File: /home/accuhealthinsuranceadvisors/public_html/form.php
<form id="valForm" name="valForm" class="valForm" method="get" class="p-4">
<input type="hidden" name="xxTrustedFormCertUrl" id="xxTrustedFormCertUrl_0" value="https://cert.trustedform.com/454a35b802f3e7b63ffabb4efedb7c6ebe67886c">
<input type="hidden" name="DateOfBirth" id="dob">
<!--Get Client IP -->
<?php
$ip = getClientIp();
echo '<input name="IPAddress" type="hidden" value="' . $ip . '" />';
?>
<input type="hidden" name="CompanyId" id="CompanyId" value="16">
<div class="row">
<h3 class="display-6 mb-3 text-center"> Who are we speaking to?</h3>
<div class="col-md-6">
<div class="form-floating mb-4">
<input id="firstname" type="text" name="firstname" class="firstname form-control alpha required" placeholder="First Name" required>
<label for="firstname d-flex justify-content-center">First Name *</label>
<div class="valid-feedback"> Looks good! </div>
<div class="invalid-feedback"> Please enter your First Name. </div>
</div>
</div>
<!-- /column -->
<div class="col-md-6">
<div class="form-floating mb-4">
<input id="lastname" type="text" name="lastname" class="lastname form-control alpha" placeholder="Last Name" required>
<label for="lastname d-flex justify-content-center">Last Name *</label>
<div class="valid-feedback"> Looks good! </div>
<div class="invalid-feedback"> Please enter your Last Name. </div>
</div>
</div>
<div class="col-md-6">
<div class="form-floating mb-4">
<input type="text" class="form-control phone numer" name="phone" id="phone" placeholder="Phone Number" minlength="10" maxlength="10" maxlength="30" required>
<label for="phone">Phone Number *</label>
<div class="valid-feedback"> Looks good! </div>
<div class="invalid-feedback"> Please enter your Phone Number. </div>
</div>
</div>
<!-- /column -->
<div class="col-md-6">
<div class="form-floating mb-4">
<input id="email" type="text" name="email" class="email form-control" placeholder="Email Address" required>
<label for="email">Email *</label>
<div class="valid-feedback"> Looks good! </div>
<div class="invalid-feedback"> Please enter your Email Address. </div>
</div>
</div>
<section>
<div class="row">
<h3 class="display-6 mb-3 text-center"> What is your Date of Birth?</h3>
<div class="col-md-4 col-sm-12">
<label>Month</label>
<select id="dobmonth" class="dobmonth form-select" name="month" required></select>
</div>
<div class="col-md-4 col-sm-12">
<label>Day</label>
<select id="dobday" class="dobday form-select" name="day" required></select>
</div>
<div class="col-md-4 col-sm-12">
<label>Year</label>
<select id="dobyear" class="dobyear form-select" name="year" required></select>
</div>
</div>
</section>
<!--Step 5 -->
<section class="wrapper bg-gradient-primary mb-1">
<h2 class="display-6 mb-3 text-center mt-5"> What is your current address?</h2>
<div class="row formStepper-p-0">
<div class="col-md-12">
<div class="form-floating mb-4">
<input id="address" type="text" name="address" class="address form-control" placeholder="Street Address" required>
<label for="address" class="he-form-field">Street Address *</label>
</div>
</div>
<div class="col-md-4">
<div class="form-floating mb-4">
<input type="text" class="form-control numer zipCode" minlength="5" maxlength="5" name="zip" id="zipCode" placeholder="Zip Code" onkeyup="zipCodeLookup(1);" value="<?php echo $_POST["zipCode"]; ?>">
<label for="zipcode">Zip Code *</label>
</div>
</div>
<!-- /column -->
<div class="col-md-4">
<div class="form-floating mb-4">
<input type="text" class="form-control numer city" name="city" id="city" placeholder="City" value="<?php echo $_POST["city"]; ?>" required>
<label for="city">City *</label>
</div>
</div>
<div class="col-md-4">
<div class="form-floating mb-4">
<input type="text" class="form-control numer state" name="state" id="state" placeholder="State" value="<?php echo $_POST["state"]; ?>" required>
<label for="state">State *</label>
</div>
</div>
<div class="col-md-12">
<p>By Clicking “Connect Now!” above you agree to receive SMS notification regarding
your enrollment application and account registered with, by and from Accu-Health Insurance Advisors.
