nationwideobamacare.net
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Submitted URL: https://www.nationwideobamacare.net/
Effective URL: https://nationwideobamacare.net/
Submission: On August 25 via automatic, source certstream-suspicious — Scanned from CA
Effective URL: https://nationwideobamacare.net/
Submission: On August 25 via automatic, source certstream-suspicious — Scanned from CA
Form analysis 1 forms found in the DOM
<form class="max-w-7xl" id="leif_lead_form">
<div class="max-w-full w-full mx-auto rounded border border-gray-300 border-b-0">
<div x-show="!completed">
<div class="h-2 border-b bg-slate-200 rounded-tl rounded-tr">
<div class="h-2 bg-green-600 rounded-tl" :class="{ 'bg-green-600 rounded-tl': !completed }" role="progressbar" :style="{ width: (totalCompletedSteps/totalSteps * 100) + '%' }" style="width: 14.2857%;"></div>
</div>
</div>
<div class="p-3">
<div x-show="completed" x-transition:enter.duration.750ms="" id="final" style="display: none;">
<div class="pt-2 pb-2 rounded">
<div class="font-bold text-lg lg:text-xl my-2 py-0 not-prose text-center">
<p>Congratulations, it's a match! Enter your phone number and submit:</p>
</div>
</div>
<div class="validate pt-2 pb-2 rounded" @keyup.enter="submitForm()">
<div class="not-prose"><input type="tel" @pageshow.window="leadFields.phone = $el.value" name="phone" id="phone" data-validation="["required", "minLength:10"]" @keyup.enter="!completed && await forward"
autocomplete="tel" class="valid block w-full shadow-sm rounded-md border-gray-300 p-6 text-sm lg:text-base placeholder:text-slate-500 placeholder:text-base" placeholder="(510) 867-5310" x-mask="(999) 999-9999" x-model="leadFields.phone"
required="" autofocus=""> <small class="hidden error-text"></small></div><button type="button" @click="submitForm()" :disabled="buttonDisabled"
class="cursor-pointer w-full flex justify-center items-center bg-primary disabled:opacity-75 text-white no-underline font-semibold shadow-md text-2xl rounded-md my-2 h-16"><span x-show="buttonDisabled"
class="flex items-center justify-center" style="display: none;"><svg class="animate-spin -ml-1 mr-3 h-5 w-5 text-white" xmlns="http://www.w3.org/2000/svg" fill="none" viewBox="0 0 24 24">
<circle class="opacity-25" cx="12" cy="12" r="10" stroke="currentColor" stroke-width="4"></circle>
<path class="opacity-75" fill="currentColor" d="M4 12a8 8 0 018-8V0C5.373 0 0 5.373 0 12h4zm2 5.291A7.962 7.962 0 014 12H0c0 3.042 1.135 5.824 3 7.938l3-2.647z"></path>
</svg> Processing </span><span x-show="!buttonDisabled">Submit</span></button>
<div class="flex justify-center items-center mt-2"><span class="inline-flex items-center rounded-md bg-green-100 px-2.5 py-0.5 text-sm font-medium text-green-800"><svg class="-ml-0.5 mr-1.5 h-2 w-2 text-green-400" fill="currentColor"
viewBox="0 0 8 8">
<circle cx="4" cy="4" r="3"></circle>
</svg> Your data is securely encrypted</span></div>
</div><label class="tcpa mt-6 text-xs no-underline text-gray-600" id="tcpa_statement"><input type="hidden" name="tcpa" id="leadid_tcpa_disclosure">
<p>By submitting this request, I am providing my express written consent to share my information with up to five (5) of <a href="http://nationwideobamacare.net">nationwideobamacare.net</a>'s
<a href="/pages/partners" target="_blank">Network Partners</a>, and for those <a href="/pages/partners" target="_blank">Network Partners</a>, <a href="http://nationwideobamacare.net">nationwideobamacare.net</a>, and authorized third
parties calling on their behalf, to contact me via telephone calls or text messages, including for marketing purposes, using an automatic telephone dialing system or an artificial or pre-recorded voice to the phone number I have provided.
