dsnp.securitybenefitscenter.com
Open in
urlscan Pro
3.133.107.159
Public Scan
URL:
https://dsnp.securitybenefitscenter.com/
Submission: On October 29 via automatic, source certstream-suspicious — Scanned from DE
Submission: On October 29 via automatic, source certstream-suspicious — Scanned from DE
Form analysis 1 forms found in the DOM
GET https://gosbc.agilecrm.com/formsubmit
<form class="form-view theme1" id="agile-form" action="https://gosbc.agilecrm.com/formsubmit" style="max-width:450px;" method="GET">
<fieldset>
<!-- Form Name -->
<legend class="agile-hide-formname">DSNP</legend>
<p class="agile-form-description">For Michigan, Thousands in FREE BENEFITS Available! Please Complete This Form to QUALIFY NOW!</p>
<div style="display: none; height: 0px; width: 0px;">
<input type="hidden" id="_agile_form_name" name="_agile_form_name" value="DSNP">
<input type="hidden" id="_agile_domain" name="_agile_domain" value="gosbc">
<input type="hidden" id="_agile_api" name="_agile_api" value="gugj9gtekgv2rl2cpdn0u5p6l7">
<input type="hidden" id="_agile_redirect_url" name="_agile_redirect_url" value="#">
<input type="hidden" id="_agile_document_url" name="_agile_document_url" value="">
<input type="hidden" id="_agile_confirmation_msg" name="_agile_confirmation_msg" value="Keep your phone close by! An agent at Security Benefits Center will be contacting you shortly. Be Sure to ANSWER!">
<input type="hidden" id="_agile_form_id_tags" name="tags" value="DSNP,DYL Import,DSNPVIDEO">
<input type="hidden" id="_agile_form_id" name="_agile_form_id" value="5663401019703296">
</div>
<!-- Text input-->
<div class="agile-group required-control">
<label class="agile-label" for="agilefield-1">Enter your First Name<span class="agile-span-asterisk"> *</span></label>
<div class="agile-field-xlarge agile-field">
<input maxlength="250" id="agilefield-1" name="first_name" type="text" placeholder="" class="agile-height-default" required="">
</div>
<div class="agile-custom-clear"></div>
</div>
<!-- Text input-->
<div class="agile-group required-control">
<label class="agile-label" for="agilefield-5">Enter your Last Name<span class="agile-span-asterisk"> *</span></label>
<div class="agile-field-xlarge agile-field">
<input maxlength="250" id="agilefield-5" name="last_name" type="text" placeholder="" class="agile-height-default" required="">
</div>
<div class="agile-custom-clear"></div>
</div>
<!-- Text input-->
<div class="agile-group required-control">
<label class="agile-label" for="agilefield-3">Enter your Email<span class="agile-span-asterisk"> *</span></label>
<div class="agile-field-xlarge agile-field">
<input maxlength="250" id="agilefield-3" name="email" type="email" placeholder="" class="agile-height-default" required="">
</div>
<div class="agile-custom-clear"></div>
</div>
<!-- Text input-->
<div class="agile-group required-control">
<label class="agile-label" for="agilefield-2">Enter your Phone<span class="agile-span-asterisk"> *</span></label>
<div class="agile-field-xlarge agile-field">
<input maxlength="250" id="agilefield-2" name="phone" type="text" placeholder="" class="agile-height-default" required="">
</div>
<div class="agile-custom-clear"></div>
</div>
<!-- Text input-->
<div class="agile-group required-control">
<label class="agile-label" for="agilefield-6">Street Addres<span class="agile-span-asterisk"> *</span></label>
<div class="agile-field-xlarge agile-field">
<input maxlength="250" id="agilefield-6" name="address" type="text" placeholder="" class="agile-height-default" required="">
</div>
<div class="agile-custom-clear"></div>
</div>
<!-- Text input-->
<div class="agile-group required-control">
<label class="agile-label" for="agilefield-9">City<span class="agile-span-asterisk"> *</span></label>
<div class="agile-field-xlarge agile-field">
<input maxlength="250" id="agilefield-9" name="city" type="text" placeholder="" class="agile-height-default" required="">
</div>
<div class="agile-custom-clear"></div>
</div>
<!-- Text input-->
<div class="agile-group required-control">
<label class="agile-label" for="agilefield-10">State<span class="agile-span-asterisk"> *</span></label>
<div class="agile-field-xlarge agile-field">
<input maxlength="250" id="agilefield-10" name="state" type="text" placeholder="" class="agile-height-default" required="">
</div>
<div class="agile-custom-clear"></div>
</div>
<!-- Text input-->
<div class="agile-group required-control">
<label class="agile-label" for="agilefield-4">Zip Code<span class="agile-span-asterisk"> *</span></label>
<div class="agile-field-xlarge agile-field">
<input maxlength="250" id="agilefield-4" name="zip" type="text" placeholder="" class="agile-height-default" required="">
</div>
<div class="agile-custom-clear"></div>
</div>
<!--recaptcha aglignment-->
<!-- Button -->
<div class="agile-group">
<label class="agile-label"> </label>
<div class="agile-field agile-button-field">
<button type="submit" class="agile-button">Qualify Now</button>
<br><span id="agile-error-msg"></span>
</div>
</div>
</fieldset>
</form>Text Content
Toggle navigation Security Benefits Center Call 616-965-6275 * Home * About * Benefits * Contact DSNP For Michigan, Thousands in FREE BENEFITS Available! Please Complete This Form to QUALIFY NOW! Enter your First Name * Enter your Last Name * Enter your Email * Enter your Phone * Street Addres * City * State * Zip Code * Qualify Now DON'T MISS OUT ON BENEFITS YOU ARE ENTITLED TO! * Do you have MEDICARE and MEDICAID? We can help you receive the Extra FREE Benefits you Deserve! * These benefits work together with the Medicare and Medicaid benefits you already have. * You only have MORE BENEFITS to gain. * COMPLETE THIS FORM or Contact Us and we will give you all the information you need to sign up for your EXTRA BENEFITS! ADDRESS Security Benefits Center 2350 32nd St SE, Suite 100 Kentwood, MI 49508 PHONE Call or Text us: 616-965-6275 EMAIL Email us at: info@securitybenefitscenter.com We're social, come meet and meet us: