0" class="" style=""><span class="text">KY</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="19"><a tabindex="0" class="" style=""><span class="text">LA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="20"><a tabindex="0" class="" style=""><span class="text">ME</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="21"><a tabindex="0" class="" style=""><span class="text">MD</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="22"><a tabindex="0" class="" style=""><span class="text">MA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="23"><a tabindex="0" class="" style=""><span class="text">MI</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="24"><a tabindex="0" class="" style=""><span class="text">MN</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="25"><a tabindex="0" class="" style=""><span class="text">MS</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="26"><a tabindex="0" class="" style=""><span class="text">MO</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="27"><a tabindex="0" class="" style=""><span class="text">MT</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="28"><a tabindex="0" class="" style=""><span class="text">NE</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="29"><a tabindex="0" class="" style=""><span class="text">NV</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="30"><a tabindex="0" class="" style=""><span class="text">NH</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="31"><a tabindex="0" class="" style=""><span class="text">NJ</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="32"><a tabindex="0" class="" style=""><span class="text">NM</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="33"><a tabindex="0" class="" style=""><span class="text">NY</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="34"><a tabindex="0" class="" style=""><span class="text">NC</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="35"><a tabindex="0" class="" style=""><span class="text">ND</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="36"><a tabindex="0" class="" style=""><span class="text">OH</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="37"><a tabindex="0" class="" style=""><span class="text">OK</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="38"><a tabindex="0" class="" style=""><span class="text">OR</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="39"><a tabindex="0" class="" style=""><span class="text">PA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="40"><a tabindex="0" class="" style=""><span class="text">PR</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="41"><a tabindex="0" class="" style=""><span class="text">RI</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="42"><a tabindex="0" class="" style=""><span class="text">SC</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="43"><a tabindex="0" class="" style=""><span class="text">SD</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="44"><a tabindex="0" class="" style=""><span class="text">TN</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="45"><a tabindex="0" class="" style=""><span class="text">TX</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="46"><a tabindex="0" class="" style=""><span class="text">UT</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="47"><a tabindex="0" class="" style=""><span class="text">VT</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="48"><a tabindex="0" class="" style=""><span class="text">VA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="49"><a tabindex="0" class="" style=""><span class="text">WA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="50"><a tabindex="0" class="" style=""><span class="text">WV</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="51"><a tabindex="0" class="" style=""><span class="text">WI</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="52"><a tabindex="0" class="" style=""><span class="text">WY</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
</ul>
</div>
</div>
</div>
</div>
</div>
<div data-role="fieldcontain" class="field-container"><label class="col-xs-12 col-sm-2 col-md-2 col-lg-2 control-label control-label" for="VehicleLicensePlateNumber">Plate #</label><span class="field-validation-valid"
data-valmsg-for="VehicleLicensePlateNumber" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-4 col-md-5 col-lg-5"><input class="form-control input-text" data-clear-btn="true" id="VehicleLicensePlateNumber" maxlength="50" name="VehicleLicensePlateNumber" type="text" value=""></div>
</div>
</div>
<div data-role="fieldcontain" class="field-container form-group" style="display: block;"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="VehicleVIN">VIN</label><span class="field-validation-valid"
data-valmsg-for="VehicleVIN" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-4 col-md-4 col-lg-4"><input class="form-control input-text" data-clear-btn="true" id="VehicleVIN" maxlength="100" name="VehicleVIN" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="VehicleDamageDescription">Damage</label><span class="field-validation-valid"
