File: /home/healthcareenrollmenteligibility/public_html/form.php
<?php include("header.php"); ?>
<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>
<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;
}
.home-section2 {
padding-top: 138px !important;
padding-bottom: 50px !important;
}
input.register-input, select.register-input {
color:#757a7f !important;
}
input.register-input, select.register-input {
width: 100%!important;
height: 60px!important;
padding-left: 3%!important;
padding-right: 5%!important;
margin-bottom: 15px!important;
color: #757a7f !important;
border: 2px solid #0387cb;
background-color: #fff;
font-size: 16px!important;
border-radius: 2px !important;
}
input.register-submit {
background: #0387cb !important;
border: none;
color: #fff;
letter-spacing: 1px;
cursor: pointer;
display: inline-block;
font-size: 14px;
font-weight: 700;
width: 100%;
padding: 20px 0;
text-transform: uppercase;
-webkit-border-radius: 3px 3px;
-moz-border-radius: 3px 3px;
border-radius: 3px 3px;
transition: all .50s ease-in-out;
-moz-transition: all .50s ease-in-out;
-webkit-transition: all .50s ease-in-out;
}
.error {
color:#C92228 !important;
}
</style>
<!--begin home section -->
<section class="home-section2" id="home">
<div class="home-section-overlay"></div>
<!--begin container -->
<div class="container">
<!--begin row -->
<div class="row">
<!--begin col-md-6-->
<div class="col-md-6 margin-top-40 hero-content">
<h1 style="color: #fff !important;">Contact Us</h1>
<p class="hero-text" style="color: #fff !important;">Discover the future of healthcare with Trusted Healthcare Providers.</p>
<!--begin newsletter_form_box -->
<div class="newsletter_form_box">
<!--begin success_box -->
<p class="newsletter_success_box" style="display:none;">We received your message and you'll hear from us soon. Thank You!</p>
<!--end success_box -->
<!--begin newsletter-form -->
</div>
<!--end newsletter_form_box -->
</div>
<!--end col-md-6-->
<!--begin col-md-6-->
<div class="col-md-6">
</div>
<!--end col-md-6-->
</div>
<!--end row -->
</div>
<!--end container -->
</section>
<!--end home section -->
<section class="section-grey" id="contact">
<!--begin container-->
<div class="container">
<!--begin row -->
<div class="row">
<!--begin col-md-12-->
<div class="col-md-12 text-center padding-bottom-10">
<h3 class="section-title">Get Your Free Consultation</h3>
<p class="section-subtitle">Call us toll-free at <a href="Tel: +1 (855) 298-8388">+1 (855) 298-8388</a> or fill out the form to get in touch.</b></p>
</div>
<!--end col-md-12 -->
</div>
<!--end row -->
<!--begin row-->
<div class="row justify-content-md-center">
<!--begin col-md-8-->
<div class="col-md-12 text-center margin-top-10">
<!--begin register-form-wrapper-->
<div class="register-form-wrapper wow bounceIn" data-wow-delay="0.5s" style="visibility: visible; animation-delay: 0.5s; animation-name: bounceIn;">
<!--begin form-->
<div>
<!--begin success message -->
<p class="register_success_box" style="display:none;">We received your message and you will hear from us soon. Thank You!</p>
<!--end success message -->
<!--begin register form -->
<form id="valForm" name="valForm" method="get">
<!------------------------------------------------>
<!-- Personal Information -->
<!------------------------------------------------>
<div class="row">
<div class="col-sm-12">
<h4 class="text-left"> Contact Information</h4>
</div>
<div class="col-sm-6 form-group">
<input type="text" id="firstname" class="register-input" name="firstname" placeholder="First Name*" required>
</div>
<div class="col-sm-6 form-group">
<input type="text" id="lastname" class="register-input" name="lastname" placeholder="Last Name*" required>
</div>
<div class="col-sm-6 form-group">
<input type="text" id="phone" class="register-input" name="phone" placeholder="(___) ___-____" minlength="10" maxlength="10" required>
</div>
<div class="col-sm-6 form-group">
<input type="email" id="email" class="register-input" name="email" placeholder="Email Adress*" required>
</div>
<div class="col-sm-12 form-group">
<input type="date" id="dateofbirth" class="register-input" name="dateofbirth" placeholder="Date of Birth" required>
</div>
</div>
<!------------------------------------------------>
<!-- Address -->
<!------------------------------------------------>
<div class="row">
<div class="col-sm-12">
<h4 class="text-left"> Address</h4>
</div>
<div class="col-sm-12 form-group">
<input type="text" id="address" class="register-input form-control" name="address" placeholder="Street Address" required>
</div>
<div class="col-md-4 form-group">
<input type="text" id="zipCode" class="register-input form-control" name="zipCode" placeholder="Zipcode" value="<?php echo $_POST["zipCode"]; ?>">
</div>
<div class="col-md-4 form-group">
<input type="text" id="city" class="register-input form-control city" name="city" placeholder="City" value="<?php echo $_POST["city"]; ?>" readonly required>
</div>
<div class="col-md-4 form-group">
<input type="text" id="state" class="register-input form-control state" name="state" placeholder="State" value="<?php echo $_POST["state"]; ?>" readonly required>
</div>
</div>
<!------ ROW END ------>
<input value="Submit" id="submitButton" sid="datepicker" class="register-submit" type="submit">
</form>
<!--end register form -->
<p class="register-form-terms">THIS IS NOT HEALTH INSURANCE</p>
<div class="col-md-12" style="color: #c4c4c4; font-size: 12px; padding: 70px 0 70px 0;">
<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 <a href="https://trustedhealthassociates.com/">trustedhealthassociates.com</a> and/or its marketing partners 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. Trusted Health Associates 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> Trusted Health Associates is an independent website and is not a federal or state Marketplace website. Trusted Health Associates 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>
<!--end form-->
</div>
<!--end register-form-wrapper-->
</div>
<!--end col-md-8-->
</div>
<!--end row-->
</div>
<!--end container-->
</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.html";
},
error:function(){
console.log('Error');
window.location.href = "form-success.html";
}
})
};
$(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>
<?php include("footer.php"); ?>