I understand that I am providing this consent to receive such telephone calls even if my telephone number is currently listed on any federal, state, local, internal, or corporate Do-Not-Call ("DNC") Lists. I understand that consent is not
required as a condition of purchasing any services or products. <a href="/pages/privacy-policy/#california-rights" target="_blank">California Notice</a>.</p>
</label>
<div class="mt-3 text-xs no-underline text-gray-600">
<p><u>THIS SITE DOES NOT REPRESENT OR IS AFFILIATED WITH ANY GOVERNMENT ASSISTANCE PROGRAMS.</u></p>
</div>
</div>
<div x-show.transition="!completed" id="steps"><template x-if="urlData?.zip == null">
<div data-step="1" x-show="step == 1" x-transition:enter.duration.450ms="">
<div class="font-bold text-lg lg:text-xl my-2 py-0 not-prose">
<p>Enter Your Zip Code Below To Check</p>
</div>
<div class="validate">
<div class="not-prose"><input type="text" @pageshow.window="leadFields.zip = $el.value" name="zip" id="zip" data-validation="["required", "onlyLettersNumbers", "minLength:5"]"
@keyup.enter="!completed && await forward" autocomplete="postal-code" class="valid block w-full shadow-sm rounded-md border-gray-300 p-6 text-sm lg:text-base placeholder:text-slate-500 placeholder:text-base"
placeholder="Enter Your Zip Code" x-model="leadFields.zip" required="" autofocus=""> <small class="hidden error-text"></small></div>
</div>
<div class="not-prose mt-6"><button type="button" x-show="!completed" x-on:click.prevent="await forward"
class="cursor-pointer w-full flex justify-center items-center bg-primary disabled:opacity-50 text-white no-underline font-semibold shadow-md text-lg rounded-md my-2 h-16">Next</button>
<div class="flex justify-center items-center mt-2"><span class="inline-flex items-center rounded-md bg-green-100 px-2.5 py-0.5 text-sm font-medium text-green-800"><svg class="-ml-0.5 mr-1.5 h-2 w-2 text-green-400" fill="currentColor"
viewBox="0 0 8 8">
<circle cx="4" cy="4" r="3"></circle>
</svg> Your data is securely encrypted</span></div>
</div>
</div>
</template>
<div data-step="1" x-show="step == 1" x-transition:enter.duration.450ms="">
<div class="font-bold text-lg lg:text-xl my-2 py-0 not-prose">
<p>Enter Your Zip Code Below To Check</p>
</div>
<div class="validate">
<div class="not-prose"><input type="text" @pageshow.window="leadFields.zip = $el.value" name="zip" id="zip" data-validation="["required", "onlyLettersNumbers", "minLength:5"]"
@keyup.enter="!completed && await forward" autocomplete="postal-code" class="valid block w-full shadow-sm rounded-md border-gray-300 p-6 text-sm lg:text-base placeholder:text-slate-500 placeholder:text-base"
placeholder="Enter Your Zip Code" x-model="leadFields.zip" required="" autofocus=""> <small class="hidden error-text"></small></div>
</div>
<div class="not-prose mt-6"><button type="button" x-show="!completed" x-on:click.prevent="await forward"
class="cursor-pointer w-full flex justify-center items-center bg-primary disabled:opacity-50 text-white no-underline font-semibold shadow-md text-lg rounded-md my-2 h-16">Next</button>
<div class="flex justify-center items-center mt-2"><span class="inline-flex items-center rounded-md bg-green-100 px-2.5 py-0.5 text-sm font-medium text-green-800"><svg class="-ml-0.5 mr-1.5 h-2 w-2 text-green-400" fill="currentColor"
viewBox="0 0 8 8">
<circle cx="4" cy="4" r="3"></circle>
</svg> Your data is securely encrypted</span></div>
</div>
</div>
<div data-step="2" x-show="step == 2" x-transition:enter.duration.450ms="" style="display: none;">
<div class="font-bold text-lg lg:text-xl my-2 py-0 not-prose">
<p>Would You Like To Get Coverage For Yourself, Or Include Family?</p>
</div>
<div class="validate">
<div class="box-flex wrap flex-center not-prose" x-init="extraFields.coverage_for = 'individual'">
<div class="my-2"><input type="radio" name="coverage_for" id="radio_coverage_for_1" @keyup.enter="completed ? await submitForm() : await forward()" x-show="!completed" class="sr-only peer" value="individual"
x-model="extraFields.coverage_for"> <label for="radio_coverage_for_1"
class="flex p-5 bg-white border border-gray-300 rounded-lg cursor-pointer focus:outline-none hover:bg-gray-50 peer-checked:ring-green-600 peer-checked:ring-2 peer-checked:border-transparent">
<p>Myself Only</p>
</label></div>
<div class="my-2"><input type="radio" name="coverage_for" id="radio_coverage_for_2" @keyup.enter="completed ? await submitForm() : await forward()" x-show="!completed" class="sr-only peer" value="family"
x-model="extraFields.coverage_for"> <label for="radio_coverage_for_2"
class="flex p-5 bg-white border border-gray-300 rounded-lg cursor-pointer focus:outline-none hover:bg-gray-50 peer-checked:ring-green-600 peer-checked:ring-2 peer-checked:border-transparent">
<p>Family</p>
</label></div>
</div>
</div>
<div class="not-prose mt-6"><button type="button" x-show="!completed" x-on:click.prevent="await forward"
class="cursor-pointer w-full flex justify-center items-center bg-primary disabled:opacity-50 text-white no-underline font-semibold shadow-md text-lg rounded-md my-2 h-16">Next</button>
<div class="flex justify-center items-center mt-2"><span class="inline-flex items-center rounded-md bg-green-100 px-2.5 py-0.5 text-sm font-medium text-green-800"><svg class="-ml-0.5 mr-1.5 h-2 w-2 text-green-400" fill="currentColor"
viewBox="0 0 8 8">
<circle cx="4" cy="4" r="3"></circle>
</svg> Your data is securely encrypted</span></div>
</div>
</div>
<div data-step="3" x-show="step == 3" x-transition:enter.duration.450ms="" style="display: none;">
<div class="font-bold text-lg lg:text-xl my-2 py-0 not-prose">
<p>What's Your Approximate Annual Household Income?</p>
</div>
<div class="validate">
<div class="box-flex wrap flex-center not-prose" x-init="extraFields.annual_income = '$35000_$40000'">
<div class="my-2"><input type="radio" name="annual_income" id="radio_annual_income_1" @keyup.enter="completed ? await submitForm() : await forward()" x-show="!completed" class="sr-only peer" value="$35000_$40000"
x-model="extraFields.annual_income"> <label for="radio_annual_income_1"
class="flex p-5 bg-white border border-gray-300 rounded-lg cursor-pointer focus:outline-none hover:bg-gray-50 peer-checked:ring-green-600 peer-checked:ring-2 peer-checked:border-transparent">
<p>$35,000 - $40,000</p>
</label></div>
<div class="my-2"><input type="radio" name="annual_income" id="radio_annual_income_2" @keyup.enter="completed ? await submitForm() : await forward()" x-show="!completed" class="sr-only peer" value="$30000_$35000"
x-model="extraFields.annual_income"> <label for="radio_annual_income_2"
class="flex p-5 bg-white border border-gray-300 rounded-lg cursor-pointer focus:outline-none hover:bg-gray-50 peer-checked:ring-green-600 peer-checked:ring-2 peer-checked:border-transparent">
<p>$30,000 - $35,000</p>
</label></div>
<div class="my-2"><input type="radio" name="annual_income" id="radio_annual_income_3" @keyup.enter="completed ? await submitForm() : await forward()" x-show="!completed" class="sr-only peer" value="$25000_$30000"
x-model="extraFields.annual_income"> <label for="radio_annual_income_3"
class="flex p-5 bg-white border border-gray-300 rounded-lg cursor-pointer focus:outline-none hover:bg-gray-50 peer-checked:ring-green-600 peer-checked:ring-2 peer-checked:border-transparent">
<p>$25,000 - $30,000</p>
</label></div>
<div class="my-2"><input type="radio" name="annual_income" id="radio_annual_income_4" @keyup.enter="completed ? await submitForm() : await forward()" x-show="!completed" class="sr-only peer" value="$20000_$25000"
x-model="extraFields.annual_income"> <label for="radio_annual_income_4"
class="flex p-5 bg-white border border-gray-300 rounded-lg cursor-pointer focus:outline-none hover:bg-gray-50 peer-checked:ring-green-600 peer-checked:ring-2 peer-checked:border-transparent">
<p>$20,000 - $25,000</p>
</label></div>
<div class="my-2"><input type="radio" name="annual_income" id="radio_annual_income_5" @keyup.enter="completed ? await submitForm() : await forward()" x-show="!completed" class="sr-only peer" value="$17000_$20000"
x-model="extraFields.annual_income"> <label for="radio_annual_income_5"
class="flex p-5 bg-white border border-gray-300 rounded-lg cursor-pointer focus:outline-none hover:bg-gray-50 peer-checked:ring-green-600 peer-checked:ring-2 peer-checked:border-transparent">
<p>$17,000 - $20,000</p>
</label></div>
<div class="my-2"><input type="radio" name="annual_income" id="radio_annual_income_6" @keyup.enter="completed ? await submitForm() : await forward()" x-show="!completed" class="sr-only peer" value="$17000"
x-model="extraFields.annual_income"> <label for="radio_annual_income_6"
class="flex p-5 bg-white border border-gray-300 rounded-lg cursor-pointer focus:outline-none hover:bg-gray-50 peer-checked:ring-green-600 peer-checked:ring-2 peer-checked:border-transparent">
<p>Below $17,000</p>
</label></div>
</div>
</div>
<div class="not-prose mt-6"><button type="button" x-show="!completed" x-on:click.prevent="await forward"
class="cursor-pointer w-full flex justify-center items-center bg-primary disabled:opacity-50 text-white no-underline font-semibold shadow-md text-lg rounded-md my-2 h-16">Next</button>
<div class="flex justify-center items-center mt-2"><span class="inline-flex items-center rounded-md bg-green-100 px-2.5 py-0.5 text-sm font-medium text-green-800"><svg class="-ml-0.5 mr-1.5 h-2 w-2 text-green-400" fill="currentColor"
viewBox="0 0 8 8">
<circle cx="4" cy="4" r="3"></circle>
</svg> Your data is securely encrypted</span></div>
</div>
</div><template x-if="urlData?.street == null">
<div x-cloak="" data-step="4" x-show="step == 4" x-transition:enter.duration.450ms="">
<div class="font-bold text-lg lg:text-xl my-2 py-0 not-prose">
<p>Enter Your Street Address Below.</p>
</div>
<div class="validate">
<div class="not-prose"><input type="text" @pageshow.window="leadFields.street = $el.value" name="street" id="street" data-validation="["required", "minLength:5"]" @keyup.enter="!completed && await forward"
class="valid block w-full shadow-sm rounded-md border-gray-300 p-6 text-sm lg:text-base placeholder:text-slate-500 placeholder:text-base" placeholder="Type e.g: 123 Midway St" x-init="loadGooglePlaces" x-model="leadFields.street"
@google-loaded.window="initGooglePlaces" autocomplete="off" required="" autofocus=""> <small class="hidden error-text"></small></div>
</div>
<div class="not-prose mt-6"><button type="button" x-show="!completed" x-on:click.prevent="await forward"
class="cursor-pointer w-full flex justify-center items-center bg-primary disabled:opacity-50 text-white no-underline font-semibold shadow-md text-lg rounded-md my-2 h-16">Next</button>
<div class="flex justify-center items-center mt-2"><span class="inline-flex items-center rounded-md bg-green-100 px-2.5 py-0.5 text-sm font-medium text-green-800"><svg class="-ml-0.5 mr-1.5 h-2 w-2 text-green-400" fill="currentColor"
viewBox="0 0 8 8">
<circle cx="4" cy="4" r="3"></circle>
</svg> Your data is securely encrypted</span></div>
