oshcaustralia.com.au Open in urlscan Pro
34.149.230.143  Public Scan

Form analysis
1 forms found in the DOM

POST /es/policy_applications/OSHC3930621677/policy_auth

<form class="simple_form form-horizontal policy-application" id="new_policy_application" novalidate="novalidate" action="/es/policy_applications/OSHC3930621677/policy_auth" accept-charset="UTF-8" method="post"><input name="utf8" type="hidden"
    value="✓" autocomplete="off"><input type="hidden" name="authenticity_token" value="zdGhG1cbA3pZPfUD+Fl0nwjigT8viIHjwP5R9EN78RpEplU00eEnB686U8aC0dkK3xVWGIMQgcYH3tDaQ+F+2g==" autocomplete="off">
  <legend>Información del estudiante</legend>
  <div class="control-group string required policy_application_given_name"><label class="string required control-label" for="policy_application_given_name"><abbr title="Obligatorio">*</abbr> Nombre</label>
    <div class="controls"><input class="string required" type="text" name="policy_application[given_name]" id="policy_application_given_name"></div>
  </div>
  <div class="control-group string required policy_application_surname"><label class="string required control-label" for="policy_application_surname"><abbr title="Obligatorio">*</abbr> Apellidos</label>
    <div class="controls"><input class="string required" type="text" name="policy_application[surname]" id="policy_application_surname"></div>
  </div>
  <div class="control-group date required policy_application_dob"><label class="date required control-label" for="policy_application_dob_3i"><abbr title="Obligatorio">*</abbr> Fecha de Nacimiento</label>
    <div class="controls"><select id="policy_application_dob_3i" name="policy_application[dob(3i)]" class="date required input-medium">
        <option value="" label=" "></option>
        <option value="1">1</option>
        <option value="2">2</option>
        <option value="3">3</option>
        <option value="4">4</option>
        <option value="5">5</option>
        <option value="6">6</option>
        <option value="7">7</option>
        <option value="8">8</option>
        <option value="9">9</option>
        <option value="10">10</option>
        <option value="11">11</option>
        <option value="12">12</option>
        <option value="13">13</option>
        <option value="14">14</option>
        <option value="15">15</option>
        <option value="16">16</option>
        <option value="17">17</option>
        <option value="18">18</option>
        <option value="19">19</option>
        <option value="20">20</option>
        <option value="21">21</option>
        <option value="22">22</option>
        <option value="23">23</option>
        <option value="24">24</option>
        <option value="25">25</option>
        <option value="26">26</option>
        <option value="27">27</option>
        <option value="28">28</option>
        <option value="29">29</option>
        <option value="30">30</option>
        <option value="31">31</option>
      </select>
      <select id="policy_application_dob_2i" name="policy_application[dob(2i)]" class="date required input-medium">
        <option value="" label=" "></option>
        <option value="1">enero</option>
        <option value="2">febrero</option>
        <option value="3">marzo</option>
        <option value="4">abril</option>
        <option value="5">mayo</option>
        <option value="6">junio</option>
        <option value="7">julio</option>
        <option value="8">agosto</option>
        <option value="9">septiembre</option>
        <option value="10">octubre</option>
        <option value="11">noviembre</option>
        <option value="12">diciembre</option>
      </select>
      <select id="policy_application_dob_1i" name="policy_application[dob(1i)]" class="date required input-medium">
        <option value="" label=" "></option>
        <option value="2018">2018</option>
        <option value="2017">2017</option>
        <option value="2016">2016</option>
        <option value="2015">2015</option>
        <option value="2014">2014</option>
        <option value="2013">2013</option>
        <option value="2012">2012</option>
        <option value="2011">2011</option>
        <option value="2010">2010</option>
        <option value="2009">2009</option>
        <option value="2008">2008</option>
        <option value="2007">2007</option>
        <option value="2006">2006</option>
        <option value="2005">2005</option>
        <option value="2004">2004</option>
        <option value="2003">2003</option>
        <option value="2002">2002</option>
        <option value="2001">2001</option>
        <option value="2000">2000</option>
        <option value="1999">1999</option>
        <option value="1998">1998</option>
        <option value="1997">1997</option>
        <option value="1996">1996</option>
        <option value="1995">1995</option>
        <option value="1994">1994</option>
        <option value="1993">1993</option>
        <option value="1992">1992</option>
        <option value="1991">1991</option>
        <option value="1990">1990</option>
        <option value="1989">1989</option>
        <option value="1988">1988</option>
        <option value="1987">1987</option>
        <option value="1986">1986</option>
        <option value="1985">1985</option>
        <option value="1984">1984</option>
        <option value="1983">1983</option>
        <option value="1982">1982</option>
        <option value="1981">1981</option>
        <option value="1980">1980</option>
        <option value="1979">1979</option>
        <option value="1978">1978</option>
        <option value="1977">1977</option>
        <option value="1976">1976</option>
        <option value="1975">1975</option>
        <option value="1974">1974</option>
        <option value="1973">1973</option>
        <option value="1972">1972</option>
        <option value="1971">1971</option>
        <option value="1970">1970</option>
        <option value="1969">1969</option>
        <option value="1968">1968</option>
        <option value="1967">1967</option>
        <option value="1966">1966</option>
        <option value="1965">1965</option>
        <option value="1964">1964</option>
        <option value="1963">1963</option>
        <option value="1962">1962</option>
        <option value="1961">1961</option>
        <option value="1960">1960</option>
        <option value="1959">1959</option>
        <option value="1958">1958</option>
        <option value="1957">1957</option>
        <option value="1956">1956</option>
        <option value="1955">1955</option>
        <option value="1954">1954</option>
        <option value="1953">1953</option>
        <option value="1952">1952</option>
        <option value="1951">1951</option>
        <option value="1950">1950</option>
        <option value="1949">1949</option>
        <option value="1948">1948</option>
        <option value="1947">1947</option>
        <option value="1946">1946</option>
        <option value="1945">1945</option>
        <option value="1944">1944</option>
        <option value="1943">1943</option>
      </select>
    </div>
  </div>
  <div class="control-group radio_buttons required policy_application_gender"><label class="radio_buttons required control-label"><abbr title="Obligatorio">*</abbr> Sexo</label>
    <div class="controls"><input type="hidden" name="policy_application[gender]" value="" autocomplete="off"><span class="radio"><label for="policy_application_gender_male"><input class="radio_buttons required" type="radio" value="male"
            name="policy_application[gender]" id="policy_application_gender_male">Hombre</label></span><span class="radio"><label for="policy_application_gender_female"><input class="radio_buttons required" type="radio" value="female"
            name="policy_application[gender]" id="policy_application_gender_female">Mujer</label></span></div>
  </div>
  <input type="hidden" name="target" id="target" value="/es/policy_applications/OSHC3930621677/payment" autocomplete="off">
  <div class="form-actions">
    <input type="submit" name="commit" value="Siguiente" class="btn btn-primary" data-disable-with="Siguiente">
  </div>
</form>

Text Content

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students.

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IDENTIFICATION REQUIRED

In order to protect your privacy, we require you to confirm your details before
we can show you any details about this policy. Please confirm your first name,
surname and date of birth below.

Información del estudiante
* Nombre

* Apellidos

* Fecha de Nacimiento
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30
31 enero febrero marzo abril mayo junio julio agosto septiembre octubre
noviembre diciembre 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007
2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991
1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975
1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959
1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943
* Sexo
HombreMujer

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