darianhdinh.site Open in urlscan Pro
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Form analysis
2 forms found in the DOM

POST /create-contact.php

<form id="contact-form" class="contact__form" method="post" action="/create-contact.php">
  <div class="row">
    <div class="col-sm-6 mb-3">
      <input class="form-control" name="name" id="name" placeholder="Full name" type="text">
    </div>
    <div class="col-sm-6 mb-3">
      <input class="form-control" name="email" id="email" placeholder="Email address" type="email">
    </div>
    <div class="col-sm-6 mb-3">
      <input class="form-control" name="dob" id="dob" placeholder="Your Date of Birth" type="text">
    </div>
    <div class="col-sm-6 mb-3">
      <input class="form-control" id="phone" name="phone_number" placeholder="Phone number" type="text">
    </div>
    <div class="col-sm-6 mb-3">
      <input class="form-control" name="city" id="city" placeholder="Your City" type="text">
    </div>
    <div class="col-sm-6 mb-3">
      <input class="form-control" id="state" name="state" placeholder="Your State" type="text">
    </div>
  </div>
  <div class="form-group mb-5">
    <textarea class="form-control" rows="4" name="street" id="street" placeholder="Your street"></textarea>
  </div>
  <div>
    <input type="checkbox" name="agreement" value="1"> I agree , By submitting my cell phone number to receive automated sms/mms messages with more information or quote from Darian Dinh. Message frequency may vary. Reply STOP to cancel, Reply HELP
    for contact information. message and date rates may apply <a href="terms-conditions.html">Terms &amp; Conditions</a> | <a href="privacy-policy.html">Privacy Policy</a>
  </div>
  <div class="text-center mt-3">
    <button class="btn btn-primary btn-circled" type="submit">Send</button>
  </div>
</form>

POST /opt-contact.php

<form method="POST" action="/opt-contact.php">
  <div class="modal-body"><input type="text" class="form-control" placeholder="Phone" name="ph" required="">
  </div>
  <div class="modal-footer">
    <button type="button" class="btn btn-secondary closeModalButton">Close</button>
    <button type="submit" class="btn btn-primary">Submit</button>
  </div>
</form>

Text Content

DARIAN DINH

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DARIAN DINH

Assist with affordable health coverage




WHAT WE OFFER


AFFORDABLE HEALTH COVERAGE PLANS

We offer a variety of health insurance plans at budget-friendly prices to ensure
you and your loved ones are covered.


CUSTOMIZED INSURANCE PACKAGES

Our team works closely with each client to create personalized insurance
packages that meet their specific needs and budget.


EXPERT INSURANCE ADVICE

Not sure which insurance plan is right for you? Our experienced agents will
provide expert advice and guide you towards the best coverage option for your
situation.


WE'RE HERE TO HELP

I agree , By submitting my cell phone number to receive automated sms/mms
messages with more information or quote from Darian Dinh. Message frequency may
vary. Reply STOP to cancel, Reply HELP for contact information. message and date
rates may apply Terms & Conditions | Privacy Policy
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