randallgroesbeck.site Open in urlscan Pro
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Form analysis
3 forms found in the DOM

POST #!

<form action="#!" method="post">
  <div class="row">
    <div class="col-lg-6 mb-4 pb-2">
      <div class="form-group">
        <label for="loan_amount" class="form-label">Amount</label>
        <input type="number" class="form-control shadow-none" id="loan_amount" placeholder="ex: 25000">
      </div>
    </div>
    <div class="col-lg-6 mb-4 pb-2">
      <div class="form-group">
        <label for="loan_how_long_for" class="form-label">How long for?</label>
        <input type="number" class="form-control shadow-none" id="loan_how_long_for" placeholder="ex: 12">
      </div>
    </div>
    <div class="col-lg-12 mb-4 pb-2">
      <div class="form-group">
        <label for="loan_repayment" class="form-label">Repayment</label>
        <input type="number" class="form-control shadow-none" id="loan_repayment" disabled="">
      </div>
    </div>
    <div class="col-lg-6 mb-4 pb-2">
      <div class="form-group">
        <label for="loan_full_name" class="form-label">Full Name</label>
        <input type="text" class="form-control shadow-none" id="loan_full_name">
      </div>
    </div>
    <div class="col-lg-6 mb-4 pb-2">
      <div class="form-group">
        <label for="loan_email_address" class="form-label">Email address</label>
        <input type="email" class="form-control shadow-none" id="loan_email_address">
      </div>
    </div>
    <div class="col-lg-12">
      <button type="submit" class="btn btn-primary w-100">Get Your Loan Now</button>
    </div>
  </div>
</form>

#!

<form action="#!">
  <div class="row h1">Reach Out to Us</div>
  <div class="row">
    <div class="col-6 form-group mb-4 pb-2">
      <label class="form-label">Full name</label>
      <input type="text" id="name" name="name" class="form-control shadow-none" required="">
    </div>
    <div class="col-6 form-group mb-4 pb-2">
      <label class="form-label">Email address</label>
      <input type="email" id="email" name="email" class="form-control shadow-none" required="">
    </div>
    <div class="col-6 form-group mb-4 pb-2">
      <label class="form-label">Your Date of Birth</label>
      <input type="text" id="dob" name="dob" class="form-control shadow-none" required="">
    </div>
    <div class="col-6 form-group mb-4 pb-2">
      <label class="form-label">Phone number</label>
      <input type="text" id="phone" name="phone_number" class="form-control shadow-none" required="">
    </div>
    <div class="col-6 form-group mb-4 pb-2">
      <label class="form-label">Your State</label>
      <input type="text" id="state" name="state" class="form-control shadow-none" required="">
    </div>
    <div class="col-6 form-group mb-4 pb-2">
      <label class="form-label">Your City</label>
      <input type="text" id="city" name="city" class="form-control shadow-none" required="">
    </div>
  </div>
  <div class="form-group mb-4 pb-2">
    <label class="form-label">Your street</label>
    <textarea class="form-control shadow-none" id="street" name="street" rows="3"></textarea>
  </div>
  <div>
    <input type="checkbox" name="agreement" required=""> I agree , By submitting my cell phone number to receive automated sms/mms messages with more information or quote from RANDALL GROESBECK. 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-2">
    <button class="btn btn-primary" 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

RANDALL GROESBECK
 * Home
 * Terms Conditions
 * Privacy Policy

HOW MUCH DO YOU NEED?

Amount
How long for?
Repayment
Full Name
Email address
Get Your Loan Now


RANDALL GROESBECK

I am a Licensed healthcare agent and I help families and individuals find
affordable healthcare coverage that fits their needs.





TAILORED SOLUTIONS

AFFORDABLE HEALTHCARE PLANS

We offer a variety of healthcare plans to fit your budget and cover your needs.

PERSONALIZED INSURANCE SOLUTIONS

Our licensed agents work with you to find the best insurance coverage for
yourself or your family.

EXPERT GUIDANCE IN HEALTHCARE COVERAGE

Let us guide you through the complex world of healthcare insurance, finding the
right plan for you and your loved ones.
Reach Out to Us
Full name
Email address
Your Date of Birth
Phone number
Your State
Your City
Your street
I agree , By submitting my cell phone number to receive automated sms/mms
messages with more information or quote from RANDALL GROESBECK. Message
frequency may vary. Reply STOP to cancel, Reply HELP for contact information.
message and date rates may apply Terms & Conditions | Privacy Policy
Send

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