File: /home/valuehealthquotes/public_html/old/form.html
<?php
//Ip Function
function getClientIp() {
$ipaddress = '';
if (getenv('HTTP_CLIENT_IP'))
$ipaddress = getenv('HTTP_CLIENT_IP');
else if(getenv('HTTP_X_FORWARDED_FOR'))
$ipaddress = getenv('HTTP_X_FORWARDED_FOR');
else if(getenv('HTTP_X_FORWARDED'))
$ipaddress = getenv('HTTP_X_FORWARDED');
else if(getenv('HTTP_FORWARDED_FOR'))
$ipaddress = getenv('HTTP_FORWARDED_FOR');
else if(getenv('HTTP_FORWARDED'))
$ipaddress = getenv('HTTP_FORWARDED');
else if(getenv('REMOTE_ADDR'))
$ipaddress = getenv('REMOTE_ADDR');
else
$ipaddress = 'UNKNOWN';
return $ipaddress;
}
?>
<!doctype html>
<html lang="en">
<head>
<!-- Google Tag Manager -->
<script>(function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':
new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],
j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src=
'https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);
})(window,document,'script','dataLayer','GTM-MWH78H7');</script>
<!-- End Google Tag Manager -->
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1, shrink-to-fit=no">
<link rel="stylesheet" href="https://stackpath.bootstrapcdn.com/bootstrap/4.3.1/css/bootstrap.min.css" integrity="sha384-ggOyR0iXCbMQv3Xipma34MD+dH/1fQ784/j6cY/iJTQUOhcWr7x9JvoRxT2MZw1T" crossorigin="anonymous">
<link rel="stylesheet" type="text/css" href="css/styles.css">
<link rel="apple-touch-icon" sizes="180x180" href="images/apple-touch-icon.png">
<link rel="icon" type="image/png" sizes="32x32" href="images/favicon-32x32.png">
<link rel="icon" type="image/png" sizes="16x16" href="images/favicon-16x16.png">
<link rel="manifest" href="images/site.webmanifest">
<title>Getting Started - ValueHealth Quotes</title>
<style>
.error{
color:red;
}
</style>
<!-- Navigation -->
<nav class="navbar navbar-expand-lg navbar-dark fixed-top">
<div class="container">
<a class="navbar-brand" href="index.html"><img height="30px;" src="images/logo.png"></a>
<div>
<span class="navbar-text navbar-contact navbar-toggle collapsed"><a href="tel:+18559181595"> Call Now: (855) 918-1595 </a></span>
<span><a class="navbar-contact-logo" href="tel:+18559181595"><i class="fas fa-phone"></i> (855) 918-1595</a></span>
</div>
</div>
</nav>
</head>
<body>
<!-- Google Tag Manager (noscript) -->
<noscript><iframe src="https://www.googletagmanager.com/ns.html?id=GTM-MWH78H7"
height="0" width="0" style="display:none;visibility:hidden"></iframe></noscript>
<!-- End Google Tag Manager (noscript) -->
<!-- Page Content -->
<section class="py-5" id="about">
<div class="container text-center">
<div class="row">
<div class="col">
<br>
<div class="form-header">
<h3>Find Your Perfect Plan</h3>
<div class="row align-items-center">
<div class="col-md">
<h4><i class="far fa-check-square"></i> Zero Obligation</h4>
</div>
<div class="col-md">
<h4><i class="far fa-check-square"></i> Affordable Prices</h4>
</div>
<div class="col-md">
<h4><i class="far fa-check-square"></i> Trusted Providers</h4>
</div>
</div>
</div>
<form id="quoteWizard" name="quoteWizard" method="get">
<!--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="form-row">
<div class="form-group col-sm">
<input type="text" class="form-control" name="firstname" id="firstname" placeholder="First Name" required>
</div>
<div class="form-group col-sm">
<input type="text" class="form-control" name="lastname" id="lastname" placeholder="Last Name" required>
</div>
</div>
<br>
<div class="form-row">
<div class="form-group col-sm">
<input type="date" class="form-control" name="dateofbirth" id="dob" placeholder="Date of Birth" required>
</div>
<div class="form-group col-sm">
<select class="form-control" name="typeofplan" value="ind" required>
<option selected disabled hidden>Who Are We Looking For?</option>
<option value="ind">Just For Me</option>
<option value="ind1">Myself & Spouse/Child</option>
<option value="family">The Whole Family</option>
</select>
</div>
</div>
<br>
<div class="form-row">
<div class="form-group col-sm">
<input type="text" class="form-control bfh-phone" id="phone" name="phone" minlength="10" maxlength="10" placeholder="Phone Number" required>
</div>
<div class="form-group col-sm">
<input type="email" class="form-control" id="email" name="email" placeholder="Email Address" required>
</div>
</div>
<br>
<div class="form-group">
<input type="text" class="form-control" id="address" name="address" placeholder="Street Address" required>
</div>
<div class="form-row">
<div class="form-group col-sm">
<input type="text" class="form-control" id="zipCode" name="zip" onkeyup="zipCodeLookup(1);" placeholder="Zip" required>
</div>
<div class="form-group col-sm">
<input type="text" class="form-control-plaintext city" name="city" id="city" placeholder="City" readonly required>
</div>
<div class="form-group col-sm">
<input type="text" class="form-control-plaintext state" name="state" id="state" placeholder="State" readonly required>
</div>
</div>
<br>
<button type="submit" class="modalButton"><i class="fas fa-lock"></i> Submit</button>
</form>
<br><br><br>
<div class="appFooter">
<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 Privacy Policy and Terms of Use. You also authorize healthcare-quotes.com and/or its marketing partners to contact you for marketing/telemarketing purposes at the number and address provided above, inclding 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.</p>
<p>Healthcare Quotes is an independent website and is not a federal or state Marketplace website. Healthcare Quotes 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>
</div>
</div>
</div>
</section>
<footer>
<section>
<div class="container-fluid text-center">
<div class="row footer-bg">
<div class="col-sm">
<p>© Value Health Quotes 2019-2020 All Rights Reserved | <span><a href="privacy-policy.html" style="text-decoration: none;"><b>Privacy Policy</b></a> | <span><a href="terms.html" style="text-decoration: none;"><b>Terms of Service</b></a></span></span></p>
</div>
</div>
</div>
</section>
</footer>
<script src="https://code.jquery.com/jquery-3.4.1.min.js" crossorigin="anonymous"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/popper.js/1.14.7/umd/popper.min.js" integrity="sha384-UO2eT0CpHqdSJQ6hJty5KVphtPhzWj9WO1clHTMGa3JDZwrnQq4sF86dIHNDz0W1" crossorigin="anonymous"></script>
<script src="https://stackpath.bootstrapcdn.com/bootstrap/4.3.1/js/bootstrap.min.js" integrity="sha384-JjSmVgyd0p3pXB1rRibZUAYoIIy6OrQ6VrjIEaFf/nJGzIxFDsf4x0xIM+B07jRM" crossorigin="anonymous"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery-validate/1.19.1/jquery.validate.min.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery-validate/1.19.1/additional-methods.min.js" integrity="sha256-vb+6VObiUIaoRuSusdLRWtXs/ewuz62LgVXg2f1ZXGo=" crossorigin="anonymous"></script>
<script src="https://kit.fontawesome.com/69fd8ad995.js" crossorigin="anonymous"></script>
<script type="text/javascript" src="js/zipCodeLookup.js"></script>
<script type="text/javascript" src="js/main.js"></script>
<!--Form posting -->
<script>
function submitForm()
{
$.ajax({
type: 'post',
dataType:'jsonp',
url: 'https://ushaleads.healthinsuranceguide.org/api/LeadAPI',
data: $('form').serialize(),
success: function () {
window.location.href = "form-success.html";
},
error:function(){
window.location.href = "form-success.html";
}
});
};
$("#quoteWizard").submit(function(e) {
e.preventDefault();
}).validate({
rules:{
phone:{
required:true,
phoneUS:true,
minlength:10,
maxlength:10
},
firstname:{
required:true
},
lastname:{
required:true
},
dateofbirth:{
required:true
},
typeofplan:{
required: true
},
email:{
required:true,
email:true
},
city:{
required:true
},
state:{
required:true
},
zip:{
required:true
}
},
messages: {
phone: {
required: "Please enter a valid phone number"
},
},
submitHandler: function(event)
{
submitForm();
}
});
</script>
<script>
function getParameterByName(name, url) {
if (!url) url = window.location.href;
name = name.replace(/[\[\]]/g, '\\$&');
var regex = new RegExp('[?&]' + name + '(=([^&#]*)|&|#|$)'),
results = regex.exec(url);
if (!results) return null;
if (!results[2]) return '';
return decodeURIComponent(results[2].replace(/\+/g, ' '));
}
$('#city').val(getParameterByName('city'));
$('#state').val(getParameterByName('state'));
$('#zipCode').val(getParameterByName('zipCode'));
</script>
</body>
</html>