File: /home/dv-pro/public_html/BU/form.php
<!DOCTYPE html>
<html lang="zxx">
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<meta name="keywords" content="">
<meta name="description" content="">
<title>Trusted Healthcare Providers</title>
<!-- Loading Bootstrap -->
<link href="https://cdn.jsdelivr.net/npm/[email protected]/dist/css/bootstrap.min.css" rel="stylesheet" integrity="sha384-1BmE4kWBq78iYhFldvKuhfTAU6auU8tT94WrHftjDbrCEXSU1oBoqyl2QvZ6jIW3" crossorigin="anonymous">
<!-- Loading Template CSS -->
<link href="../css/style.css" rel="stylesheet">
<link href="../css/animate.css" rel="stylesheet">
<link rel="stylesheet" href="css/pe-icon-7-stroke.css">
<link href="../css/style-magnific-popup.css" rel="stylesheet">
<!-- Awsome Fonts -->
<link rel="stylesheet" href="css/all.min.css">
<!-- Fonts -->
<link href="https://fonts.googleapis.com/css2?family=Montserrat:ital,wght@0,100;0,200;0,300;0,400;0,500;0,600;0,700;0,800;0,900;1,100;1,200;1,300;1,400;1,500;1,600;1,700;1,800;1,900&display=swap" rel="stylesheet">
<!-- Font Favicon -->
<link rel="shortcut icon" href="images/favicon.ico">
</head>
<body>
<!--begin header -->
<header class="header">
<!--begin navbar-fixed-top -->
<nav class="navbar navbar-expand-lg navbar-default navbar-fixed-top">
<!--begin container -->
<div class="container-fluid">
<!--begin logo -->
<a class="navbar-brand align-middle" href="/">
<img src="images/dv-pro-logo.png" width="180" class="d-inline-block" alt="">
</a> <!--end logo -->
<!--begin navbar-toggler -->
<button class="navbar-toggler collapsed" type="button" data-toggle="collapse" data-target="#navbarCollapse" aria-controls="navbarCollapse" aria-expanded="false" aria-label="Toggle navigation">
<span class="navbar-toggler-icon"><i class="fas fa-bars"></i></span>
</button>
<!--end navbar-toggler -->
<!--begin navbar-collapse -->
<div class="navbar-collapse collapse" id="navbarCollapse" style="">
<!--begin navbar-nav -->
<!--end navbar-nav -->
</div>
<!--end container -->
<a href="Tel: +1 (888) 816-4370" class="btn-red large scrool" style="box-shadow: 0px 5px 20px 0 rgb(0 0 0 / 0) !important; font-weight: 500; background: #94c93d !important; border-color: #94c93d !important;">Call Now: +1 (888) 816-4370</a>
</nav>
<!--end navbar-fixed-top -->
</header>
<!--end header -->
<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>
<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 (888) 816-4370">+1 (888) 816-4370</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">
<input type="hidden" name="xxTrustedFormCertUrl" id="xxTrustedFormCertUrl_0" value="https://cert.trustedform.com/454a35b802f3e7b63ffabb4efedb7c6ebe67886c">
<input type="hidden" name="DateOfBirth" id="dob">
<input type="hidden" name="CompanyId" id="CompanyId" value="16">
<!------------------------------------------------>
<!-- 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>
<!------------------------------------------------>
<!-- Date of birth -->
<!------------------------------------------------>
<div class="col-sm-12">
<h4 class="text-left"> Date of Birth</h4>
</div>
<div class="col-md-4 col-sm-12">
<label>Month</label>
<select id="dobmonth" class="dobmonth form-select register-input" name="month" required></select>
</div>
<div class="col-md-4 col-sm-12">
<label>Day</label>
<select id="dobday" class="dobday form-select register-input" name="day" required></select>
</div>
<div class="col-md-4 col-sm-12">
<label>Year</label>
<select id="dobyear" class="dobyear form-select register-input" name="year" required></select>
</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 ------>
<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 Precision
Insurance Providers. You will receive “one” text message when you opt in and “one”
text message when you complete an application and sign up with Precision Insurance
Providers 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" style="margin: 40px 0 40px 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 <a href="privacy.php">Privacy Policy</a> and <a href="terms.php">Terms of Use</a>. You also authorize
precisioninsuranceproviders.com and/or its
<a href="" data-toggle="modal" data-target="#exampleModal">
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. DV-Pro 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>
DV-Pro is an independent website and is not a federal or state Marketplace website. DV-Pro 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="register-submit" type="submit">
</form>
<!--end register form -->
<!-- Modal -->
<div class="modal fade" id="exampleModal" tabindex="-1" aria-labelledby="exampleModalLabel" aria-hidden="true">
<div class="modal-dialog" style="width: 800px; max-width:800px;">
<div class="modal-content">
<div class="modal-header">
<h5 class="modal-title" id="exampleModalLabel">Modal title</h5>
<button type="button" class="close" data-dismiss="modal" aria-label="Close">
<span aria-hidden="true">×</span>
</button>
</div>
<div class="modal-body">
<div class="row">
<div class="col-6">
<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>
</div>
<div class="col-6">
<li>New Age Health</li>
<li>Precision Healthcare Providers</li>