data-valmsg-for="VehicleDamageDescription" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><textarea class="form-control-multiline" data-clear-btn="true" id="VehicleDamageDescription" name="VehicleDamageDescription"></textarea></div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="VehicleFactsOfLossDescription">Facts of Loss</label><span class="field-validation-valid"
data-valmsg-for="VehicleFactsOfLossDescription" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><textarea class="form-control-multiline" data-clear-btn="true" id="VehicleFactsOfLossDescription" name="VehicleFactsOfLossDescription"></textarea></div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="VehicleInstructionDescription">Instructions</label><span class="field-validation-valid"
data-valmsg-for="VehicleInstructionDescription" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><textarea class="form-control-multiline" data-clear-btn="true" id="VehicleInstructionDescription" name="VehicleInstructionDescription"></textarea></div>
</div>
</div>
<div class="">
<div class="border-bottom clearfix">
<h2 class="pull-left">Bodyshop Info</h2>
<button id="btnClearBodyShop" data-onclickconfirmjs="ClaimAssignment.ClearBodyShop" title="" data-prevent-default="true" class="jq-buttons btn-close btn btn-link pull-left skip-focus" data-original-title="Clear"
tabindex="-1">(Clear)</button>
</div>
<div class="form-group" style="display: block;">
<div data-role="fieldcontain" class="field-container"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label bodyshop-Required control-label" for="BodyShopName">Bodyshop</label><span class="field-validation-valid"
data-valmsg-for="BodyShopName" data-valmsg-replace="false">*</span>
<div class="col-xs-10 col-sm-6 col-md-7 col-lg-7"><input autocomplete="off" class="autocomplete form-control" data-clear-btn="true" data-createhiddenfield="1" data-delay="700" data-displayfield="DisplayText" data-items="-1"
data-on-change="ClaimAssignment.BodyshopOnChange" data-param-name="query" data-textcontrolid="BodyShopName" data-url="https://www.edoan.com:443/ClaimAssignment/GetBodyShops?itemCount=5" data-value="0" data-valuecontrolid="BodyShopID"
data-valuefield="Value" id="BodyShopName" name="BodyShopName" type="text" value=""><input type="hidden" id="BodyShopID" name="BodyShopID" value="0"></div>
</div>
</div>
<div data-role="fieldcontain" class="field-container form-group" style="display:none;"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label bodyshop-Required control-label" for="Contractor">Contractor</label><span
class="field-validation-valid" data-valmsg-for="Contractor" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" id="Contractor" name="Contractor" type="text" value=""></div>
</div>
<div class="form-group" data-role="fieldcontain">
<div data-role="fieldcontain" class="field-container"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label bodyshop-Required control-label" for="BodyShopZipCode">Zip</label><span class="field-validation-valid"
data-valmsg-for="BodyShopZipCode" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-3 col-md-3 col-lg-3"><input class="form-control input-text" data-clear-btn="true" data-val="true" data-val-regex="Please enter valid Bodyshop Zip" data-val-regex-pattern="^\d{5}(-\d{4})?$" id="BodyShopZipCode"
maxlength="10" name="BodyShopZipCode" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container"><label class="col-xs-12 col-sm-1 col-md-2 col-lg-2 control-label bodyshop-Required control-label" for="BodyShopStateID">State</label><span class="field-validation-valid"
data-valmsg-for="BodyShopStateID" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-4 col-md-4 col-lg-4">
<div data-role="fieldcontain"><select id="BodyShopStateID" name="BodyShopStateID" class="bs-select show-tick" data-title="--Select--" data-width="100%" data-style=" btn-default" data-clear-btn="true" title=""
data-original-title="--Select--" style="display: none;">
<option value=""></option>
<option value="AL">AL</option>
<option value="AK">AK</option>
<option value="AZ">AZ</option>
<option value="AR">AR</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DE">DE</option>
<option value="DC">DC</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="IA">IA</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="ME">ME</option>
<option value="MD">MD</option>
<option value="MA">MA</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MS">MS</option>
<option value="MO">MO</option>
<option value="MT">MT</option>
<option value="NE">NE</option>
<option value="NV">NV</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NY">NY</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="PR">PR</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VT">VT</option>
<option value="VA">VA</option>
<option value="WA">WA</option>
<option value="WV">WV</option>
<option value="WI">WI</option>
<option value="WY">WY</option>
</select>
<div class="btn-group bootstrap-select bs-select show-tick" style="width: 100%;"><button type="button" class="btn dropdown-toggle selectpicker btn-default" data-toggle="dropdown" data-id="BodyShopStateID" title="--Select--"><span