You will receive “one” text message when you opt in and “one”
text message when you complete an application and sign up with Accu-Health Insurance Advisors
as your agency on record of your application and enrollment process. Future
communications for plan information, billing and updates will be sent “one” time if
there is anything urgent pertaining to your application that requires your immediate
attention. Message and data rates may apply. At any time, you can reply “HELP” for
support or “STOP” to unsubscribe. Before clicking “Connect Now!” above please select
(at least one) forms of communication</p>
<div class="form-check form-check-inline">
<input class="form-check-input" type="checkbox" id="phonecheckbox" value="option1">
<label class="form-check-label" for="phonecheckbox">Phone</label>
</div>
<div class="form-check form-check-inline">
<input class="form-check-input" type="checkbox" id="smscheckbox" value="option2">
<label class="form-check-label" for="smscheckbox">SMS</label>
</div>
<div class="form-check form-check-inline">
<input class="form-check-input" type="checkbox" id="emailcheckbox" value="option3">
<label class="form-check-label" for="emailcheckbox">Email</label>
</div>
<div class="form-check form-check-inline">
<input class="form-check-input" type="checkbox" id="mailcheckbox" value="option4">
<label class="form-check-label" for="mailcheckbox">Mail</label>
</div>
</div>
<div class="col-md-12">
<p>
By entering a phone number and email address and submitting this form, you represent that you are at least 18 years old and agree to our <a href="privacy.html">Privacy Policy</a> and <a href="privacy.html">Terms of Use</a>. You also authorize accuhealthinsuranceadvisors.com and/or its
<a data-toggle="modal" href="#partnerModal" style="color: #0031e3; font-style=">marketing partners
</a> to contact you for marketing/telemarketing purposes at the number and address provided above, including your wireless number if provided, using live operators, automated telephone
dialing systems, pre-recorded messages, text messages and/or emails, even if the number you provide is on a state or Federal Do Not Call registry. You are not required to consent as a condition of purchasing goods or services
and may revoke consent at anytime. Accu-Health Insurance Advisors has the option to send communication such as texting via a short code and will not allow third parties to send messages or communications on their behalf.
</p>
<p>
Accu-Health Insurance Advisors is an independent website and is not a federal or state Marketplace website. Accu-Health Insurance Advisors does not provide quotes or sell insurance directly to consumers, is not affiliated with any exchange, and is not a
licensed insurance agent or broker. Accordingly, you should not send us (via mail or email) any sensitive information, including personal health information or applications. Any such communications will not be treated as
confidential and will be discarded, as, in offering this website, we are required to comply with the standards established under 45 CFR 155.260 to protect the privacy and security of personally identifiable information.
</p>
</div>
<input value="Submit" id="submitButton" sid="datepicker" class="button white" type="submit">
</form>
<style>
.modal-backdrop {
z-index: -8 !important;
}
.modal-dialog {
width: 600px;
margin: 100px auto;
color: #000;
font-size: 17px;
}
.modal-title {
margin: 0;
line-height: 1.42857143;
font-size: 24px;
font-weight: 900;
}
</style>
<div class="modal" id="partnerModal" role="dialog" tabindex="-1">
<div class="modal-dialog" role="document">
<div class="modal-content">
<div class="modal-header">
<h5 class="modal-title text-black col-md-6 text-left">
/ Select Partners
</h5><button aria-label="Close" class="close col-6" data-dismiss="modal" type="button"><span aria-hidden="true">×</span></button>
</div>
<div class="modal-body text-black">
<ul style="list-style-type: none; margin: 0; padding: 0;">
<li>Affordable Health Group</li>
<li>Alliance National Health</li>
<li>Alternative Alpha Health, LLC.</li>
<li>America's Health Center, Inc.</li>
<li>America's Health Providers</li>
<li>Cypress Bend Marketing </li>
<li>Fuego Leads, LLC.</li>
<li>Genesis Marketing Group</li>
<li>Get Me Healthcare</li>
<li>Get Me Medicare</li>
<li>H&M Advisors</li>
<li>HIC Marketing Group, LLC.</li>
<li>Health and Medicare Advisors</li>
<li>Medicare Benefits Direct</li>
<li>National Health Agents</li>
<li>National Health Plans, LLC.</li>
<li>SolidQuote, LLC.</li>
<li>New Age Health</li>
<li>Precision Healthcare Providers</li>
<li>Precision Insurance Providers, LLC.</li>
<li>Premier Health Associates</li>
<li>Quotehound, Inc.</li>
<li>Reasonable Health Coverage</li>
<li>Reasonable Insurance Group </li>
<li>Reasonable Insurance Group</li>
<li>Seniors Get Benefits</li>
<li>Tobias and Associates</li>
<li>Trusted Health Associates</li>
<li>Trusted Healthcare Providers, LLC.</li>
<li> Affordable Healthcare Assoicates, LLC. </li>
<li> Allied Health Insurance Agency, LLC. </li>
<li> Direct Insurance Providers, LLC.</li>
<li> New Age Health Solutions</li>
<li>QuoteManage, LLC.</li>
</ul>
</div>
<div class="modal-footer">
<button class="btn btn-secondary" data-dismiss="modal" type="button">Close</button>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class=" footer-bottom ">
