LifeSafer uses cookies on this website to provide anonymous usage reporting. By continuing to navigate this site you will be accepting the use of cookies in this way. To learn more about how and why we use cookies or to change your cookie preferences at any time please visit our privacy policy. Accept
[gravityforms id="38" title="false"]
<script type="text/javascript">var gform;gform||(document.addEventListener("gform_main_scripts_loaded",function(){gform.scriptsLoaded=!0}),window.addEventListener("DOMContentLoaded",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener("DOMContentLoaded",o):document.addEventListener("gform_main_scripts_loaded",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook("action",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook("filter",o,n,r,t)},doAction:function(o){gform.doHook("action",o,arguments)},applyFilters:function(o){return gform.doHook("filter",o,arguments)},removeAction:function(o,n){gform.removeHook("action",o,n)},removeFilter:function(o,n,r){gform.removeHook("filter",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+"_"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){"function"!=typeof(t=o.callable)&&(t=window[t]),"action"==n?t.apply(null,r):r[0]=t.apply(null,r)})),"filter"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});</script>
<div class='gf_browser_unknown gform_wrapper gravity-theme' id='gform_wrapper_38' >
<div class='gform_heading'>
<span class='gform_description'></span>
</div><form method='post' enctype='multipart/form-data' id='gform_38' action='/locations/kentucky/madisonville/6937/' novalidate>
<div class='gform_body gform-body'><div id='gform_fields_38' class='gform_fields top_label form_sublabel_below description_below'><div id="field_38_1" class="gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible" data-js-reload="field_38_1"><label class='gfield_label' for='input_38_1' >First Name<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label><div class='ginput_container ginput_container_text'><input name='input_1' id='input_38_1' type='text' value='' class='large' placeholder='First Name' aria-required="true" aria-invalid="false" /> </div></div><div id="field_38_3" class="gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible" data-js-reload="field_38_3"><label class='gfield_label' for='input_38_3' >Last Name<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label><div class='ginput_container ginput_container_text'><input name='input_3' id='input_38_3' type='text' value='' class='large' placeholder='Last Name' aria-required="true" aria-invalid="false" /> </div></div><div id="field_38_12" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_38_12"><label class='gfield_label' for='input_38_12' >Do you currently have a LifeSafer device installed?<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label><div class='ginput_container ginput_container_select'><select name='input_12' id='input_38_12' class='large gfield_select' aria-required="true" aria-invalid="false" ><option value='Yes' >Yes</option><option value='No' >No</option></select></div></div><div id="field_38_4" class="gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible" data-js-reload="field_38_4"><label class='gfield_label' for='input_38_4' >Phone<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label><div class='ginput_container ginput_container_phone'><input name='input_4' id='input_38_4' type='tel' value='' class='large' placeholder='Phone Number' aria-required="true" aria-invalid="false" /></div></div><div id="field_38_5" class="gfield gfield--width-half gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible" data-js-reload="field_38_5"><label class='gfield_label' for='input_38_5' >State<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label><div class='ginput_container ginput_container_select'><select name='input_5' id='input_38_5' class='large gfield_select' aria-required="true" aria-invalid="false" ><option value='' selected='selected' class='gf_placeholder'>Choose State</option><option value='Alabama' >Alabama</option><option value='Alaska' >Alaska</option><option value='Arizona' >Arizona</option><option value='Arkansas' >Arkansas</option><option value='California' >California</option><option value='Colorado' >Colorado</option><option value='Connecticut' >Connecticut</option><option value='Delaware' >Delaware</option><option value='District of Columbia' >District of Columbia</option><option value='Florida' >Florida</option><option value='Georgia' >Georgia</option><option value='Hawaii' >Hawaii</option><option value='Idaho' >Idaho</option><option value='Illinois' >Illinois</option><option value='Indiana' >Indiana</option><option value='Iowa' >Iowa</option><option value='Kansas' >Kansas</option><option value='Kentucky' >Kentucky</option><option value='Louisiana' >Louisiana</option><option value='Maine' >Maine</option><option value='Maryland' >Maryland</option><option value='Massachusetts' >Massachusetts</option><option value='Michigan' >Michigan</option><option value='Minnesota' >Minnesota</option><option