class="filter-option pull-left">--Select--</span> <span class="caret"></span></button>
<div class="dropdown-menu open">
<ul class="dropdown-menu inner selectpicker" role="menu">
<li rel="0" class="selected"><a tabindex="0" class="" style=""><span class="text"></span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="1"><a tabindex="0" class="" style=""><span class="text">AL</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="2"><a tabindex="0" class="" style=""><span class="text">AK</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="3"><a tabindex="0" class="" style=""><span class="text">AZ</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="4"><a tabindex="0" class="" style=""><span class="text">AR</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="5"><a tabindex="0" class="" style=""><span class="text">CA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="6"><a tabindex="0" class="" style=""><span class="text">CO</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="7"><a tabindex="0" class="" style=""><span class="text">CT</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="8"><a tabindex="0" class="" style=""><span class="text">DE</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="9"><a tabindex="0" class="" style=""><span class="text">DC</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="10"><a tabindex="0" class="" style=""><span class="text">FL</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="11"><a tabindex="0" class="" style=""><span class="text">GA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="12"><a tabindex="0" class="" style=""><span class="text">HI</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="13"><a tabindex="0" class="" style=""><span class="text">ID</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="14"><a tabindex="0" class="" style=""><span class="text">IL</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="15"><a tabindex="0" class="" style=""><span class="text">IN</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="16"><a tabindex="0" class="" style=""><span class="text">IA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="17"><a tabindex="0" class="" style=""><span class="text">KS</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="18"><a tabindex="0" class="" style=""><span class="text">KY</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="19"><a tabindex="0" class="" style=""><span class="text">LA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="20"><a tabindex="0" class="" style=""><span class="text">ME</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="21"><a tabindex="0" class="" style=""><span class="text">MD</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="22"><a tabindex="0" class="" style=""><span class="text">MA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="23"><a tabindex="0" class="" style=""><span class="text">MI</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="24"><a tabindex="0" class="" style=""><span class="text">MN</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="25"><a tabindex="0" class="" style=""><span class="text">MS</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="26"><a tabindex="0" class="" style=""><span class="text">MO</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="27"><a tabindex="0" class="" style=""><span class="text">MT</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="28"><a tabindex="0" class="" style=""><span class="text">NE</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="29"><a tabindex="0" class="" style=""><span class="text">NV</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="30"><a tabindex="0" class="" style=""><span class="text">NH</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="31"><a tabindex="0" class="" style=""><span class="text">NJ</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="32"><a tabindex="0" class="" style=""><span class="text">NM</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="33"><a tabindex="0" class="" style=""><span class="text">NY</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="34"><a tabindex="0" class="" style=""><span class="text">NC</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="35"><a tabindex="0" class="" style=""><span class="text">ND</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="36"><a tabindex="0" class="" style=""><span class="text">OH</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="37"><a tabindex="0" class="" style=""><span class="text">OK</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="38"><a tabindex="0" class="" style=""><span class="text">OR</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="39"><a tabindex="0" class="" style=""><span class="text">PA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="40"><a tabindex="0" class="" style=""><span class="text">PR</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="41"><a tabindex="0" class="" style=""><span class="text">RI</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="42"><a