File: /home/healthvaluequotes/public_html/backup2/complete.php
<?php
function get_client_ip() {
$ipaddress = '';
if (isset($_SERVER['HTTP_CLIENT_IP'])) {
$ipaddress = $_SERVER['HTTP_CLIENT_IP'];
} elseif (isset($_SERVER['HTTP_X_FORWARDED_FOR'])) {
$ipaddress = $_SERVER['HTTP_X_FORWARDED_FOR'];
} elseif (isset($_SERVER['HTTP_X_FORWARDED'])) {
$ipaddress = $_SERVER['HTTP_X_FORWARDED'];
} elseif (isset($_SERVER['HTTP_FORWARDED_FOR'])) {
$ipaddress = $_SERVER['HTTP_FORWARDED_FOR'];
} elseif (isset($_SERVER['HTTP_FORWARDED'])) {
$ipaddress = $_SERVER['HTTP_FORWARDED'];
} elseif (isset($_SERVER['REMOTE_ADDR'])) {
$ipaddress = $_SERVER['REMOTE_ADDR'];
} else {
$ipaddress = 'UNKNOWN';
}
return htmlspecialchars($ipaddress, ENT_QUOTES, 'UTF-8'); // Prevents XSS
}
?>
<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="utf-8" />
<title>Health Value Quotes</title>
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<meta name="description" content="Value Health Quotes" />
<meta name="keywords" content="Value Health Quotes, Health Insurance, Health Insurance Advisors" />
<!-- Google tag (gtag.js) -->
<script async src="https://www.googletagmanager.com/gtag/js?id=AW-867661804"></script>
<script>
window.dataLayer = window.dataLayer || [];
function gtag(){dataLayer.push(arguments);}
gtag('js', new Date());
gtag('config', 'AW-867661804');
</script>
<!-- favicon -->
<link rel="shortcut icon" href="images/favicon.ico">
<!--Slider-->
<link rel="stylesheet" href="css/owl.carousel.min.css" />
<link rel="stylesheet" href="css/owl.theme.default.min.css" />
<!-- css -->
<link href="https://cdn.jsdelivr.net/npm/[email protected]/dist/css/bootstrap.min.css" rel="stylesheet" integrity="sha384-9ndCyUaIbzAi2FUVXJi0CjmCapSmO7SnpJef0486qhLnuZ2cdeRhO02iuK6FUUVM" crossorigin="anonymous">
<link href="css/style.min.css" rel="stylesheet" type="text/css" />
</head>
<body>
<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.5.1/jquery.min.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery-validate/1.19.2/jquery.validate.min.js" integrity="sha512-UdIMMlVx0HEynClOIFSyOrPggomfhBKJE28LKl8yR3ghkgugPnG6iLfRfHwushZl1MOPSY6TsuBDGPK2X4zYKg==" crossorigin="anonymous"></script>
<nav class="navbar navbar-expand-sm navbar-light">
<div class="container-fluid ">
<img src="images/logo.svg" alt="logo" class="logo-light" height="64">
<div class="collapse navbar-collapse " id="navbarSupportedContent">
<ul class="navbar-nav ms-auto">
<li class="nav-item">
<i class="mdi mdi-phone mr-1"></i><span style="font-size: 18px; font-weight: 600">Call now: +1 (855) 364-1844</span></a>
</li>
</ul>
</div>
</div>
</nav>
<!-- Navbar End -->
<style>
input:invalid+span:after {
contepxnt: '✖';
padding-left: 5px;
color: red;
}
input:valid+span:after {
content: '✓';
padding-left: 5px;
color:green;
}
.hero-1-bg {
padding: 170px 0 30px !important;
}
.disclaimer {
color: #bcbdcc !important;
font-size:12px !important;
}
.row {
margin-bottom: 15px;
}
</style>
<!-- Hero Start -->
<section class="hero-1-bg position-relative d-flex" id="home" style="background: #cfedf9; box-shadow: 0px 0px 30px 0px rgba(82, 63, 105, 0);">
<div class="container">
<div class="row">
<div class="col-lg-12" style="background:#fff">
<div class="col-lg-12 mt-5">
<div class="hero-title pr-lg-5">
<h1 class="hero-1-title mb-4 line-height-1_4 font-weight-bold text-center">We're almost done, one last step.
