my.certificial.com
Open in
urlscan Pro
54.185.236.230
Public Scan
URL:
https://my.certificial.com/sign-up-agent/new/grms
Submission: On March 19 via manual from US — Scanned from DE
Submission: On March 19 via manual from US — Scanned from DE
Form analysis 2 forms found in the DOM
<form class="ant-form ant-form-horizontal">
<div>Please enter your agency email address:</div>
<div class="ant-row">
<div class="ant-col ant-col-16">
<div class="ant-row ant-form-item">
<div class="ant-col ant-form-item-control-wrapper">
<div class="ant-form-item-control"><span class="ant-form-item-children"><span class="ant-input-affix-wrapper" style="width: 30vw;"><span
class="ant-input-prefix"><i aria-label="icon: mail" class="anticon anticon-mail" style="color: rgba(0, 0, 0, 0.25);"><svg viewBox="64 64 896 896" focusable="false" class="" data-icon="mail" width="1em" height="1em" fill="currentColor" aria-hidden="true"><path d="M928 160H96c-17.7 0-32 14.3-32 32v640c0 17.7 14.3 32 32 32h832c17.7 0 32-14.3 32-32V192c0-17.7-14.3-32-32-32zm-40 110.8V792H136V270.8l-27.6-21.5 39.3-50.5 42.8 33.3h643.1l42.8-33.3 39.3 50.5-27.7 21.5zM833.6 232L512 482 190.4 232l-42.8-33.3-39.3 50.5 27.6 21.5 341.6 265.6a55.99 55.99 0 0 0 68.7 0L888 270.8l27.6-21.5-39.3-50.5-42.7 33.2z"></path></svg></i></span><input
type="email" placeholder="E-mail" id="signupVerifyUser_email" data-__meta="[object Object]" data-__field="[object Object]" class="ant-input" value=""></span></span></div>
</div>
</div>
</div>
<div class="ant-col ant-col-6 submit-buttom"><button type="button" class="ant-btn ant-btn-primary"><span>Submit</span></button></div>
</div>
</form><form class="ant-form ant-form-horizontal" style="display: none;">
<div class="ant-row">
<div class="ant-col ant-col-12 p-12">
<div class="ant-row ant-form-item">
<div class="ant-col ant-form-item-label"><label for="SignUp_firstName" class="ant-form-item-required" title="First Name">First Name</label></div>
<div class="ant-col ant-form-item-control-wrapper">
<div class="ant-form-item-control"><span class="ant-form-item-children"><span class="ant-input-affix-wrapper"><span
class="ant-input-prefix"><i aria-label="icon: user" class="anticon anticon-user" style="color: rgba(0, 0, 0, 0.25);"><svg viewBox="64 64 896 896" focusable="false" class="" data-icon="user" width="1em" height="1em" fill="currentColor" aria-hidden="true"><path d="M858.5 763.6a374 374 0 0 0-80.6-119.5 375.63 375.63 0 0 0-119.5-80.6c-.4-.2-.8-.3-1.2-.5C719.5 518 760 444.7 760 362c0-137-111-248-248-248S264 225 264 362c0 82.7 40.5 156 102.8 201.1-.4.2-.8.3-1.2.5-44.8 18.9-85 46-119.5 80.6a375.63 375.63 0 0 0-80.6 119.5A371.7 371.7 0 0 0 136 901.8a8 8 0 0 0 8 8.2h60c4.4 0 7.9-3.5 8-7.8 2-77.2 33-149.5 87.8-204.3 56.7-56.7 132-87.9 212.2-87.9s155.5 31.2 212.2 87.9C779 752.7 810 825 812 902.2c.1 4.4 3.6 7.8 8 7.8h60a8 8 0 0 0 8-8.2c-1-47.8-10.9-94.3-29.5-138.2zM512 534c-45.9 0-89.1-17.9-121.6-50.4S340 407.9 340 362c0-45.9 17.9-89.1 50.4-121.6S466.1 190 512 190s89.1 17.9 121.6 50.4S684 316.1 684 362c0 45.9-17.9 89.1-50.4 121.6S557.9 534 512 534z"></path></svg></i></span><input