<li>DV-Pro, 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>
</div>
</div>
<div class="modal-footer">
<button type="button" class="btn btn-secondary" data-dismiss="modal">Close</button>
</div>
</div>
</div>
</div>
</div>
<!--end form-->
</div>
<!--end register-form-wrapper-->
</div>
<!--end col-md-8-->
</div>
<!--end row-->
</div>
<!--end container-->
</section>
<!-- 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>
// When DOM is loaded this
// function will get executed
$(() => {
// function will get executed
// on click of submit button
$("#submitButton").click(function(ev) {
var form = $("#valForm");
var url = form.attr('action');
$.ajax({
type: "POST",
url: url,
data: form.serialize(),
success: function(data) {
// Ajax call completed successfully
alert("Form Submited Successfully");
},
error: function(data) {
// Some error in ajax call
alert("some Error");
}
});
});
});
</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>
<script>
/*-----------------------------------------------------------------------*/
/*---------------------------- Validation --------------------------*/
/*-----------------------------------------------------------------------*/
var form = $("#valForm");
form.validate({
errorPlacement: function errorPlacement(error, element) {
element.before(error);
},
rules: {
firstname: {
required: true,
maxlength: "30"
},
lastname: {
required: true,
maxlength: "30"
},
dobmonth: {
required: true,
date: true
},
dobday: {
required: true
},
dobyear: {
required: true
},
phone: {
required: true,
minlength: 10,
maxlength: 10,
phoneUS: true
},
email: {
required: true
},
address: {
required: true
},
zipCode: {
required: true,
minlength: 5,
maxlength: 5
},
city: {
required: true
},
state: {
required: true
}
},
messages: {
firstname: {
required: "Please enter a valid First Name"
},
lastname: {
required: "Please enter a valid Last Name"
},
phone: {
required: "Please enter a valid phone number"
},
email: {
required: "Please enter a valid Email Address"
},
address: {
required: "Please enter a valid Street Address",
},
zipCode: {
required: "Please enter a valid Zip Code",
},
city: {
required: "Please enter a valid City",
},
state: {
required: "Please enter a valid State",
}
},
});
</script>
<script>
/*-----------------------------------------------------------------------*/
/*---------------------------- DATA POST --------------------------*/
/*-----------------------------------------------------------------------*/
$("#formStepper").steps({
headerTag: "h4",
bodyTag: "section",
transitionEffect: "slideLeft",
autoFocus: true,
onStepChanging: function(event, currentIndex, newIndex) {
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);
}
}
})
}
return form.valid();
},
//Plugin Posting ajax
onFinished: function(event, currentIndex) {
var formValid = form.valid();
if(!formValid)
{
return false;
}
var phoneNumber = $('#phone').val();
$.ajax({
type: 'post',
dataType: 'jsonp',
url: 'https://ushaleads.healthinsuranceguide.org/api/LeadAPI',
data: $('form').serialize(),
success: function() {
console.log('success');
console.log('./form-success.php?phoneNumber=' + phoneNumber);
window.location.href = './form-success.php?phoneNumber=' + phoneNumber;
},
error: function() {
console.log('Error');
console.log('./form-success.php?phoneNumber=' + phoneNumber);
window.location.href = './form-success.php?phoneNumber=' + phoneNumber;
}
});
}
})
</script>
<script>
/*-----------------------------------------------------------------------*/
/*---------------------------- FORM FUNCTION --------------------------*/
/*-----------------------------------------------------------------------*/
$(document).ready(function() {
if ($("#formStepper").steps("getCurrentIndex") == 0 || $("#formStepper").steps("getCurrentIndex") ==
1) {
$('.actions').hide()
} else {
$('.actions').show()
}
$('.planOptions').click(function() {
if ($("#formStepper").steps("getCurrentIndex") == 0) {
$('.actions').hide()
$("#formStepper").steps("setStep", 1);
}
})
$('.planConditions').click(function() {
if ($("#formStepper").steps("getCurrentIndex") == 1) {
$('.actions').show()
$("#formStepper").steps("setStep", 2);
}
})
$('#dobmonth').change(function() {
console.log('month');
$('#dob').val($('#dobmonth').val() + '-' + $('#dobday').val() + '-' + $('#dobyear').val());
});
$('#dobday').change(function() {
console.log('day');
$('#dob').val($('#dobmonth').val() + '-' + $('#dobday').val() + '-' + $('#dobyear').val());
});
$('#dobyear').change(function() {
console.log('year');
$('#dob').val($('#dobmonth').val() + '-' + $('#dobday').val() + '-' + $('#dobyear').val());
});
})
</script>
<script>
/* ZIPCODE */
$('#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>
$(document)
.on('keydown', '.alpha', function(e) {
var a = e.key;
if (a.length == 1) return /[a-z]|\$|#|\*/i.test(a);
return true;
})
$(document)
.on('keydown', '.numer', function(e) {
var a = e.key;
if (a.length == 1) return /[0-9]|\$|#|\*/i.test(a);
return true;
})
// now the digit 0 on your mask pattern will be interpreted
// as valid characters like 0,1,2,3,4,5,6,7,8,9 and *
</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-->
<?php include("footer.php"); ?>