tabindex="0" class="" style=""><span class="text">SC</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="43"><a tabindex="0" class="" style=""><span class="text">SD</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="44"><a tabindex="0" class="" style=""><span class="text">TN</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="45"><a tabindex="0" class="" style=""><span class="text">TX</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="46"><a tabindex="0" class="" style=""><span class="text">UT</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="47"><a tabindex="0" class="" style=""><span class="text">VT</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="48"><a tabindex="0" class="" style=""><span class="text">VA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="49"><a tabindex="0" class="" style=""><span class="text">WA</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="50"><a tabindex="0" class="" style=""><span class="text">WV</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="51"><a tabindex="0" class="" style=""><span class="text">WI</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
<li rel="52"><a tabindex="0" class="" style=""><span class="text">WY</span><i class="glyphicon glyphicon-ok icon-ok check-mark"></i></a></li>
</ul>
</div>
</div>
</div>
</div>
</div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label bodyshop-Required control-label" for="BodyShopCity">City</label><span class="field-validation-valid"
data-valmsg-for="BodyShopCity" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" id="BodyShopCity" maxlength="100" name="BodyShopCity" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label bodyshop-Required control-label" for="BodyShopAddress">Address</label><span class="field-validation-valid"
data-valmsg-for="BodyShopAddress" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" id="BodyShopAddress" maxlength="200" name="BodyShopAddress" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="BodyShopContactName">Contact Name</label><span class="field-validation-valid"
data-valmsg-for="BodyShopContactName" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" id="BodyShopContactName" maxlength="100" name="BodyShopContactName" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="BodyShopEmailAddress">Email</label><span class="field-validation-valid"
data-valmsg-for="BodyShopEmailAddress" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9"><input class="form-control input-text" data-clear-btn="true" data-val="true" data-val-regex="The field Email is invalid email address format."
data-val-regex-pattern="^[\w-']+(\.[\w-']+)*@([a-zA-Z0-9-]+(\.[a-zA-Z0-9-]+)*?\.[a-zA-Z]{2,6}|(\d{1,3}\.){3}\d{1,3})(:\d{4})?$" id="BodyShopEmailAddress" maxlength="150" name="BodyShopEmailAddress" type="text" value=""></div>
</div>
<div class="form-group" data-role="fieldcontain">
<div data-role="fieldcontain" class="field-container"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label bodyshop-Required control-label" for="BodyShopPhoneNumberOffice">Phone (Office)</label><span
class="field-validation-valid" data-valmsg-for="BodyShopPhoneNumberOffice" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-5 col-md-5 col-lg-4"><input class="form-control input-text inputmask" data-clear-btn="true" data-input-mask="(999) 999-9999" data-val="true" data-val-regex="Please enter valid Bodyshop Phone (office)."
data-val-regex-pattern="^\(\d{3}\)\s\d{3}-\d{4}$" id="BodyShopPhoneNumberOffice" maxlength="35" name="BodyShopPhoneNumberOffice" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container"><label class="col-xs-12 col-sm-1 col-md-1 col-lg-1 control-label control-label" for="BodyShopPhoneNumberOfficeExt">Ext</label><span class="field-validation-valid"
data-valmsg-for="BodyShopPhoneNumberOfficeExt" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-2 col-md-3 col-lg-2"><input class="form-control input-text" data-clear-btn="true" id="BodyShopPhoneNumberOfficeExt" maxlength="10" name="BodyShopPhoneNumberOfficeExt" type="text" value=""></div>
</div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="BodyShopPhoneNumberTollFree">Phone (Toll Free)</label><span class="field-validation-valid"
data-valmsg-for="BodyShopPhoneNumberTollFree" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-5 col-md-5 col-lg-4"><input class="form-control input-text inputmask" data-clear-btn="true" data-input-mask="(999) 999-9999" data-val="true" data-val-regex="Please enter valid Phone (Toll Free)."
data-val-regex-pattern="^\(\d{3}\)\s\d{3}-\d{4}$" id="BodyShopPhoneNumberTollFree" maxlength="35" name="BodyShopPhoneNumberTollFree" type="text" value=""></div>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label control-label" for="BodyShopFaxNumber">Fax</label><span class="field-validation-valid"
data-valmsg-for="BodyShopFaxNumber" data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-5 col-md-5 col-lg-4"><input class="form-control input-text inputmask" data-clear-btn="true" data-input-mask="(999) 999-9999" data-val="true" data-val-regex="Please enter valid Fax."
