pcrm.rhoadsonline.com Open in urlscan Pro
208.82.207.217  Public Scan

Form analysis
1 forms found in the DOM

Name: onBoardIndProfileBean — POST /home/onBoardIndProfileAction.do

<form name="onBoardIndProfileBean" method="post" action="/home/onBoardIndProfileAction.do" target="agent.form.hlj">
  <div><input type="hidden" name="org.apache.struts.taglib.html.TOKEN" value="7a531edd7e99f6cdebee305b6acace2a"></div>
  <div id="onBoardProfileDiv" style="display: block; height: 982px;">
    <table class="MainTable">
      <colgroup>
        <col width="13%" align="left">
        <col width="20%" align="left">
        <col width="13%" align="left">
        <col width="20%" align="left">
        <col width="13%" align="left">
        <col width="20%" align="left">
      </colgroup>
      <tbody>
        <tr>
          <td colspan="6" class="SectionHead">Licensee Identification <span class="pagetextbold" style="margin-left:20px;"> </span><br>
          </td>
        </tr>
        <input type="hidden" name="clientCode" value="HLJ" id="clientCode"> <input type="hidden" name="mode" value="0"> <input type="hidden" name="actionMode" value="0"><input type="hidden" name="agentEntityType" value="I">
        <input type="hidden" name="employeeId" value="HLJ577646980" id="invtProducerCode"> <input type="hidden" name="invt" value="true" id="isInvt">
        <input type="hidden" name="invitationId" value="577646980" id="invitationId">
        <input type="hidden" name="accessedBy" value="">
        <tr>
          <td>Entity Type</td>
          <td colspan="4"><select name="agentEntityType" disabled="disabled" class="inputMediumCombo">
              <option value=""></option>
              <option value="I" selected="selected">Individual</option>
            </select></td>
        </tr>
        <tr>
          <td>Last Name<span class="asterisk">*</span></td>
          <td><input type="text" name="lastName" maxlength="100" value="" class="inputLastName" autocomplete="off"></td>
          <td>First Name</td>
          <td><input type="text" name="firstName" maxlength="25" value="" class="inputFirstName"></td>
          <td>Middle Name</td>
          <td><input type="text" name="middleName" maxlength="25" value="" class="inputMiddleName"></td>
        </tr>
        <tr>
          <td>DOB <span class="asterisk">*</span></td>
          <td colspan="4"><input type="text" name="DOB" maxlength="10" value="" onfocus="setMask(this,'date')" class="inputDate" autocomplete="off">
            <a href="#" onclick="return openCalendarWindow(this,event);"> <img src="Images/Calander_Icon.gif" align="middle" border="0"></a></td>
        </tr>
        <tr>
          <td id="ssnAstKID">SSN(last 4 digits)&nbsp;<span class="asterisk">*</span></td>
          <td id="ssnWithoutAstKID" style="display: none;">SSN(last 4 digits)&nbsp;</td>
          <td colspan="4"><input type="text" name="SSN" maxlength="4" size="4" value="" onkeypress="return isNumberKey(event);" id="disabSSN" autocomplete="off"></td>
        </tr>
        <tr>
          <td>Form Type</td>
          <td colspan="4"><select name="formType" disabled="disabled" id="formType" class="inputMediumCombo">
              <option value=""></option>
              <option value="Q1">Background Questionnaire</option>
              <option value="PRO" selected="selected">Producer</option>
            </select></td>
        </tr>
        <input type="hidden" name="formType" value="PRO" id="formTypeID">
        <input type="hidden" name="requestType" value="" id="requestType">
        <input type="hidden" name="auth" value="false" id="isAuth">
        <input type="hidden" name="agentEntityType" value="I" id="agentEntityType">
        <tr>
          <td colspan="6"></td>
        </tr>
        <tr>
          <td colspan="5"></td>
          <td align="left">
            <input type="button" name="button" value="Next->" onclick="submitForm(document.forms[0])" id="nextbutton" class="MediumButton">
          </td>
        </tr>
        <tr>
          <td colspan="6"></td>
        </tr>
        <tr>
          <td colspan="6"></td>
        </tr>
        <tr>
          <td colspan="6"></td>
        </tr>
        <tr>
          <td colspan="6"></td>
        </tr>
        <tr>
          <td colspan="6"></td>
        </tr>
        <tr>
          <td colspan="6"></td>
        </tr>
        <tr>
          <td colspan="6" align="center" style="color: blue; font-size: 14pt;"></td>
        </tr>
      </tbody>
    </table>
  </div>
</form>

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producer
Licensee Identification

Licensee Identification
Entity Type Individual Last Name* First Name Middle Name DOB * SSN(last 4
digits) * SSN(last 4 digits)  Form Type Background Questionnaire Producer

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