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mva-yt-zjzt8.ondigitalocean.app Open in urlscan Pro
2a06:98c1:58::60  Public Scan

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URL: https://mva-yt-zjzt8.ondigitalocean.app/
Submission: On August 04 via api from US — Scanned from DE

Form analysis 1 forms found in the DOM

javascript:void(0);

<form class="container bg-white lg:p-6 md:p-0 sm:p-0 lg:w-9/12 md:w-10/12 sm:w-10/12 rounded-3xl shadow-form-shadow pt-2 overflow-hidden" id="regForm" action="javascript:void(0);">
  <input type="hidden" id="token" name="token" value="">
  <input id="leadid_token" name="universal_leadid" type="hidden" value="D4EC4E2B-D393-7583-B0FA-2EB7C56ECC9F">
  <div>
    <div data-tab="" class="tab text-white text-3xl font-bodyFont" style="display: block;">
      <div class="animation">
        <input data-store="" type="text" name="accident" class="hidden">
        <div class="font-bold pt-5 text-center p-5">
          <div class="text-five">Question 1/4</div>
          <h1 class="pb-2 pt-16 text-4xl text-five"> Was the accident your fault? </h1>
        </div>
        <div class="flex justify-center items-center pt-4">
          <button type="button" data-btn="" onclick="nextPrev(1)"
            class="duration-btn bg s text-xl gap-2 font-medium text-white bg-primary hover:bg-opacity-90 rounded-[10px] p-4 w-[80%] lg:w-4/12 md:w-7/12 sm:w-10/12 py-5 mb-2 text-center items-center"> No, it Wasn't my Fault </button>
        </div>
        <div class="flex justify-center items-center pt-6">
          <button type="button" data-btn="" onclick="nextPrev(1)"
            class="duration-btn bg s text-xl gap-2 font-medium text-white bg-primary hover:bg-opacity-90 rounded-[10px] p-4 w-[80%] lg:w-4/12 md:w-7/12 sm:w-10/12 py-5 mb-2 text-center items-center"> Yes, it Was my Fault </button>
        </div>
      </div>
      <div class="progress">
        <div class="progress-content">
          <div class="progress-bar">
            <div class="myProgress">
              <div class="myBar" style="width: 0%;"></div>
            </div>
          </div>
        </div>
      </div>
    </div>
    <div data-tab="" class="tab text-white text-3xl font-bodyFont">
      <div class="animation">
        <input data-store="" type="text" name="lawyer" class="hidden">
        <div class="font-bold pt-5 text-center p-5">
          <div class="text-five">Question 2 / 4</div>
          <h1 class="pb-2 pt-16 text-4xl text-five"> Do You Have a Lawyer Assigned to the Case? </h1>
        </div>
        <div class="flex justify-center items-center pt-4">
          <button type="button" data-btn="" onclick="nextPrev(1)"
            class="duration-btn bg s text-xl gap-2 font-medium text-white bg-primary hover:bg-opacity-90 rounded-[10px] p-4 w-[80%] lg:w-4/12 md:w-7/12 sm:w-10/12 py-5 mb-2 text-center items-center"> No, I don't Have Anyone </button>
        </div>
        <div class="flex justify-center items-center pt-6">
          <button type="button" data-btn="" onclick="nextPrev(1)"
            class="duration-btn bg s text-xl gap-2 font-medium text-white bg-primary hover:bg-opacity-90 rounded-[10px] p-4 w-[80%] lg:w-4/12 md:w-7/12 sm:w-10/12 py-5 mb-2 text-center items-center"> Yes, I Already Have One </button>
        </div>
      </div>
      <div class="progress">
        <div class="progress-content">
          <div class="progress-bar">
            <div class="myProgress">
              <div class="myBar" style="width: 0%;"></div>
            </div>
          </div>
        </div>
      </div>
    </div>
    <div class="tab text-white text-4xl font-bodyFont">
      <div class="animation">
        <div class="font-bold pt-5 text-center p-5">
          <div class="text-five">Question 3 / 4</div>
          <h1 class="pb-2 pt-16 text-3xl text-center text-five"> Estimated Accident Date </h1>
        </div>
        <div class="flex justify-center pt-5">
          <div class="lg:w-[50%] date rounded">
            <div class="dob-container flex items-center">
              <input maxlength="2" type="text" id="dob-month" inputmode="numeric" class="dob-input text-gray-500 font-semibold placeholder-gray-500" placeholder="MM">
              <div class="bg-white text-primary text-lg font-bold">/</div>
              <input maxlength="2" type="text" id="dob-day" inputmode="numeric" class="dob-input text-gray-500 font-semibold placeholder-gray-500" placeholder="DD">
              <div class="bg-white text-primary text-lg font-bold">/</div>
              <input maxlength="4" type="text" id="dob-year" inputmode="numeric" class="dob-input text-gray-500 font-semibold placeholder-gray-500" placeholder="YYYY">
            </div>
          </div>
        </div>
        <div class="text-lg" id="date-error" style="text-align: center; padding-top: 5px"></div>
        <div class="flex justify-center items-center pt-6 pb-6">
          <button type="button" data-btn="" onclick="nextPrev(1)"