data-val-regex-pattern="^\(\d{3}\)\s\d{3}-\d{4}$" id="BodyShopFaxNumber" maxlength="35" name="BodyShopFaxNumber" type="text" value=""></div>
</div>
</div>
<div class="">
<div class="border-bottom clearfix">
<h2 class="pull-left">Attachments</h2>
</div>
<div data-role="fieldcontain" class="field-container form-group"><label class="col-xs-12 col-sm-3 col-md-3 col-lg-3 control-label" for="Attachments">File</label><span class="field-validation-valid" data-valmsg-for="Attachments"
data-valmsg-replace="false">*</span>
<div class="col-xs-12 col-sm-8 col-md-9 col-lg-9 upload-block">
<div id="Attachments" data-url="/Handlers/FileUploader.ashx?_msv=sAh_2V9OH7608gsi63r29g2&_authcn=eDoanWebuser" data-maxchunksize="1048576000" data-sequentialuploads="True" data-maxnumberoffiles="999" data-previewmaxwidth="80"
data-previewmaxheight="80" data-disablevideopreview="True" class="jq-file-upload well upload-on-save">
<div class="fileupload-buttonbar"><span class="btn btn-success fileinput-button"><i class="glyphicon glyphicon-plus"></i><span>Add files...</span><input type="file" name="files[]" multiple=""><input type="hidden" id="Attachments_ssa"
name="Attachments_ssa"
value="i3BM4u5Tbpi6JNqwEYI2NyuoJIf9mzTO8TXuo7Y6Ju6qUSz4wpu2PY3e_QPfPZ6toV2VY_I4VFVRwhgDv0vGMyUZw--pkk2nnQ15WQaWXmLMyTLCnZH3m8lg5RRWPvrOr8CJbelHThL7oBcIs6jDB7nESqpFw08IIEF0m7zL_LTE1iPH-0YNYAs0GgfdDb9VFj6msRx0NM6EN8opUUM6D8GXPqsoEjM7RM0tEYr8gEID28xYMFu-bFv_UP3yJE1U07HbCWj3Hb6yfSx0Z0HBt2LgL3p6Wx8UF698K_NzpDg1"><input
type="hidden" id="Attachments_files" name="Attachments_files" value=""></span><span class="text-muted margin-left-5px">or drag/drop files here...</span></div>
<div role="presentation" class="files"></div>
</div>
<div id="blueimp-gallery" class="blueimp-gallery blueimp-gallery-controls" data-filter=":even">
<div class="slides"></div>
<h3 class="title"></h3>
<a class="prev">‹</a>
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<a class="close">×</a>
<a class="play-pause"></a>
<ol class="indicator"></ol>
</div>
<script id="Attachments-template-upload" type="text/x-tmpl"> {% for (var i=0, file; file=o.files[i]; i++) { %}
<div class="template-upload fade multiple-files">
<div class="pull-left" style="width:85px" >
<span class="preview margin-right-5px"></span>
</div>
<div class="pull-left">
<div>
<div class="pull-left">
<p class="name margin-right-5px">{%=file.name%}</p>
</div>
<div class="pull-left text-muted margin-right-5px">
(<span class="size ">Processing...</span>)
</div>
<div class="clearfix"></div>
</div>
<div>
{% if (!i && !o.options.autoUpload) { %}
<div class="pull-left margin-right-5px" >
<button class="btn btn-primary start" disabled>
<i class="glyphicon glyphicon-upload"></i>
<span>Start Upload</span>
</button>
</div>
{% } %}
{% if (!i) { %}
<div class="pull-left">
<button class="btn btn-warning cancel">
<i class="glyphicon glyphicon-ban-circle"></i>
<span>Cancel</span>
</button>
</div>
{% } %}
<div class="clearfix"></div>
</div>
<div>
<div class="pull-left">
<strong class="error text-danger"></strong>
</div>
<div class="pull-left" style="width:100%;">
<div class="progress progress-striped active margin-top-5px" role="progressbar" aria-valuemin="0" aria-valuemax="100" aria-valuenow="0"><div class="progress-bar progress-bar-success" style="width:0%;"></div></div>