</div>
<div class="hero-title pr-lg-5">
<h4 class="mb-4 line-height-1_4 font-weight-light text-center">Finish the form and we will give you your quote.</h4>
</div>
<form id="valForm" name="valForm" method="get" class="p-4" >
<input type="hidden" name="TrustedURL" id="TrustedURL" value="https://cert.trustedform.com/454a35b802f3e7b63ffabb4efedb7c6ebe67886c">
<!-- Get Client IP -->
<?php
$ip = get_client_ip(); // Function name corrected
echo '<input name="IPAddress" type="hidden" value="' . $ip . '" />';
?>
<input type="hidden" name="CampaignKey" id="CampaignKey" value="4964496a-ca19-4771-b9e5-010e06eb902a">
<input type="hidden" name="ck" id="ck" value="MsdJoRZ">
<input type="hidden" name="ok" id="ok" value="YFu">
<input type="hidden" name="x787" id="x787" value="198">
<input type="hidden" name="x788" id="x788" value="198">
<input type="hidden" name="x1003" id="x1003" value="AHLID">
<div class="row">
<div class="form-group col-sm">
<label>First Name</label>
<input type="text" class="form-control" name="FirstName" id="FirstName" placeholder="First Name" required>
</div>
<div class="form-group col-sm">
<label>Last Name</label>
<input type="text" class="form-control" name="LastName" id="LastName" placeholder="Last Name" required>
</div>
</div>
<div class="row">
<div class="form-group col-sm">
<label>Date of Birth</label>
<input type="text" class="form-control js-datemask" name="DateOfBirth" id="datepicker" placeholder="Date of Birth" required>
</div>
<div class="form-group col-sm">
<label>Choose Your Health Plan</label>
<select class="form-control" name="PlanType" value="<?php echo $_POST["PlanType"]; ?>" required>
<option value="Just For Me">Just For Me</option>
<option value="Myself/Spouse/Child">Myself/Spouse/Child</option>
<option value="Whole Family">Whole Family</option>
</select>
</div>
</div>
<div class="row">
<div class="form-group col-sm">
<label>Phone Number</label>
<input type="text" class="form-control" id="PhoneNumber" name="PhoneNumber" placeholder="Phone Number" maxlength="10" minlength="10" required>
</div>
<div class="form-group col-sm">
<label>Email Address</label>
<input type="EmailAddress" class="form-control" id="EmailAddress" name="EmailAddress" placeholder="Email Address" required>
</div>
</div>
<div class="row">
<div class="form-group col-sm">
<label>Street Address</label>
<input type="text" class="form-control" id="address" name="address" placeholder="Street Address" required>
</div>
</div>
<div class="row">
<div class="form-group col-sm">
<label>Zipcode</label>
<input type="text" class="form-control" name="ZipCode" id="ZipCode" placeholder="ZipCode" maxlength="5" minlength="5" value="<?php echo $_POST["ZipCode"]; ?>" required>
</div>
<div class="form-group col-sm">
<label>City</label>
<input type="text" class="form-control" name="City" id="City" placeholder="City" value="<?php echo $_POST["City"]; ?>" readonly required>
</div>
<div class="form-group col-sm">
<label>State</label>
<input type="text" class="form-control" name="State" id="State" placeholder="State" value="<?php echo $_POST["State"]; ?>" readonly required>
</div>
<div class="col-md-12 mt-3">
<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 completeinsuranceadvisors.com and/or its
<a data-toggle="modal" href="#partnerModal" style="color: #0031e3; ">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. Complete 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>
Complete Insurance Advisors is an independent website and is not a federal or state Marketplace website. Complete 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>
<div class="row text-center mt-5" style="font-weight: 600; font-size: 16px;">
<div class="col-md-12">
<div class="row">
<p>Please select the communication channels through which you would like to receive information:</p>
<div class="col-3 d-flex justify-content-center">
<input type="checkbox" class="form-check-input" id="phonecheckbox" name="checkbox" checked>
<label for="form-control" style="-3.25rem"> Phone</label>
</div>
<div class="col-3 d-flex justify-content-center">
<input type="checkbox" class="form-check-input" id="smscheckbox" name="checkbox" >
<label for="form-control"> SMS</label>
</div>
<div class="col-3 d-flex justify-content-center">
<input type="checkbox" class="form-check-input" id="emailcheckbox" name="checkbox" >
<label for="emailcheckbox"> Email</label>
</div>
<div class="col-3 d-flex justify-content-center">
<input type="checkbox" class="form-check-input" id="mailcheckbox" name="checkbox" >
<label for="mailcheckbox"> Mail</label>
</div>
</div>
<div class="form-group col-sm-12 pt-2 text-center">
<button type="submit" id="submitButton" class="btn btn-warning"><i class="fas fa-lock"></i> Submit</button>
</div>
</div>
</div>
</div>
<!-- Generate a TrustedForm Certificate -->
<script type="text/javascript">
(function() {
var field = 'TrustedURL';
var provideReferrer = false;
var tf = document.createElement('script');
tf.type = 'text/javascript'; tf.async = true;
tf.src = 'http' + ('https:' == document.location.protocol ? 's' : '') +
'://api.trustedform.com/trustedform.js?provide_referrer=' + escape(provideReferrer) + '&field=' + escape(field) + '&l='+new Date().getTime()+Math.random();
var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(tf, s); }
)();
</script>
<noscript>
<img src="http://api.trustedform.com/ns.gif" />
</noscript>
<!-- End TrustedForm Certificate -->
</form>
</div>
</div>
</section>
<!-- Hero End -->
<section class="position-relative d-flex align-items-center" id="home" style="background: #cfedf9">
<div class="container">
<div class="row align-items-center">
<div class="row">
<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>National Health Plans, LLC.