<div class="row ">
<div class="col-xs-12 text-center ">
<p style="font-size: 8pt; color:#fff ">©America's Health Center 2019 | All Rights Reserved. This website is privately owned, and neither affiliated with, nor endorsed by, nor operated by any government agency. If you are looking for the government's official website
visit <a href="https://www.healthcare.gov " style="color:#fff; ">HealthCare.gov</a></p>
</div>
</div>
</div>
</footer>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery/3.5.1/jquery.min.js"></script>
<script src="https://code.jquery.com/ui/1.12.1/jquery-ui.js"></script>
<script src="https://cdn.jsdelivr.net/npm/[email protected]/dist/jquery.validate.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery.mask/1.14.15/jquery.mask.min.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery-ui-timepicker-addon/1.6.3/jquery-ui-timepicker-addon.min.js"></script>
<script src="./js/dobpicker.js"></script>
<!-- TrustedForm -->
<script type="text/javascript">
(function() {
var tf = document.createElement('script');
tf.type = 'text/javascript'; tf.async = true;
tf.src = ("https:" == document.location.protocol ? 'https' : 'http') + "://api.trustedform.com/trustedform.js?field=xxTrustedFormCertUrl&identifier=VHQ&ping_field=xxTrustedFormPingUrl&l=" + new Date().getTime() + Math.random();
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(tf, s);
})();
</script>
<noscript>
<img src="https://api.trustedform.com/ns.gif" />
</noscript>
<!-- End TrustedForm -->
<script>
function submitForm()
{
$('#submitButton').prop('disabled', true);
$.ajax({
type: 'post',
dataType:'jsonp',
url: 'https://ushaleads.healthinsuranceguide.org/api/LeadAPI',
data: $('form').serialize(),
success: function () {
console.log('success');
window.location.href = "form-success.php";
},
error:function(){
console.log('Error');
window.location.href = "form-success.php";
}
})
};
$(document).ready(function(){
$('input:checkbox').click(function() {
$('input:checkbox').not(this).prop('checked', false);
});
});
/*-----------------------------------------------------------------------*/
/*----------------------- Phone Number Input Mask -----------------------*/
/*-----------------------------------------------------------------------*/
$(document).ready(function(){
$('#phone').mask('0000000000');
});
/*-----------------------------------------------------------------------*/
/*---------------------------- Zip Code Lookup --------------------------*/
/*-----------------------------------------------------------------------*/
$('#zipCode').on("input",function(){
var zipCode = $('#zipCode').val();
if(zipCode.length == 5)
{
$.ajax({
type: 'GET',
url:'https://ziplookup.visualyzers.com/Ziplookup?zipcode=' + zipCode,
success:function(results){
$('#city').val(results.city);
$('#state').val(results.state);
}
})
}
});
/*-------------------------------------------------------------------------*/
/*---------------------------- Validation Lookup --------------------------*/
/*-------------------------------------------------------------------------*/
$("#valForm").submit(function(e) {
e.preventDefault();
}).validate({
rules:{
phone:{
required:true,
minlength:10,
maxlength:10
},
firstname:{
required:true
},
lastname:{
required:true
},
dateofbirth:{
required:true,
date:true,
},
typeofplan:{
required: true
},
email:{
required:true,
email:true
},
city:{
required:true
},
state:{
required:true
},
zipCode:{
required:true,
minlength:5,
maxlength:5
}
},
messages: {
phone: {
required: "Please enter a valid phone number"
},
},
submitHandler: function(event)
{
submitForm();
}
});
$(function() {
$( "#datepicker" ).datepicker({
dateFormat : 'mm/dd/yy',
changeMonth : true,
changeYear : true,
yearRange: '-100y:c+nn',
maxDate: '-1d'
});
});
</script>
<script>
/*-----------------------------------------------------------------------*/
/*--------------------------- Date of Birth ----------------------------*/
/*-----------------------------------------------------------------------*/
$(document).ready(function() {
$.getJSON('https://api.ipify.org?format=jsonp&callback=?', function(data) {
$('#IpAddress').val(data.ip);
});
$.dobPicker({
daySelector: '#dobday',
/* Required */
monthSelector: '#dobmonth',
/* Required */
yearSelector: '#dobyear',
/* Required */
dayDefault: 'Day',
/* Optional */
monthDefault: 'Month',
/* Optional */
yearDefault: 'Year',
/* Optional */
minimumAge: 18,
/* Optional */
maximumAge: 100 /* Optional */
});
});
</script>
<script>
window.dataLayer = window.dataLayer || [];
$.dataLayer.push({
'event':'ec_formsubmit',
'enhanced_conversion_data': {
first_name: $('#firstname').val(),
last_name: $('#lastname').val(),
phone_number: $('#phone').val(),
email_address: $('#email').val(),
street: $('#street').val(),
city: $('#city').val(),
postal_code: $('#zip').val(),
dobday: $('#dobday').val(),
dobmonth: $('#dobmonth').val(),
dobyear: $('#dobyear').val(),
date_of_birth: $('#dob').val(),
plan_condition: $('.planConditions').val(),
plan_option: $('.planOption').val(),
}
})
</script>
<!--Vendor-JS-->
<script src="https://cdn.jsdelivr.net/npm/[email protected]/dist/js/bootstrap.bundle.min.js" integrity="sha384-MrcW6ZMFYlzcLA8Nl+NtUVF0sA7MsXsP1UyJoMp4YLEuNSfAP+JcXn/tWtIaxVXM" crossorigin="anonymous"></script>
<!--Plugin-JS-->
<!--Main-active-JS-->
<script src="js/main.js "></script>
</body>
</html>