placeholder="First Name" type="text" id="SignUp_firstName" data-__meta="[object Object]" data-__field="[object Object]" class="ant-input" value=""></span></span></div>
</div>
</div>
</div>
<div class="ant-col ant-col-12 p-12">
<div class="ant-row ant-form-item">
<div class="ant-col ant-form-item-label"><label for="SignUp_lastName" class="ant-form-item-required" title="Last Name">Last Name</label></div>
<div class="ant-col ant-form-item-control-wrapper">
<div class="ant-form-item-control"><span class="ant-form-item-children"><span class="ant-input-affix-wrapper"><span
class="ant-input-prefix"><i aria-label="icon: user" class="anticon anticon-user" style="color: rgba(0, 0, 0, 0.25);"><svg viewBox="64 64 896 896" focusable="false" class="" data-icon="user" width="1em" height="1em" fill="currentColor" aria-hidden="true"><path d="M858.5 763.6a374 374 0 0 0-80.6-119.5 375.63 375.63 0 0 0-119.5-80.6c-.4-.2-.8-.3-1.2-.5C719.5 518 760 444.7 760 362c0-137-111-248-248-248S264 225 264 362c0 82.7 40.5 156 102.8 201.1-.4.2-.8.3-1.2.5-44.8 18.9-85 46-119.5 80.6a375.63 375.63 0 0 0-80.6 119.5A371.7 371.7 0 0 0 136 901.8a8 8 0 0 0 8 8.2h60c4.4 0 7.9-3.5 8-7.8 2-77.2 33-149.5 87.8-204.3 56.7-56.7 132-87.9 212.2-87.9s155.5 31.2 212.2 87.9C779 752.7 810 825 812 902.2c.1 4.4 3.6 7.8 8 7.8h60a8 8 0 0 0 8-8.2c-1-47.8-10.9-94.3-29.5-138.2zM512 534c-45.9 0-89.1-17.9-121.6-50.4S340 407.9 340 362c0-45.9 17.9-89.1 50.4-121.6S466.1 190 512 190s89.1 17.9 121.6 50.4S684 316.1 684 362c0 45.9-17.9 89.1-50.4 121.6S557.9 534 512 534z"></path></svg></i></span><input
autocomplete="off" placeholder="Last Name" type="text" id="SignUp_lastName" data-__meta="[object Object]" data-__field="[object Object]" class="ant-input" value=""></span></span></div>
</div>
</div>
</div>
</div>
<div style="display: none;">
<div class="ant-row">
<div class="ant-col ant-col-12 p-12">
<div class="ant-row ant-form-item">
<div class="ant-col ant-form-item-label"><label class="" title="email">email</label></div>
<div class="ant-col ant-form-item-control-wrapper">
<div class="ant-form-item-control"><span class="ant-form-item-children"><input autocomplete="username" type="text" class="ant-input" value=""></span></div>
</div>
</div>
</div>
</div>
</div>
<div class="ant-row">
<div class="ant-col ant-col-11 p-12">
<div class="ant-row ant-form-item">
<div class="ant-col ant-form-item-label"><label for="SignUp_password" class="ant-form-item-required" title="Password">Password</label></div>
<div class="ant-col ant-form-item-control-wrapper">
<div class="ant-form-item-control"><span class="ant-form-item-children"><span class="ant-input-password ant-input-affix-wrapper"><span
class="ant-input-prefix"><i aria-label="icon: lock" class="anticon anticon-lock" style="color: rgba(0, 0, 0, 0.45);"><svg viewBox="64 64 896 896" focusable="false" class="" data-icon="lock" width="1em" height="1em" fill="currentColor" aria-hidden="true"><path d="M832 464h-68V240c0-70.7-57.3-128-128-128H388c-70.7 0-128 57.3-128 128v224h-68c-17.7 0-32 14.3-32 32v384c0 17.7 14.3 32 32 32h640c17.7 0 32-14.3 32-32V496c0-17.7-14.3-32-32-32zM332 240c0-30.9 25.1-56 56-56h248c30.9 0 56 25.1 56 56v224H332V240zm460 600H232V536h560v304zM484 701v53c0 4.4 3.6 8 8 8h40c4.4 0 8-3.6 8-8v-53a48.01 48.01 0 1 0-56 0z"></path></svg></i></span><input
placeholder="Password" minlength="8" autocomplete="new-password" action="click" id="SignUp_password" data-__meta="[object Object]" data-__field="[object Object]" type="password" class="ant-input"><span
class="ant-input-suffix"><i aria-label="icon: eye-invisible" tabindex="-1" class="anticon anticon-eye-invisible ant-input-password-icon"><svg viewBox="64 64 896 896" focusable="false" class="" data-icon="eye-invisible" width="1em" height="1em" fill="currentColor" aria-hidden="true"><path d="M942.2 486.2Q889.47 375.11 816.7 305l-50.88 50.88C807.31 395.53 843.45 447.4 874.7 512 791.5 684.2 673.4 766 512 766q-72.67 0-133.87-22.38L323 798.75Q408 838 512 838q288.3 0 430.2-300.3a60.29 60.29 0 0 0 0-51.5zm-63.57-320.64L836 122.88a8 8 0 0 0-11.32 0L715.31 232.2Q624.86 186 512 186q-288.3 0-430.2 300.3a60.3 60.3 0 0 0 0 51.5q56.69 119.4 136.5 191.41L112.48 835a8 8 0 0 0 0 11.31L155.17 889a8 8 0 0 0 11.31 0l712.15-712.12a8 8 0 0 0 0-11.32zM149.3 512C232.6 339.8 350.7 258 512 258c54.54 0 104.13 9.36 149.12 28.39l-70.3 70.3a176 176 0 0 0-238.13 238.13l-83.42 83.42C223.1 637.49 183.3 582.28 149.3 512zm246.7 0a112.11 112.11 0 0 1 146.2-106.69L401.31 546.2A112 112 0 0 1 396 512z"></path><path d="M508 624c-3.46 0-6.87-.16-10.25-.47l-52.82 52.82a176.09 176.09 0 0 0 227.42-227.42l-52.82 52.82c.31 3.38.47 6.79.47 10.25a111.94 111.94 0 0 1-112 112z"></path></svg></i></span></span></span>
</div>
</div>
</div>
</div>
<div class="ant-col ant-col-1">
<div style="line-height: 3.6;">
<i aria-label="icon: info-circle" class="anticon anticon-info-circle" style="color: rgb(53, 150, 219); vertical-align: bottom;"><svg viewBox="64 64 896 896" focusable="false" class="" data-icon="info-circle" width="1em" height="1em" fill="currentColor" aria-hidden="true"><path d="M512 64C264.6 64 64 264.6 64 512s200.6 448 448 448 448-200.6 448-448S759.4 64 512 64zm0 820c-205.4 0-372-166.6-372-372s166.6-372 372-372 372 166.6 372 372-166.6 372-372 372z"></path><path d="M464 336a48 48 0 1 0 96 0 48 48 0 1 0-96 0zm72 112h-48c-4.4 0-8 3.6-8 8v272c0 4.4 3.6 8 8 8h48c4.4 0 8-3.6 8-8V456c0-4.4-3.6-8-8-8z"></path></svg></i>
</div>
</div>
<div class="ant-col ant-col-12 p-12">
<div class="ant-row ant-form-item">
<div class="ant-col ant-form-item-label"><label for="SignUp_confirm" class="ant-form-item-required" title="Confirm Password">Confirm Password</label></div>
<div class="ant-col ant-form-item-control-wrapper">
<div class="ant-form-item-control"><span class="ant-form-item-children"><span class="ant-input-password ant-input-affix-wrapper"><span
