Universal Copy : Request Forms

ELECTRONIC ORDER FORM

<div class="location_block" id="loc_block_{0}">
		<h5>Location </h5>
		<div class="row ">
			<div class="col-md-6">
				<div class="form-group">
					<label for="location-{0}-name">Name</label>
					<input name="data[location][{0}][location_name]" class="form-control name-holder" id="location-{0}-name" type="text"/>				</div>
			</div>
			<div class="col-md-6">
				<div class="form-group">
					<label for="location-{0}-address">Address</label>
					<input name="data[location][{0}][location_address]" class="form-control address-holder" id="location-{0}-address" type="text"/>				</div>
			</div>
			<div class="col-md-6">
				<div class="form-group">
					<label for="location-{0}-city">City</label>
					<input name="data[location][{0}][location_city]" class="form-control city-holder" id="location-{0}-city" type="text"/>				</div>
			</div>
			<div class="col-md-6">
				<div class="form-group">
					<label for="location-{0}-state">State</label>
					<input name="data[location][{0}][location_state]" class="form-control state-holder" id="location-{0}-state" type="text"/>				</div>
			</div>
			<div class="col-md-6">
				<div class="form-group">
					<label for="location-{0}-zipcode">Zipcode</label>
					<input name="data[location][{0}][location_zipcode]" class="form-control zipcode-holder" id="location-{0}-zipcode" type="text"/>				</div>
			</div>
			<div class="col-md-6">
				<div class="form-group">
					<label for="location-{0}-phone">Phone</label>
					<input name="data[location][{0}][location_phone]" class="form-control phone-holder" id="location-{0}-phone" type="text"/>				</div>
			</div>
			<div class="col-md-6 checkbox-block">
									<div class="form-check form-check-inline">
						<label class="form-check-label">
							<input type="checkbox" name="data[location][{0}][record_type][]" class="record_type_block" value=medical  class=""  />  Medical						</label>
					</div>
										<div class="form-check form-check-inline">
						<label class="form-check-label">
							<input type="checkbox" name="data[location][{0}][record_type][]" class="record_type_block" value=billing  class=""  /> Billing						</label>
					</div>
										<div class="form-check form-check-inline">
						<label class="form-check-label">
							<input type="checkbox" name="data[location][{0}][record_type][]" class="record_type_block" value=xray  class=""  /> X-Ray						</label>
					</div>
										<div class="form-check form-check-inline">
						<label class="form-check-label">
							<input type="checkbox" name="data[location][{0}][record_type][]" class="record_type_block" value=employment  class=""  /> Employment						</label>
					</div>
										<div class="form-check form-check-inline">
						<label class="form-check-label">
							<input type="checkbox" name="data[location][{0}][record_type][]" class="record_type_block" value=wage  class=""  /> Wage						</label>
					</div>
										<div class="form-check form-check-inline">
						<label class="form-check-label">
							<input type="checkbox" name="data[location][{0}][record_type][]" class="record_type_block" value=calosha  class=""  /> Cal-Osha Inspection Records						</label>
					</div>
										<div class="form-check form-check-inline">
						<label class="form-check-label">
							<input type="checkbox" name="data[location][{0}][record_type][]" class="record_type_block" value=claims  class=""  /> Claims						</label>
					</div>
										<div class="form-check form-check-inline">
						<label class="form-check-label">
							<input type="checkbox" name="data[location][{0}][record_type][]" class="record_type_block" value=other  class=""  /> Other						</label>
					</div>
										<div class="form-check form-check-inline">
						<label class="form-check-label">
							<input type="checkbox" name="data[location][{0}][record_type][]" class="record_type_block" value=personal_service   class=""  /> Personal Service						</label>
					</div>
										<div class="form-check form-check-inline">
						<label class="form-check-label">
							<input type="checkbox" name="data[location][{0}][record_type][]" class="record_type_block" value=witness_appear  class=""  /> Witness to Appear						</label>
					</div>
								</div>
			<div class="col-md-12">
				<div class="form-group">
					<a href="javascript:void(0)" id="item-remove-{0}" class="btn btn-default " onclick="removeLocation('{0}')"><i class="fa fa-minus"></i> Remove</a>
				</div>
			</div>
		</div>
	</div>

ELECTRONIC ORDER FORM

APPLICANT/PLAINTIFF INFORMATION

ORDERING PARTY

CASE TYPE

BILL TO

CASE INFORMATION

PARTY LIST (If Billing Carrier)

Deliver Records To: