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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 g-3">
    <div class="col-12 col-sm-6">
      <input type="text" id="name" name="name" class="form-control border-0" placeholder="Full name" style="height: 55px;">
    </div>
    <div class="col-12 col-sm-6">
      <input type="email" id="email" name="email" class="form-control border-0" placeholder="Email address" style="height: 55px;">
    </div>
    <div class="col-12 col-sm-6">
      <input type="text" id="dob" name="dob" class="form-control border-0" placeholder="Your Date of Birth" style="height: 55px;">
    </div>
    <div class="col-12 col-sm-6">
      <input type="text" id="phone" name="phone_number" class="form-control border-0" placeholder="Phone number" style="height: 55px;">
    </div>
    <div class="col-12 col-sm-6">
      <div class="date" id="date" data-target-input="nearest">
        <input type="text" id="state" name="state" class="form-control border-0" placeholder="Your State" style="height: 55px;">
      </div>
    </div>
    <div class="col-12 col-sm-6">
      <div class="time" id="time" data-target-input="nearest">
        <input type="text" id="city" name="city" class="form-control border-0" placeholder="Your City" style="height: 55px;">
      </div>
    </div>
    <div class="col-12">
      <textarea id="street" name="street" class="form-control border-0" rows="5" 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 UNION JMD LLC. 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="col-12">
      <button class="btn btn-primary w-100 py-3" type="submit">Send</button>
    </div>
  </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

UNION JMD LLC

Home Terms Conditions Privacy Policy


UNION JMD LLC


JACK DOMBROWSKI

I'm a licensed health coverage advisor with years of fruitful experience in the
health insurance industry. With my knowledge and understanding of the whole
process, I am more than able to provide excellent assistance to families and
individuals with their search for an affordable health plan.


WHAT WE OFFER

PERSONALIZED HEALTH COVERAGE PLANS

Let us help you find the perfect health insurance plan for you and your family
based on your individual needs and budget.

AFFORDABLE INSURANCE OPTIONS

We understand that finding affordable health insurance can be challenging, but
our team of experts is dedicated to finding the best options for you at a price
that fits your budget.

EXPERT GUIDANCE AND SUPPORT

Navigating the world of health insurance can be overwhelming, but with our
licensed advisors by your side, we'll provide you with expert guidance and
support every step of the way.


LET'S CONNECT

Call Us Now

+17169081483

Mail Us Now

MONTYWORLD122@GMAIL.COM

I agree , By submitting my cell phone number to receive automated sms/mms
messages with more information or quote from UNION JMD LLC. 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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