class="ant-input-prefix"><i aria-label="icon: lock" class="anticon anticon-lock" style="color: rgba(0, 0, 0, 0.25);"><svg viewBox="64 64 896 896" focusable="false" class="" data-icon="lock" width="1em" height="1em" fill="currentColor" aria-hidden="true"><path d="M832 464h-68V240c0-70.7-57.3-128-128-128H388c-70.7 0-128 57.3-128 128v224h-68c-17.7 0-32 14.3-32 32v384c0 17.7 14.3 32 32 32h640c17.7 0 32-14.3 32-32V496c0-17.7-14.3-32-32-32zM332 240c0-30.9 25.1-56 56-56h248c30.9 0 56 25.1 56 56v224H332V240zm460 600H232V536h560v304zM484 701v53c0 4.4 3.6 8 8 8h40c4.4 0 8-3.6 8-8v-53a48.01 48.01 0 1 0-56 0z"></path></svg></i></span><input
placeholder="Confirm Password" autocomplete="new-password" action="click" id="SignUp_confirm" data-__meta="[object Object]" data-__field="[object Object]" type="password" class="ant-input"><span
class="ant-input-suffix"><i aria-label="icon: eye-invisible" tabindex="-1" class="anticon anticon-eye-invisible ant-input-password-icon"><svg viewBox="64 64 896 896" focusable="false" class="" data-icon="eye-invisible" width="1em" height="1em" fill="currentColor" aria-hidden="true"><path d="M942.2 486.2Q889.47 375.11 816.7 305l-50.88 50.88C807.31 395.53 843.45 447.4 874.7 512 791.5 684.2 673.4 766 512 766q-72.67 0-133.87-22.38L323 798.75Q408 838 512 838q288.3 0 430.2-300.3a60.29 60.29 0 0 0 0-51.5zm-63.57-320.64L836 122.88a8 8 0 0 0-11.32 0L715.31 232.2Q624.86 186 512 186q-288.3 0-430.2 300.3a60.3 60.3 0 0 0 0 51.5q56.69 119.4 136.5 191.41L112.48 835a8 8 0 0 0 0 11.31L155.17 889a8 8 0 0 0 11.31 0l712.15-712.12a8 8 0 0 0 0-11.32zM149.3 512C232.6 339.8 350.7 258 512 258c54.54 0 104.13 9.36 149.12 28.39l-70.3 70.3a176 176 0 0 0-238.13 238.13l-83.42 83.42C223.1 637.49 183.3 582.28 149.3 512zm246.7 0a112.11 112.11 0 0 1 146.2-106.69L401.31 546.2A112 112 0 0 1 396 512z"></path><path d="M508 624c-3.46 0-6.87-.16-10.25-.47l-52.82 52.82a176.09 176.09 0 0 0 227.42-227.42l-52.82 52.82c.31 3.38.47 6.79.47 10.25a111.94 111.94 0 0 1-112 112z"></path></svg></i></span></span></span>
</div>
</div>
</div>
</div>
</div>
<div class="ant-row"></div>
<div>
<div class="ant-row">
<div class="ant-col ant-col-12 p-12">
<div class="ant-row ant-form-item">
<div class="ant-col ant-form-item-label"><label for="SignUp_agentLicenseNumber" class="ant-form-item-no-colon" title=""><span>Agent License Number: <span
style="color: gray; font-size: 12px;">(Optional)</span> <i aria-label="icon: info-circle" class="anticon anticon-info-circle" style="color: rgb(53, 150, 219);"><svg viewBox="64 64 896 896" focusable="false" class="" data-icon="info-circle" width="1em" height="1em" fill="currentColor" aria-hidden="true"><path d="M512 64C264.6 64 64 264.6 64 512s200.6 448 448 448 448-200.6 448-448S759.4 64 512 64zm0 820c-205.4 0-372-166.6-372-372s166.6-372 372-372 372 166.6 372 372-166.6 372-372 372z"></path><path d="M464 336a48 48 0 1 0 96 0 48 48 0 1 0-96 0zm72 112h-48c-4.4 0-8 3.6-8 8v272c0 4.4 3.6 8 8 8h48c4.4 0 8-3.6 8-8V456c0-4.4-3.6-8-8-8z"></path></svg></i></span></label>
</div>
<div class="ant-col ant-form-item-control-wrapper">
<div class="ant-form-item-control"><span class="ant-form-item-children"><input placeholder="Agent License Number" type="text" id="SignUp_agentLicenseNumber" data-__meta="[object Object]" data-__field="[object Object]" class="ant-input"
value=""></span></div>
</div>
</div>
