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reimbursementpolicy.formstack.com Open in urlscan Pro
65.9.66.118  Public Scan

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Submitted URL: https://fwtrack.esvvs.com/v1/clk/pAJr3z0cRrC3SaqHcqY5MQ,MA_y9ToZQquOZrQBvw2JRg,0,aHR0cHM6Ly9yZWltYnVyc2VtZW50cG9saWN5LmZvc...
Effective URL: https://reimbursementpolicy.formstack.com/forms/acknowledgment
Submission: On December 05 via manual from IN — Scanned from DE

Form analysis 1 forms found in the DOM

POST https://reimbursementpolicy.formstack.com/forms/index.php

<form id="fsForm5535787" method="post" class="StyledForm-sc-1xaj75q-0 gZiXEE fsForm" action="https://reimbursementpolicy.formstack.com/forms/index.php" novalidate="" enctype="multipart/form-data"><input type="hidden" tabindex="-1"
    name="formstackFormSchemaVersion" value="4"><input type="hidden" tabindex="-1" name="formstackFormRendererVersion" value="master"><input type="hidden" tabindex="-1" name="form" value="5535787"><input type="hidden" tabindex="-1" name="viewkey"
    value="Xk0m0wCB3p"><input type="hidden" tabindex="-1" name="password" value=""><input type="hidden" tabindex="-1" name="hidden_fields" value=""><input type="hidden" tabindex="-1" name="_submit" value="1"><input type="hidden" tabindex="-1"
    name="incomplete" value=""><input type="hidden" tabindex="-1" name="incomplete_email" value=""><input type="hidden" tabindex="-1" name="incomplete_password" value=""><input type="hidden" tabindex="-1" name="latitude" value=""><input type="hidden"
    tabindex="-1" name="longitude" value=""><input id="fsUserAgent" type="hidden" tabindex="-1" name="fsUserAgent" value="Mozilla/5.0 (Windows NT 10.0; Win64; x64) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/119.0.6045.199 Safari/537.36">
  <div id="fsPage5535787-1" class="StyledPage-sc-15mrpfq-0 hCMMok fsPage">
    <div data-testid="section0-col1" id="fsSection0" class="StyledSection-sc-1jyjf4h-0 gcHUoI fsSection"><span class="StyledLabel-sc-vn5hkq-0 evOLxK fsLabelVertical" id="label-field155137690" for="field155137690"
        data-testid="field-155137690"><a id="field-anchor-155137690" tabindex="-1" aria-hidden="true"></a>
        <div class="StyledLabelText-sc-1bsmirz-0 lnOUqW fsLabel"></div>
        <div class="">
          <p>&nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;<strong> EMPLOYEE INDIVIDUAL ACKNOWLEDGEMENT REQUIRED</strong></p>
          <p>Note: Upon completion of the below compliance section, Ignorance will no longer be contained as a reason for claim with no basis</p>
        </div>
      </span><span class="StyledLabel-sc-vn5hkq-0 evOLxK fsLabelVertical" id="label-field155135318" for="field155135318" data-testid="field-155135318"><a id="field-anchor-155135318" tabindex="-1" aria-hidden="true"></a>
        <div class="StyledLabelText-sc-1bsmirz-0 lnOUqW fsLabel fsRequiredLabel">Employee Identification<span class="fsRequiredMarker">*</span></div>
        <div class="StyledSubFieldGroup-sc-ik27pq-0 gfzGQs fsSubFieldGroup">
          <div class="StyledSubField-sc-1wt4t9i-0 bdsNVQ fsSubField fsNameFirst"><input autocomplete="given-name" class="StyledInput-sc-1cxwxcf-0 dDIdEu" id="field155135318-first" type="text" label="Employee Identification" required="" maxlength="20"
              name="field155135318-first" data-fs-field-id="155135318" data-fs-field-name="name" data-fs-field-alias="first" value=""><label for="field155135318-first" class="StyledLabel-sc-vn5hkq-0 eOdDYB">First Name</label></div>
          <div class="StyledSubField-sc-1wt4t9i-0 bdsNVQ fsSubField fsNameLast"><input autocomplete="family-name" class="StyledInput-sc-1cxwxcf-0 dDIdEu" id="field155135318-last" type="text" label="Employee Identification" required="" maxlength="20"
              name="field155135318-last" data-fs-field-id="155135318" data-fs-field-name="name" data-fs-field-alias="last" value=""><label for="field155135318-last" class="StyledLabel-sc-vn5hkq-0 eOdDYB">Last Name</label></div>
        </div>
      </span><span class="StyledLabel-sc-vn5hkq-0 evOLxK fsLabelVertical" id="label-field155135245" for="field155135245" data-testid="field-155135245-vertical"><a id="field-anchor-155135245" tabindex="-1" aria-hidden="true"></a>
        <div class="StyledLabelText-sc-1bsmirz-0 lnOUqW fsLabel fsRequiredLabel">Acknowledgement<span class="fsRequiredMarker">*</span></div>
        <fieldset aria-labelledby="155135245-legend" role="radiogroup" aria-required="true" class="StyledFieldset-sc-1r8yz9c-0 StyledOptionWrapper-sc-1ah0fdf-0 cdlqHK PSYyM"><span
            style="position: absolute; left: -999em; width: 0.1em; height: 0.1em; overflow: hidden;">
            <legend id="155135245-legend">Acknowledgement</legend>
          </span>
          <div><label for="field155135245_1" class="StyledOptionLabel-sc-1bymt4x-0 czQxLs fsOptionLabel"><input label="Acknowledgement" required="" class="StyledOptionButton-sc-wqe0tc-0 inKqGo" type="radio" name="field155135245" id="field155135245_1"
                data-fs-field-id="155135245" data-fs-field-name="radio" data-fs-field-alias="*" value="I, the above named employee agree and comply with these policies">I, the above named employee agree and comply with these policies</label></div>
        </fieldset>
      </span></div>
  </div>
  <div id="fsSubmit5535787" class="StyledFormFooter-sc-9cjpwp-0 dPhaIv fsSubmit fsPagination">
    <div class="StyledFormNavigations-sc-t0vu6u-0 jnnwJH"><button id="fsSubmitButton5535787" class="StyledSubmitButton-sc-1ylq3c5-0 cfDACd fsSubmitButton" type="submit">Authenticate Acknowledgement/ Save a copy of Reviewed Policies</button></div>
  </div>
</form>

Text Content

                                    EMPLOYEE INDIVIDUAL ACKNOWLEDGEMENT REQUIRED

Note: Upon completion of the below compliance section, Ignorance will no longer
be contained as a reason for claim with no basis

Employee Identification*
First Name
Last Name
Acknowledgement*
Acknowledgement
I, the above named employee agree and comply with these policies
Authenticate Acknowledgement/ Save a copy of Reviewed Policies