</div>
<div class="clearfix"></div>
</div>
</div>
<div class="clearfix"></div>
</div>
{% } %}
</script>
<script id="Attachments-template-download" type="text/x-tmpl"> {% for (var i=0, file; file=o.files[i]; i++) { %}
<div class="template-download fade multiple-files" data-uid="{%=file.fuid%}" >
<div class="pull-left" style="width:85px">
<span class="preview margin-right-5px">
{% if (file.thumbnailUrl) { %}
<a href="{%=file.url%}" title="{%=file.name%}" download="{%=file.name%}" {%=file.isImage?'data-gallery':''%}><img src="{%=file.thumbnailUrl%}"></a>
{% } %}
</span>
</div>
<div class="pull-left">
<div>
<div class="pull-left">
<p class="name margin-right-5px">
{% if (file.url && !file.error) { %}
<a href="{%=file.url%}" title="{%=file.name%}" download="{%=file.name%}" {%=file.isImage?'data-gallery':''%}>{%=file.name%}</a>
{% } else { %}
<span>{%=file.name%}</span>
{% } %}
</p>
</div>
<div class="pull-left text-muted margin-right-5px">
(<span class="size">{%=o.formatFileSize(file.size)%}</span>)
</div>
<div class="clear">
</div>
{% if (file.deleteUrl) { %}
<div class="pull-left margin-right-5px">
<button class="btn btn-danger delete" data-type="{%=file.deleteType%}" data-url="{%=file.deleteUrl%}"{% if (file.deleteWithCredentials) { %} data-xhr-fields='{"withCredentials":true}'{% } %}>
<i class="glyphicon glyphicon-trash"></i>
<span>Delete</span>
</button>
</div>
{% } else { %}
<div class="pull-left">
<button class="btn btn-warning cancel">
<i class="glyphicon glyphicon-ban-circle"></i>
<span>Cancel</span>
</button>
</div>
{% } %}
<div class="clearfix"></div>
</div>
{% if (file.error) { %}
<div><span class="label label-danger">Error</span> {%=file.error%}</div>
{% } %}
</div>
<div class="clearfix"></div>
</div>
{% } %}
</script>
</div>
</div>
</div>
<div class="">
<div class="border-bottom clearfix"></div>
<div class="pull-right">
<button id="btnSubmitToDoan" data-onclickconfirmjs="ClaimAssignment.SubmitToDoan" title="" data-prevent-default="true" class="jq-buttons btn-save btn btn-default btn-default"
data-original-title="Submit To Doan"><i class="glyphicon glyphicon-upload" aria-hidden="true"></i> Submit To Doan</button>
</div>
</div>
</div>
</div>
</form>Text Content
Toggle navigation * Sign Out Create New Assignment * * Website User as * WebsiteUser INSPECTION INFO (Clear) Claim Type** Appraisal ClauseATV/Off RoadAuctionAutoAuto - ExceptionalAuto - Specialty/ExoticCAT - AutoCAT - PropertyClassic CarDiminished ValueDOI Re-inspectionEstimate Review - AutoEstimate Review - OtherFarm EquipmentHeavy EquipmentHeavy Equipment - SpecialtyHeavy Equipment - TrailerMarine/WatercraftMotorcycleOtherPhotos and Scope OnlyPhotos DirectPhotos Direct with EstimatePhotos OnlyPropertyProperty - CommercialProperty - Farm/RanchProperty - ResidentialRV / MotorhomeScene InspectionSubrogation - AutoSubrogation - OtherVirtual Estimate --Select-- * * Appraisal Clause * ATV/Off Road * Auction * Auto * Auto - Exceptional * Auto - Specialty/Exotic * CAT - Auto * CAT - Property * Classic Car * Diminished Value * DOI Re-inspection * Estimate Review - Auto * Estimate Review - Other * Farm Equipment * Heavy Equipment * Heavy Equipment - Specialty * Heavy Equipment - Trailer * Marine/Watercraft * Motorcycle * Other * Photos and Scope Only * Photos Direct * Photos Direct with Estimate * Photos Only * Property * Property - Commercial * Property - Farm/Ranch * Property - Residential * RV / Motorhome * Scene Inspection * Subrogation - Auto * Subrogation - Other * Virtual Estimate Inspection Location** With OwnerRepair FacilityWorkplaceTow/Salvage YardOTHER --Select-- * * With Owner * Repair Facility * Workplace * Tow/Salvage Yard * OTHER Location Name* Location Phone* Zip** State** ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVAWAWVWIWY --Select-- * * AL * AK * AZ * AR * CA * CO * CT * DE * DC * FL * GA * HI * ID * IL * IN * IA * KS * KY * LA * ME * MD * MA * MI * MN * MS * MO * MT * NE * NV * NH * NJ * NM * NY * NC * ND * OH * OK * OR * PA * PR * RI * SC * SD * TN * TX * UT * VT * VA * WA * WV * WI * WY City** Inspection Address** Suite/Unit Number* CLAIM INFO (Clear) If you are new to Doan, welcome! Please feel free to contact us at 877-411-DOAN to get set up. To continue with assignment entry now, please enter ‘New’ under Client, Branch, and Adjuster. Please provide your name, company name, phone, and email in the ‘Instructions’ field below. Client** Branch** Adjuster** Claim #** Type of Loss** ComprehensiveCollisionLiabilityTheftProperty DamageUnknownOther --Select-- * * Comprehensive * Collision * Liability * Theft * Property Damage * Unknown * Other Date of Loss** Policy #* Policy Effective Dates* Mortgage Company* Deductible* Insured Name* OWNER INFO (Clear) First Name* Last Name* Zip* State* ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVAWAWVWIWY --Select-- * * AL * AK * AZ * AR * CA * CO * CT * DE * DC * FL * GA * HI * ID * IL * IN * IA * KS * KY * LA * ME * MD * MA * MI * MN * MS * MO * MT * NE * NV * NH * NJ * NM * NY * NC * ND * OH * OK * OR * PA * PR * RI * SC * SD * TN * TX * UT * VT * VA * WA * WV * WI * WY City* Address* Suite/Unit Number* Email* Phone (cell)* Phone (home)* Phone (office)* Ext* VEHICLE INFO (Clear) Year* Type of Property* ResidentialCommercialOther --Select-- * * Residential * Commercial * Other Building Description* Number of Buildings* Make* Model* Color* License State* ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVAWAWVWIWY --Select-- * * AL * AK * AZ * AR * CA * CO * CT * DE * DC * FL * GA * HI * ID * IL * IN * IA * KS * KY * LA * ME * MD * MA * MI * MN * MS * MO * MT * NE * NV * NH * NJ * NM * NY * NC * ND * OH * OK * OR * PA * PR * RI * SC * SD * TN * TX * UT * VT * VA * WA * WV * WI * WY Plate #* VIN* Damage* Facts of Loss* Instructions* BODYSHOP INFO (Clear) Bodyshop* Contractor* Zip* State* ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPAPRRISCSDTNTXUTVTVAWAWVWIWY --Select-- * * AL * AK * AZ * AR * CA * CO * CT * DE * DC * FL * GA * HI * ID * IL * IN * IA * KS * KY * LA * ME * MD * MA * MI * MN * MS * MO * MT * NE * NV * NH * NJ * NM * NY * NC * ND * OH * OK * OR * PA * PR * RI * SC * SD * TN * TX * UT * VT * VA * WA * WV * WI * WY City* Address* Contact Name* Email* Phone (Office)* Ext* Phone (Toll Free)* Fax* ATTACHMENTS File* Add files...or drag/drop files here... ‹ › × Submit To Doan Loading...