</div>
<div class="ant-col ant-col-11 p-12">
<div class="ant-row ant-form-item">
<div class="ant-col ant-form-item-label"><label for="SignUp_phone" class="ant-form-item-required" title="Agent Phone Number">Agent Phone Number</label></div>
<div class="ant-col ant-form-item-control-wrapper">
<div class="ant-form-item-control"><span class="ant-form-item-children"><span class="ant-input-affix-wrapper"><span
class="ant-input-prefix"><i aria-label="icon: phone" class="anticon anticon-phone" style="color: rgba(0, 0, 0, 0.25);"><svg viewBox="64 64 896 896" focusable="false" class="" data-icon="phone" width="1em" height="1em" fill="currentColor" aria-hidden="true"><path d="M877.1 238.7L770.6 132.3c-13-13-30.4-20.3-48.8-20.3s-35.8 7.2-48.8 20.3L558.3 246.8c-13 13-20.3 30.5-20.3 48.9 0 18.5 7.2 35.8 20.3 48.9l89.6 89.7a405.46 405.46 0 0 1-86.4 127.3c-36.7 36.9-79.6 66-127.2 86.6l-89.6-89.7c-13-13-30.4-20.3-48.8-20.3a68.2 68.2 0 0 0-48.8 20.3L132.3 673c-13 13-20.3 30.5-20.3 48.9 0 18.5 7.2 35.8 20.3 48.9l106.4 106.4c22.2 22.2 52.8 34.9 84.2 34.9 6.5 0 12.8-.5 19.2-1.6 132.4-21.8 263.8-92.3 369.9-198.3C818 606 888.4 474.6 910.4 342.1c6.3-37.6-6.3-76.3-33.3-103.4zm-37.6 91.5c-19.5 117.9-82.9 235.5-178.4 331s-213 158.9-330.9 178.4c-14.8 2.5-30-2.5-40.8-13.2L184.9 721.9 295.7 611l119.8 120 .9.9 21.6-8a481.29 481.29 0 0 0 285.7-285.8l8-21.6-120.8-120.7 110.8-110.9 104.5 104.5c10.8 10.8 15.8 26 13.3 40.8z"></path></svg></i></span><input
placeholder="Agent Phone Number" type="text" id="SignUp_phone" data-__meta="[object Object]" data-__field="[object Object]" class="ant-input" value=""></span></span></div>
</div>
</div>
</div>
</div>
</div>
<div class="ant-divider ant-divider-horizontal ant-divider-dashed" role="separator" style="margin: 12px 0px;"></div>
<div class="ant-row">
<div class="ant-col ant-col-18 p-12 ">
<div id="company-selection-form">
<div class="ant-row ant-form-item">
<div class="ant-col ant-form-item-label"><label for="SignUp_searchCompany" class="ant-form-item-required" title=""><span>Agency Name:</span></label></div>
<div class="ant-col ant-form-item-control-wrapper">
<div class="ant-form-item-control"><span class="ant-form-item-children">
<div class="ant-select-show-arrow ant-select ant-select-enabled ant-select-allow-clear" style="width: 100%;">
<div class="ant-select-selection
ant-select-selection--single" role="combobox" aria-autocomplete="list" aria-haspopup="true" aria-controls="515fd819-9171-4b4c-de33-5e820088776f" aria-expanded="false" tabindex="0">
<div class="ant-select-selection__rendered">
<div unselectable="on" class="ant-select-selection__placeholder" style="display: block; user-select: none;">Type at least the first three letters of your Agency name</div>
<div class="ant-select-search ant-select-search--inline" style="display: none;">
<div class="ant-select-search__field__wrap"><input autocomplete="off" class="ant-select-search__field" value=""><span class="ant-select-search__field__mirror"> </span></div>
</div>
</div><span class="ant-select-arrow" unselectable="on"