            class="next-btn duration-btn bg s text-xl gap-2 font-medium text-white bg-primary hover:bg-opacity-90 rounded-[10px] p-4 lg:w-3/12 md:w-5/12 sm:w-5/12 py-3 mb-2 text-center items-center"> Continue </button>
        </div>
      </div>
      <div class="progress">
        <div class="progress-content">
          <div class="progress-bar">
            <div class="myProgress">
              <div class="myBar" style="width: 0%;"></div>
            </div>
          </div>
        </div>
      </div>
    </div>
    <div class="tab text-white text-3xl font-bodyFont">
      <div class="animation">
        <div class="font-bold pt-5 text-center p-5">
          <div class="text-primary"> You Might Qualify for Monetary Compensation </div>
          <p class="pb-2 pt-16 text-xl font-medium text-center text-black"> Please Tell Us How To Reach Out </p>
        </div>
        <div class="font-bold pt-5 text-center p-5">
          <h1 class="pb-2 pt-2 text-3xl text-left text-five"> First Name </h1>
          <input class="placeholder-gray-400 font-medium text-black border-black rounded py-1" type="text" name="firstName" placeholder="First Name" id="fName">
        </div>
        <div class="font-bold pt-2 text-center p-5">
          <h1 class="pb-2 text-3xl text-left text-five">Last Name</h1>
          <input class="placeholder-gray-400 font-medium text-black border-black rounded py-1" type="text" id="lName" name="lastName" placeholder="Last Name">
        </div>
        <div class="font-bold pt-2 text-center p-5 relative">
          <h1 class="pb-2 text-3xl text-left text-five">Phone</h1>
          <input class="placeholder-gray-400 font-medium text-black border-black rounded py-1 pl-[30px]" type="text" id="phone" name="phone" inputmode="tel" placeholder="123-456-7890">
          <span class="absolute top-1/2 left-0 translate-x-[30px] translate-y-[-2px] text-[17px] font-medium text-black">+1</span>
        </div>
        <div class="font-bold pt-2 text-center p-5">
          <h1 class="pb-2 text-3xl text-left text-five">Email</h1>
          <input class="placeholder-gray-400 font-medium text-black border-black rounded py-1" type="text" id="email" name="email" placeholder="Email">
        </div>
        <div class="font-bold pt-2 text-center p-5">
          <h1 class="pb-2 text-3xl text-left text-five">Zip code</h1>
          <input class="placeholder-gray-400 font-medium text-black border-black rounded py-1" id="zip" type="number" name="zip" pattern="[0-9]*" inputmode="numeric" placeholder="Postal Code">
        </div>
        <div class="text-lg" id="error" style="text-align: center; padding-top: 5px"></div>
        <div class="flex justify-center items-center pt-6 pb-6">
          <button type="submit" data-btn="" onclick="nextPrev(1)"
            class="next-btn duration-btn bg s text-xl gap-2 font-medium text-white bg-primary hover:bg-opacity-90 rounded-[10px] p-4 lg:w-3/12 md:w-5/12 sm:w-5/12 py-3 mb-2 text-center items-center"> Submit </button>
        </div>
      </div>
      <div class="progress">
        <div class="progress-content">
          <div class="progress-bar">
            <div class="myProgress">
              <div class="myBar" style="width: 0%;"></div>
            </div>
          </div>
        </div>
      </div>
    </div>
    <div class="lg:mb-20 sm:mb-12"></div>
    <div style="text-align: center; display: none">
      <span class="step active" style="display: none;"></span>
      <span class="step" style="display: none;"></span>
      <span class="step" style="display: none;"></span>
      <span class="step" style="display: none;"></span>
      <span class="step" style="display: none;"></span>
      <span class="step" style="display: none;"></span>
      <span class="step" style="display: none;"></span>
    </div>
  </div>
  <input type="hidden" name="xxTrustedFormCertUrl" value="https://cert.trustedform.com/7ece90d8598a9cf787eed92937d10b1fde25ea03" id="xxTrustedFormCertUrl_0"><input type="hidden" name="xxTrustedFormToken"
    value="https://cert.trustedform.com/7ece90d8598a9cf787eed92937d10b1fde25ea03" id="xxTrustedFormToken_0"><input type="hidden" name="xxTrustedFormPingUrl"
    value="https://ping.trustedform.com/0.XCg0OO4k_QTWuHUg6UlOno1e2kKKKL9-lQeqONt_OArX7Wju0INBIWsfokWczn-A_QnMjIK5.NhHjKoSC-Ap4zi8yJmzmxw.1KQe4hTpmmyjMUDZ2Oo6LA" id="xxTrustedFormPingUrl_0">
</form>

Text Content

Check If You Qualify Today
Check If You Qualify Today



THANK YOU FOR TAKING THE TIME TO COMPLETE THIS SURVEY.

Question 1/4


WAS THE ACCIDENT YOUR FAULT?

No, it Wasn't my Fault
Yes, it Was my Fault

Question 2 / 4


DO YOU HAVE A LAWYER ASSIGNED TO THE CASE?

No, I don't Have Anyone
Yes, I Already Have One

Question 3 / 4


ESTIMATED ACCIDENT DATE

/
/

Continue

You Might Qualify for Monetary Compensation

Please Tell Us How To Reach Out


FIRST NAME


LAST NAME


PHONE

+1


EMAIL


ZIP CODE


Submit






HOW IT WORKS

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