File: /home/healthvaluequotes/public_html/backup2/short-form.php
<?php include("header.php"); ?>
<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;
}
.form-control {
width: 100%!important;
height: 50px!important;
margin-bottom: 15px!important;
color: #757a7f !important;
border: 2px solid #b3c0c7;
background-color: #fff;
font-size: 16px!important;
border-radius: 2px !important;
}
label {
font-size: 18px !important;
color: #364451 !important
}
.my-5 {
padding-top: 2em !important;
padding-bottom: 2em !important;
}
</style>
<!-- Hero Start -->
<section class="hero-1-bg position-relative d-flex text-center" id="home" style="background: #cfedf9; box-shadow: 0px 0px 30px 0px rgba(82, 63, 105, 0);">
<div class="container">
<div class="row align-items-center">
<div class="col-lg-12" style="background:#fff">
<div class="col-lg-12 my-5">
<div class="hero-title pr-lg-5 text-center">
<h1 class="hero-1-title mb-4 line-height-1_4 font-weight-bold">Receive Your Quote
</div>
<div class="hero-title pr-lg-5 text-center pb-2">
<h4 class="mb-4 line-height-1_4 font-weight-light">Finish the form and we will give you your quote.</h4>
</div>
<div class="col-12">
<hr>
</div>
<form id="valForm" name="valForm" method="get" class="p-4" >
<input type="hidden" name="CompanyId" id="CompanyId" value="27">
<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">
<input type="hidden" id="email" name="Email" value="[email protected]">
<input type="hidden" id="address" name="address" value="8616 State Circle Middle Village, NY 11379">
<input type="hidden" id="dateofbirth" name="dateofbirth" value="1920-01-01" />
<div class="row text-left">
<input type="hidden" name="CompanyId" id="CompanyId" value="16">
<div class="form-group col-md-6 col-sm-12">
<label for="firstname">First Name</label>
<input type="text" class="form-control" name="firstname" id="firstname" placeholder="First Name" value="<?php echo $_GET["FirstName"]; ?>" required>
</div>
<div class="form-group col-md-6 col-sm-12">
<label for="lastname">Last Name</label>
<input type="text" class="form-control" name="lastname" id="lastname" placeholder="Last Name" value="<?php echo $_GET["LastName"]; ?>" required>
</div>
<div class="form-group col-12">
<label for="phone">Phone Number</label>
<input type="text" class="form-control bfh-phone" name="phone" id="phone" placeholder="0000000000" value="<?php echo $_GET["phone"]; ?>" minlength="10" maxlength="10" required>
</div>
<hr>
<div class="form-group col-md-4 col-sm-12">
<label for="zipCode">Zipcode</label>
<input type="text" class="form-control" id="zipCode" name="zip" placeholder="Zipcode" value="<?php echo $_GET["zipCode"]; ?>">
</div>
<div class="form-group col-md-4 col-sm-12">
<label for="city">City</label>
<input type="text" class="form-control city" name="city" id="city" placeholder="City" value="<?php echo $_GET["city"]; ?>" readonly required>
</div>
<div class="form-group col-md-4 col-sm-12">
<label for="state">State</label>
<input type="text" class="form-control state" name="state" id="state" placeholder="State" value="<?php echo $_GET["state"]; ?>" readonly required>
</div>
<div class="form-group col-sm-12 pt-2 text-center">
<button type="submit" id="submitButton" sid="datepicker" class="btn btn-warning" style="width: 100%; font-size: 24px !important; font-weight:500;"><i class="fas fa-lock"></i> Submit</button>
</div>
</div>
</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">
<div class="col-12 disclaimer mb-5">
<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 valuehealthquotes.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. Value Health Quotes 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>Value Health Quotes is an independent website and is not a federal or state Marketplace website. Value Health 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>
<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);
});
});
$('#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);
}
}
})
}
});
</script>
<script>
/*---Validation---*/
$("#zipForm").submit(function(e) {
}).validate({
errorElement:'span',
errorClass:'helpClass',
rules:{
planType:{
required:true,
},
zipCode:{
required:true,
}
},
messages: {
planType: {
required: "Please Select Your Health Plan"
},
zipCode: {
required: "Please enter a valid Zip Code",
minLength:5,
maxLength:5
},
},
});
$("#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>
<?php include("footer.php"); ?>