style="user-select: none;"><i aria-label="icon: search" class="anticon anticon-search search-icon ant-select-arrow-icon"><svg viewBox="64 64 896 896" focusable="false" class="" data-icon="search" width="1em" height="1em" fill="currentColor" aria-hidden="true"><path d="M909.6 854.5L649.9 594.8C690.2 542.7 712 479 712 412c0-80.2-31.3-155.4-87.9-212.1-56.6-56.7-132-87.9-212.1-87.9s-155.5 31.3-212.1 87.9C143.2 256.5 112 331.8 112 412c0 80.1 31.3 155.5 87.9 212.1C256.5 680.8 331.8 712 412 712c67 0 130.6-21.8 182.7-62l259.7 259.6a8.2 8.2 0 0 0 11.6 0l43.6-43.5a8.2 8.2 0 0 0 0-11.6zM570.4 570.4C528 612.7 471.8 636 412 636s-116-23.3-158.4-65.6C211.3 528 188 471.8 188 412s23.3-116.1 65.6-158.4C296 211.3 352.2 188 412 188s116.1 23.2 158.4 65.6S636 352.2 636 412s-23.3 116.1-65.6 158.4z"></path></svg></i></span>
</div>
</div>
</span></div>
</div>
</div>
</div>
</div>
</div>
<div class="ant-row">
<div class="ant-col ant-col-24 p-12">
<div class="ant-row ant-form-item">
<div class="ant-col ant-form-item-label"><label for="SignUp_readOnlyCompanyAddress" class="" title="Agency Address">Agency Address</label></div>
<div class="ant-col ant-form-item-control-wrapper">
<div class="ant-form-item-control"><span class="ant-form-item-children"><input disabled="" placeholder="Agency Address" type="text" id="SignUp_readOnlyCompanyAddress" data-__meta="[object Object]" data-__field="[object Object]"
class="ant-input ant-input-disabled" value=""></span></div>
</div>
</div>
</div>
</div>
<div class="ant-row">
<div class="ant-col ant-col-18 p-12 signupForm">
<div class="ant-row ant-form-item">
<div class="ant-col ant-form-item-control-wrapper">
<div class="ant-form-item-control"><span class="ant-form-item-children"><label class="unAvailableCoverage ant-checkbox-wrapper"><span class="ant-checkbox"><input id="SignUp_acceptTerms" type="checkbox" class="ant-checkbox-input"
data-__meta="[object Object]" data-__field="[object Object]" value=""><span class="ant-checkbox-inner"></span></span><span>I understand and accept the <a>Terms and Conditions</a></span></label></span></div>
</div>
</div>
</div>
<div class="ant-col ant-col-offset-19 p-30">
<div class="ant-row ant-form-item">
<div class="ant-col ant-form-item-control-wrapper">
<div class="ant-form-item-control"><span class="ant-form-item-children"><button disabled="" type="submit" class="ant-btn ant-btn-primary" style="padding-left: 20px; padding-right: 20px;"><span>Sign Up</span></button></span></div>
</div>
</div>
</div>
</div>
</form>Text Content
DIGITAL INSURANCE VERIFICATION Powered By WELCOME! YOU’RE REGISTERING AS AN INSURANCE AGENT Click here if you’re an Insured looking to access a request for insurance or monitor your supplier's coverage. LET’S CHECK IF YOUR AGENCY ALREADY HAS A PROFILE Please enter your agency email address: Submit Next First Name Last Name email Password Confirm Password Agent License Number: (Optional) Agent Phone Number Agency Name: Type at least the first three letters of your Agency name Agency Address I understand and accept the Terms and Conditions Sign Up Already have an account? Login