</li>
<li>Alternative Alpha Health, LLC.
</li>
<li>National Health Agents
</li>
<li>Interstate Brokers of America
</li>
<li>Fuego Leads, LLC.
</li>
<li>Alliance National Health
</li>
<li>New Age Health
</li>
<li>Trusted Healthcare Providers, LLC.
</li>
<li>America's Health Center, Inc.
</li>
<li>America's Health Providers
</li>
<li>Precision Insurance Providers, LLC.
</li>
<li>Precision Healthcare Providers
</li>
<li>Accu-Health Insurance Advisors, LLC.
</li>
<li>HIC Marketing Group, LLC.
</li>
<li>Get Me Healthcare
</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>
</section>
<!-- footer Start -->
<section class="footer">
<div class="container">
<div class="row">
<div class="col-lg-12 text-center">
<div class="mb-4">
<a href="/"><img src="images/logo.svg" alt="" class="logo-dark" height="70" /></a>
<h6 class="text-muted font-weight-normal mt-2" style="font-size: 24px;">
<a href="Tel: +18553641844">Call now: +1 (855) 364-1844</a>
</h6>
</div>
</div>
</div>
</div>
</div>
<div class="row mt-5">
<div class="col-md-12">
<div class="text-center text-muted">
<p class="mb-0 f-15">©Health Value Quotes 2019-Current All Rights Reserved by America’s Health Center, Inc. | <a href="/privacy.php">Privacy Policy | <a href="terms.php">Terms and Conditions</a></p>
</div>
</div>
</div>
</div>
</section>
<!-- footer End -->
<!-- ::::::::::::::: /END FOOTER :::::::::::::::-->
<script src="js/bootstrap.bundle.min.js"></script>
<script src="js/scrollspy.min.js"></script>
<script src="js/jquery.easing.min.js"></script>
<!-- carousel -->
<script src="js/owl.carousel.min.js"></script>
<!-- Main Js -->
<script src="js/app.js"></script>
<script>
/*-----------------------------------------------------------------------*/
/*------------------------------ DATA POST ------------------------------*/
/*-----------------------------------------------------------------------*/
function submitForm()
{
$('#submitButton').prop('disabled', true);
$.ajax({
type: 'post',
dataType:'jsonp',
url: 'https://pipeline.trustedhealthinsurancegroup.com/api/Leads',
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";
}
})
};
/*-----------------------------------------------------------------------*/
/*---------------------------- 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){
if(!results){
$('#errorZip').show();
$('#submitButton').prop("disabled",true);
}
else{
$('#City').val(results.city);
$('#State').val(results.state);
$('#errorZip').hide();
$('#submitButton').prop("disabled",false);
}
}
})
}
});
/*-----------------------------------------------------------------------*/
/*---------------------------- jQuery Validation ------------------------*/
/*-----------------------------------------------------------------------*/
$("#valForm").submit(function(e) {
e.preventDefault();
}).validate({
rules:{
PhoneNumber:{
required:true,
minlength:10,
maxlength:10
},
FirstName:{
required:true
},
LastName:{
required:true
},
DateOfBirth:{
required:true,
date:true,
},
PlanType:{
required: true
},
EmailAddress:{
required:true,
email:true
},
City:{
required:true
},
State:{
required:true
},
ZipCode:{
required:true,
minlength:5,
maxlength:5
}
},
messages: {
PhoneNumber: {
required: "Please enter a valid phone number"
},
},
submitHandler: function(event)
{
submitForm();
}
});
</script>
<script>
/*-----------------------------------------------------------------------*/
/*----------------------------- DATE OF BIRTH ---------------------------*/
/*-----------------------------------------------------------------------*/
$.validator.addMethod("dateRange", function(value, element, params) {
try {
var date = new Date(value);
if (date >= params.from && date <= params.to) {
return true;
}
} catch (e) {}
return false;
}, 'Invalid Date of Birth');
var fromDate = new Date("1900-01-01");
var toDate = new Date("2003-01-01");
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</body>
</html>