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form.json
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form.json
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[
{
"type": "title",
"value": "Claim information"
},
{
"key": "information.reason",
"htmlClass": "information reason"
},
{
"key": "information.benefits_start",
"type": "date",
"htmlClass": "information benefits_start"
},
{
"type": "title",
"value": "Person claiming benefits (claimant)"
},
{
"type": "section-title",
"value": "Name"
},
{
"key": "claimant.name.first",
"htmlClass": "claimant name name-first"
},
{
"key": "claimant.name.middle",
"htmlClass": "claimant name name-middle"
},
{
"key": "claimant.name.last",
"htmlClass": "claimant name name-last"
},
{
"type": "section-title",
"value": "Home address"
},
{
"key": "claimant.address.street",
"htmlClass": "claimant address street"
},
{
"key": "claimant.address.city",
"htmlClass": "claimant address city-state-zip city"
},
{
"key": "claimant.address.state",
"htmlClass": "claimant address city-state-zip state"
},
{
"key": "claimant.address.zip",
"htmlClass": "claimant address city-state-zip zip"
},
{
"key": "claimant.address.country",
"htmlClass": "claimant address country"
},
{
"key": "claimant.email",
"htmlClass": "claimant email"
},
{
"key": "claimant.ssn",
"htmlClass": "claimant ssn"
},
{
"key": "claimant.birthdate",
"type": "date",
"htmlClass": "claimant birthdate"
},
{
"key": "claimant.language",
"htmlClass": "claimant language"
},
{
"key": "claimant.telephone",
"htmlClass": "claimant telephone"
},
{
"key": "claimant.alternative_caretaker",
"htmlClass": "claimant",
"type": "radios"
},
{
"type": "title",
"value": "Employment"
},
{
"type": "section-title",
"value": "Claimant’s employer"
},
{
"key": "employment.employer.name",
"htmlClass": "employment employer name"
},
{
"key": "employment.employer.address.street",
"htmlClass": "employment employer address"
},
{
"key": "employment.employer.address.city",
"htmlClass": "employment employer address city city-state-zip"
},
{
"key": "employment.employer.address.state",
"htmlClass": "employment employer address state city-state-zip"
},
{
"key": "employment.employer.address.zip",
"htmlClass": "employment employer address zip city-state-zip"
},
{
"key": "employment.benefits_end",
"type": "date",
"htmlClass": "employment"
},
{
"key": "employment.continue_work",
"htmlClass": "employment",
"type": "radios"
},
{
"key": "employment.workers_comp",
"htmlClass": "employment",
"type": "radios"
},
{
"key": "employment.disclose",
"htmlClass": "employment",
"type": "radios"
},
{
"type": "title",
"value": "Dependent",
"htmlClass": "dependent"
},
{
"type": "instructions",
"value": "This information is only required for claimants who are either bonding with a child or caring for someone other than themselves.",
"htmlClass": "dependent"
},
{
"type": "section-title",
"value": "Dependent’s name",
"htmlClass": "dependent"
},
{
"key": "dependent.name.first",
"htmlClass": "dependent name name-first"
},
{
"key": "dependent.name.middle",
"htmlClass": "dependent name name-middle"
},
{
"key": "dependent.name.last",
"htmlClass": "dependent name name-last"
},
{
"type": "section-title",
"htmlClass": "dependent",
"value": "Dependent’s residence"
},
{
"key": "dependent.address.street",
"htmlClass": "dependent address street"
},
{
"key": "dependent.address.city",
"htmlClass": "dependent address city city-state-zip"
},
{
"key": "dependent.address.state",
"htmlClass": "dependent address state city-state-zip"
},
{
"key": "dependent.address.zip",
"htmlClass": "dependent address zip city-state-zip"
},
{
"key": "dependent.address.country",
"htmlClass": "dependent address country"
},
{
"key": "dependent.relationship.type",
"htmlClass": "dependent relationship type"
},
{
"key": "dependent.relationship.documentation",
"htmlClass": "dependent relationship documentation"
},
{
"type": "title",
"value": "Payment"
},
{
"type": "instructions",
"value": "Please select the method by which benefits should be paid. Direct deposit requires a bank account."
},
{
"key": "payment.method",
"htmlClass": "payment",
"type": "radios"
},
{
"key": "payment.direct_deposit.bank_name",
"htmlClass": "payment direct_deposit"
},
{
"key": "payment.direct_deposit.account_number",
"htmlClass": "payment direct_deposit"
},
{
"key": "payment.direct_deposit.routing_number",
"htmlClass": "payment direct_deposit",
"pattern": "^((0[0-9])|(1[0-2])|(2[1-9])|(3[0-2])|(6[1-9])|(7[0-2])|80)([0-9]{7})$"
},
{
"key": "payment.direct_deposit.routing_number_2",
"htmlClass": "payment direct_deposit",
"pattern": "^((0[0-9])|(1[0-2])|(2[1-9])|(3[0-2])|(6[1-9])|(7[0-2])|80)([0-9]{7})$"
},
{
"type": "button",
"title": "Submit"
}
]