value='Mississippi' >Mississippi</option><option value='Missouri' >Missouri</option><option value='Montana' >Montana</option><option value='Nebraska' >Nebraska</option><option value='Nevada' >Nevada</option><option value='New Hampshire' >New Hampshire</option><option value='New Jersey' >New Jersey</option><option value='New Mexico' >New Mexico</option><option value='New York' >New York</option><option value='North Carolina' >North Carolina</option><option value='North Dakota' >North Dakota</option><option value='Ohio' >Ohio</option><option value='Oklahoma' >Oklahoma</option><option value='Oregon' >Oregon</option><option value='Pennsylvania' >Pennsylvania</option><option value='Rhode Island' >Rhode Island</option><option value='South Carolina' >South Carolina</option><option value='South Dakota' >South Dakota</option><option value='Tennessee' >Tennessee</option><option value='Texas' >Texas</option><option value='Utah' >Utah</option><option value='Vermont' >Vermont</option><option value='Virginia' >Virginia</option><option value='Washington' >Washington</option><option value='West Virginia' >West Virginia</option><option value='Wisconsin' >Wisconsin</option><option value='Wyoming' >Wyoming</option></select></div></div><div id="field_38_6" class="gfield gfield--width-full gfield_contains_required field_sublabel_below field_description_below hidden_label gfield_visibility_visible" data-js-reload="field_38_6"><label class='gfield_label' for='input_38_6' >Email<span class="gfield_required"><span class="gfield_required gfield_required_text">(Required)</span></span></label><div class='ginput_container ginput_container_email'>
<input name='input_6' id='input_38_6' type='email' value='' class='large' placeholder='Email' aria-required="true" aria-invalid="false" />
</div></div><div id="field_38_9" class="gfield gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_38_9"><p style="font-size:12px">By submitting this form, you agree and consent for LifeSafer and its affiliates to use automated technology, including emails, calls, texts, and prerecorded messages, to contact you at the information provided. No purchase necessary; message and data rates may apply.</p></div><div id="field_38_7" class="gfield gfield--width-full gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_38_7"><div class='ginput_container ginput_container_text'><input name='input_7' id='input_38_7' type='hidden' class='gform_hidden' aria-invalid="false" value='LifeSafer' /></div></div><div id="field_38_8" class="gfield gfield--width-full gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_38_8"><div class='ginput_container ginput_container_text'><input name='input_8' id='input_38_8' type='hidden' class='gform_hidden' aria-invalid="false" value='True' /></div></div><div id="field_38_10" class="gfield gfield--width-full gform_hidden field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_38_10"><div class='ginput_container ginput_container_text'><input name='input_10' id='input_38_10' type='hidden' class='gform_hidden' aria-invalid="false" value='Client' /></div></div><div id="field_38_13" class="gfield gform_validation_container field_sublabel_below field_description_below gfield_visibility_visible" data-js-reload="field_38_13"><label class='gfield_label' for='input_38_13' >Name</label><div class='ginput_container'><input name='input_13' id='input_38_13' type='text' value='' autocomplete='new-password'/></div><div class='gfield_description' id='gfield_description_38_13'>This field is for validation purposes and should be left unchanged.</div></div></div></div>
<div class='gform_footer top_label'> <input type='submit' id='gform_submit_button_38' class='gform_button button' value='Get My Offers' onclick='if(window["gf_submitting_38"]){return false;} if( !jQuery("#gform_38")[0].checkValidity || jQuery("#gform_38")[0].checkValidity()){window["gf_submitting_38"]=true;} ' onkeypress='if( event.keyCode == 13 ){ if(window["gf_submitting_38"]){return false;} if( !jQuery("#gform_38")[0].checkValidity || jQuery("#gform_38")[0].checkValidity()){window["gf_submitting_38"]=true;} jQuery("#gform_38").trigger("submit",[true]); }' />
<input type='hidden' class='gform_hidden' name='is_submit_38' value='1' />
<input type='hidden' class='gform_hidden' name='gform_submit' value='38' />
<input type='hidden' class='gform_hidden' name='gform_unique_id' value='' />
<input type='hidden' class='gform_hidden' name='state_38' value='WyJbXSIsIjFjZjBiODE4ZGUwYzFjZGUzNzBmNTA1ZjNkMWYyNzRjIl0=' />
<input type='hidden' class='gform_hidden' name='gform_target_page_number_38' id='gform_target_page_number_38' value='0' />
<input type='hidden' class='gform_hidden' name='gform_source_page_number_38' id='gform_source_page_number_38' value='1' />
<input type='hidden' name='gform_field_values' value='' />
</div>
<p style="display: none !important;"><label>Δ<textarea name="ak_hp_textarea" cols="45" rows="8" maxlength="100"></textarea></label><input type="hidden" id="ak_js_1" name="ak_js" value="156"/><script>document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() );</script></p></form>
</div>
