dev.claim.ancileo.com Open in urlscan Pro
54.255.83.208  Public Scan

Form analysis
4 forms found in the DOM

POST https://dev.claim.ancileo.com/getPolicy

<form method="post" action="https://dev.claim.ancileo.com/getPolicy" id="getPolicyForm">
  <input type="hidden" name="_token" value="SsXbysDJS8RdS3kgLUfjqarNBfH1T4QvP1aozQCb">
  <div class="form_field">
    <label>Policy number</label>
    <input name="policy_number" type="text" placeholder="HLA0123">
  </div>
  <div class="form_field">
    <label>Email</label>
    <input name="email_retrieve" type="email" placeholder="e.g. info@abc.com">
  </div>
  <div class="form_button">
    <input type="submit" name="button" value="Retrieve policy">
  </div>
</form>

POST https://dev.claim.ancileo.com/createClaim

<form method="post" action="https://dev.claim.ancileo.com/createClaim" id="createClaimForm" enctype="multipart/form-data">
  <input type="hidden" name="_token" value="SsXbysDJS8RdS3kgLUfjqarNBfH1T4QvP1aozQCb">
  <div class="form_field">
    <label>Claim Type</label>
    <select name="claim_type" id="claim_type">
      <option>Please Select</option>
      <option value="pa">Personal Accident</option>
      <option value="me">Medical Expenses</option>
      <option value="td">Travel Delay</option>
      <option value="fm">Flight Misconnection</option>
      <option value="bd">Baggage Delay</option>
      <option value="ld">Loss or Damage of Baggage/ Personal Effects/ Personal Money and Travel Cheque</option>
      <option value="ot">Others</option>
    </select>
  </div>
  <div class="form_field">
    <label>Amount Claimed</label>
    <input name="claimed_amount" type="number" step=".01" placeholder="123.45">
  </div>
  <div class="form_field date" data-provide="datepicker">
    <label>Date of the incident</label>
    <div class="form_field_inr">
      <input name="incident_date" type="date" placeholder="DD / MM / YYYY" id="incident_date">
      <div class="input-group-addon" onclick="$('#incident_date').click(); return false;">
      </div>
    </div>
  </div>
  <div class="form_field">
    <label>CLAIM DESCRIPTION</label>
    <div class="si-wrapper"><textarea name="incident_desc" type="text" placeholder="Lorem ispum" class="speech-input" lang="en" data-ready="Record your voice" style="padding-right: 0px;"></textarea><button type="button" class="si-btn"
        style="cursor: pointer; top: 0px; width: 0px; height: 0px;">speech input<span class="si-mic"></span><span class="si-holder"></span></button></div>
  </div>
</form>

POST https://dev.claim.ancileo.com/docs

<form method="post" id="claimsPostDocs" action="https://dev.claim.ancileo.com/docs" style="text-align: center;" enctype="multipart/form-data" class="box has-advanced-upload" novalidate="">
  <input type="hidden" name="_token" value="SsXbysDJS8RdS3kgLUfjqarNBfH1T4QvP1aozQCb">
  <div class="form_upload_file_field">
    <div class="form_field">
      <label>Upload receipt</label>
      <div class="form_upload_file_field_inr">
        <input type="file" name="invoice" id="invoice" class="box__file inputfile inputinvoice">
        <label for="invoice"><span>Drag &amp; drop or upload receipts here</span></label>
        <button type="submit" class="box__button" style="position: fixed; left: -2000px;">Upload</button>
      </div>
    </div>
  </div>
  <input type="hidden" name="ajax" value="1">
</form>

POST #

<form action="#" method="POST" id="completeClaimForm">
  <div class="form_button">
    <input type="submit" name="button" id="completeClaimFormButton" onclick="$('#createClaimForm').submit(); return false;" value="Process Claim">
  </div>
</form>

Text Content

1PROCESS A CLAIM

Policy number
Email


POLICY INFORMATION

 * Name: Scott
 * Last Name: Doe
 * IC Number: 233 738 4564
 * Start date trip: 12/11/2018
 * End date trip: 12/11/2018
 * Issuance date: 12/11/2018

 * Product: Health
 * Email: info@abc.com

First Name: def Last Name: def IC Number: def Start date trip: def End date
trip: def Issuance date: def Product: def Email: def

Claim Type Please Select Personal Accident Medical Expenses Travel Delay Flight
Misconnection Baggage Delay Loss or Damage of Baggage/ Personal Effects/
Personal Money and Travel Cheque Others
Amount Claimed
Date of the incident

CLAIM DESCRIPTION
speech input
Upload receipt
Drag & drop or upload receipts here Upload