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Submitted URL: http://r.emg.thgins.com/mk/cl/f/xAs-6QS5zDlj4bMyPw50cTL5nmFUi2M7mngUYiFLFnX15e9VQM7I9O1uwwBM5qrGOOnbTUoA8I1XKa7RR7j4BP0w...
Effective URL: https://share.hsforms.com/18ABwtS_eRTm-WngvXg5lwwccpkj?utm_source=sendinblue&utm_campaign=WE%20want%20your%20smoker%20clie...
Submission: On September 28 via api from US — Scanned from FR
Effective URL: https://share.hsforms.com/18ABwtS_eRTm-WngvXg5lwwccpkj?utm_source=sendinblue&utm_campaign=WE%20want%20your%20smoker%20clie...
Submission: On September 28 via api from US — Scanned from FR
Form analysis 1 forms found in the DOM
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<div class="hs-form__group">
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<div class="hs-form__field hs-form__field-email hs-email"><label id="email-label" for="email-input" class="hs-form__field__label hs-form__field__label--required" data-required="true"><span>Email</span></label><input id="email-input"
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</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-firstname hs-firstname"><label id="firstname-label" for="firstname-input" class="hs-form__field__label hs-form__field__label--required" data-required="true"><span>First name</span></label><input
id="firstname-input" class="hs-form__field__input" type="text" name="firstname" required="" autocomplete="given-name" inputmode="text" aria-invalid="false" aria-labelledby="firstname-label" aria-describedby="firstname-description"
aria-required="true" value=""></div>
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<div class="hs-form__row">
<div class="hs-form__group">
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<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-lastname hs-lastname"><label id="lastname-label" for="lastname-input" class="hs-form__field__label hs-form__field__label--required" data-required="true"><span>Last name</span></label><input
id="lastname-input" class="hs-form__field__input" type="text" name="lastname" required="" autocomplete="family-name" inputmode="text" aria-invalid="false" aria-labelledby="lastname-label" aria-describedby="lastname-description"
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<div class="hs-form__row">
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<div class="hs-form__field__phone"><input id="phone-input" class="hs-form__field__input" type="tel" name="phone" required="" autocomplete="tel" inputmode="tel" aria-invalid="false" aria-labelledby="phone-label"
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<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-company hs-company"><label id="company-label" for="company-input" class="hs-form__field__label" data-required="false"><span>Company name</span></label><input id="company-input"
class="hs-form__field__input" type="text" name="company" autocomplete="organization" inputmode="text" aria-invalid="false" aria-labelledby="company-label" aria-describedby="company-description" aria-required="false" value=""></div>
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<div class="hs-form__row">
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class="hs-form__field__input" name="message" aria-invalid="false" aria-labelledby="message-label" aria-describedby="message-description" aria-required="false"></textarea></div>
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</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-information_you_are_requesting__choose_all_that_apply__ hs-information_you_are_requesting__choose_all_that_apply__"><label id="information_you_are_requesting__choose_all_that_apply__-label"
for="information_you_are_requesting__choose_all_that_apply__-input" class="hs-form__field__label hs-form__field__label--required" data-required="true"><span>Information you are requesting? Choose all that apply.:</span></label>
<div style="display: flex; flex-grow: 1; align-items: flex-start; justify-content: flex-start; flex-direction: row;">
<div class="hs-form__field__options__container" role="group" aria-invalid="false" aria-labelledby="information_you_are_requesting__choose_all_that_apply__-label"
aria-describedby="information_you_are_requesting__choose_all_that_apply__-description">
<div style="align-self: flex-start; flex: 0 1 auto;"><label id="information_you_are_requesting__choose_all_that_apply__-label-1" class="hs-form__field__label hs-form__field__checkbox__label"><input
id="information_you_are_requesting__choose_all_that_apply__-input-1" class="hs-form__field__input hs-form__field__checkbox__input" type="checkbox"
name="information_you_are_requesting__choose_all_that_apply__-New Final Expense" aria-invalid="false" aria-labelledby="information_you_are_requesting__choose_all_that_apply__-label-1"
aria-describedby="information_you_are_requesting__choose_all_that_apply__-description" aria-required="false" aria-checked="false" value="New Final Expense"><span class="hs-form__field__checkbox__label-span">New Final
Expense</span></label></div>
<div style="align-self: flex-start; flex: 0 1 auto;"><label id="information_you_are_requesting__choose_all_that_apply__-label-2" class="hs-form__field__label hs-form__field__checkbox__label"><input
id="information_you_are_requesting__choose_all_that_apply__-input-2" class="hs-form__field__input hs-form__field__checkbox__input" type="checkbox"
name="information_you_are_requesting__choose_all_that_apply__-RX Discount Drug Card" aria-invalid="false" aria-labelledby="information_you_are_requesting__choose_all_that_apply__-label-2"
aria-describedby="information_you_are_requesting__choose_all_that_apply__-description" aria-required="false" aria-checked="false" value="RX Discount Drug Card"><span class="hs-form__field__checkbox__label-span">RX Discount
Drug Card</span></label></div>
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</div>
</div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-what_product_s__do_you_sell__choose_all_that_apply__ hs-what_product_s__do_you_sell__choose_all_that_apply__"><label id="what_product_s__do_you_sell__choose_all_that_apply__-label"
for="what_product_s__do_you_sell__choose_all_that_apply__-input" class="hs-form__field__label hs-form__field__label--required" data-required="true"><span>What product(s) do you sell? Choose all that apply.:</span></label>
<div style="display: flex; flex-grow: 1; align-items: flex-start; justify-content: flex-start; flex-direction: row;">
<div class="hs-form__field__options__container" role="group" aria-invalid="false" aria-labelledby="what_product_s__do_you_sell__choose_all_that_apply__-label"
aria-describedby="what_product_s__do_you_sell__choose_all_that_apply__-description">
<div style="align-self: flex-start; flex: 0 1 auto;"><label id="what_product_s__do_you_sell__choose_all_that_apply__-label-1" class="hs-form__field__label hs-form__field__checkbox__label"><input
id="what_product_s__do_you_sell__choose_all_that_apply__-input-1" class="hs-form__field__input hs-form__field__checkbox__input" type="checkbox" name="what_product_s__do_you_sell__choose_all_that_apply__-Health/Under 65"
aria-invalid="false" aria-labelledby="what_product_s__do_you_sell__choose_all_that_apply__-label-1" aria-describedby="what_product_s__do_you_sell__choose_all_that_apply__-description" aria-required="false" aria-checked="false"
value="Health/Under 65"><span class="hs-form__field__checkbox__label-span">Health/Under 65</span></label></div>
<div style="align-self: flex-start; flex: 0 1 auto;"><label id="what_product_s__do_you_sell__choose_all_that_apply__-label-2" class="hs-form__field__label hs-form__field__checkbox__label"><input
id="what_product_s__do_you_sell__choose_all_that_apply__-input-2" class="hs-form__field__input hs-form__field__checkbox__input" type="checkbox" name="what_product_s__do_you_sell__choose_all_that_apply__-Medicare/65 and over"
aria-invalid="false" aria-labelledby="what_product_s__do_you_sell__choose_all_that_apply__-label-2" aria-describedby="what_product_s__do_you_sell__choose_all_that_apply__-description" aria-required="false" aria-checked="false"
value="Medicare/65 and over"><span class="hs-form__field__checkbox__label-span">Medicare/65 and over</span></label></div>
<div style="align-self: flex-start; flex: 0 1 auto;"><label id="what_product_s__do_you_sell__choose_all_that_apply__-label-3" class="hs-form__field__label hs-form__field__checkbox__label"><input
id="what_product_s__do_you_sell__choose_all_that_apply__-input-3" class="hs-form__field__input hs-form__field__checkbox__input" type="checkbox" name="what_product_s__do_you_sell__choose_all_that_apply__-Other:"
aria-invalid="false" aria-labelledby="what_product_s__do_you_sell__choose_all_that_apply__-label-3" aria-describedby="what_product_s__do_you_sell__choose_all_that_apply__-description" aria-required="false" aria-checked="false"
value="Other:"><span class="hs-form__field__checkbox__label-span">Other</span></label></div>
<div style="align-self: flex-start; flex: 0 1 auto;"><label id="what_product_s__do_you_sell__choose_all_that_apply__-label-4" class="hs-form__field__label hs-form__field__checkbox__label"><input
id="what_product_s__do_you_sell__choose_all_that_apply__-input-4" class="hs-form__field__input hs-form__field__checkbox__input" type="checkbox" name="what_product_s__do_you_sell__choose_all_that_apply__-Life"
aria-invalid="false" aria-labelledby="what_product_s__do_you_sell__choose_all_that_apply__-label-4" aria-describedby="what_product_s__do_you_sell__choose_all_that_apply__-description" aria-required="false" aria-checked="false"
value="Life"><span class="hs-form__field__checkbox__label-span">Life</span></label></div>
</div>
</div>
</div>
</div>
</div>
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</div>
<div class="hs-form__row">
<div id="hsRecaptchaTarget">
<div class="grecaptcha-badge" data-style="inline" style="width: 256px; height: 60px; box-shadow: gray 0px 0px 5px;">
<div class="grecaptcha-logo"><iframe title="reCAPTCHA"
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width="256" height="60" role="presentation" name="a-t9ccghy9kd4z" frameborder="0" scrolling="no"
sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"></iframe></div>
<div class="grecaptcha-error"></div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div><iframe style="display: none;"></iframe>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__actions"><button type="submit" name="Submit" class="hs-form__actions__submit">Submit</button></div>
</div>
<div class="hs-form__row">
<div class="hs-form__virality-link"><img src="https://js.hsforms.net/sproket.png" class="hs-form__virality-link__sproket" alt=""><span class="hs-form__virality-link__text"><span>Create your own
</span><a target="_blank" rel="noopener noreferrer" href="https://app.hubspot.com/signup-hubspot/marketing?hubs_medium=virality&hubs_campaign=hubspot-forms-virality&hubs_id=forms-branding-control&hubs_source=share.hsforms.com&intent=marketingFreeForms&opt_sidebar=forms" class="hs-form__virality-link__text__link"><span>free form with HubSpot</span></a></span>
</div>
</div>
</form>Text Content
Skip to form Email First name Last name Phone number Company name Message Information you are requesting? Choose all that apply.: New Final Expense RX Discount Drug Card What product(s) do you sell? Choose all that apply.: Health/Under 65 Medicare/65 and over Other Life Submit Create your own free form with HubSpot