</div>
</div>
</template>
<div data-step="4" x-show="step == 4" x-transition:enter.duration.450ms="" style="display: none;">
<div class="font-bold text-lg lg:text-xl my-2 py-0 not-prose">
<p>Enter Your Street Address Below.</p>
</div>
<div class="validate">
<div class="not-prose"><input type="text" @pageshow.window="leadFields.street = $el.value" name="street" id="street" data-validation="["required", "minLength:5"]" @keyup.enter="!completed && await forward"
class="valid block w-full shadow-sm rounded-md border-gray-300 p-6 text-sm lg:text-base placeholder:text-slate-500 placeholder:text-base pac-target-input" placeholder="Type e.g: 123 Midway St" x-init="loadGooglePlaces"
x-model="leadFields.street" @google-loaded.window="initGooglePlaces" autocomplete="off" required="" autofocus=""> <small class="hidden error-text"></small></div>
</div>
<div class="not-prose mt-6"><button type="button" x-show="!completed" x-on:click.prevent="await forward"
class="cursor-pointer w-full flex justify-center items-center bg-primary disabled:opacity-50 text-white no-underline font-semibold shadow-md text-lg rounded-md my-2 h-16">Next</button>
<div class="flex justify-center items-center mt-2"><span class="inline-flex items-center rounded-md bg-green-100 px-2.5 py-0.5 text-sm font-medium text-green-800"><svg class="-ml-0.5 mr-1.5 h-2 w-2 text-green-400" fill="currentColor"
viewBox="0 0 8 8">
<circle cx="4" cy="4" r="3"></circle>
</svg> Your data is securely encrypted</span></div>
</div>
</div><template x-if="urlData?.email == null">
<div x-cloak="" data-step="5" x-show="step == 5" x-transition:enter.duration.450ms="">
<div class="font-bold text-lg lg:text-xl my-2 py-0 not-prose">
<p>Where can we email your results?</p>
</div>
<div class="validate">
<div class="not-prose"><input type="email" @pageshow.window="leadFields.email = $el.value" name="email" id="email" data-validation="["required", "email"]" @keyup.enter="!completed && await forward"
autocomplete="email" class="valid block w-full shadow-sm rounded-md border-gray-300 p-6 text-sm lg:text-base placeholder:text-slate-500 placeholder:text-base" placeholder="johndoe@gmail.com" x-model="leadFields.email" required=""
autofocus=""> <small class="hidden error-text"></small></div>
</div>
<div class="not-prose mt-6"><button type="button" x-show="!completed" x-on:click.prevent="await forward"
class="cursor-pointer w-full flex justify-center items-center bg-primary disabled:opacity-50 text-white no-underline font-semibold shadow-md text-lg rounded-md my-2 h-16">Next</button>
<div class="flex justify-center items-center mt-2"><span class="inline-flex items-center rounded-md bg-green-100 px-2.5 py-0.5 text-sm font-medium text-green-800"><svg class="-ml-0.5 mr-1.5 h-2 w-2 text-green-400" fill="currentColor"
viewBox="0 0 8 8">
<circle cx="4" cy="4" r="3"></circle>
</svg> Your data is securely encrypted</span></div>
</div>
</div>
</template>
<div data-step="5" x-show="step == 5" x-transition:enter.duration.450ms="" style="display: none;">
<div class="font-bold text-lg lg:text-xl my-2 py-0 not-prose">
<p>Where can we email your results?</p>
</div>
<div class="validate">
<div class="not-prose"><input type="email" @pageshow.window="leadFields.email = $el.value" name="email" id="email" data-validation="["required", "email"]" @keyup.enter="!completed && await forward"
autocomplete="email" class="valid block w-full shadow-sm rounded-md border-gray-300 p-6 text-sm lg:text-base placeholder:text-slate-500 placeholder:text-base" placeholder="johndoe@gmail.com" x-model="leadFields.email" required=""
autofocus=""> <small class="hidden error-text"></small></div>
</div>
<div class="not-prose mt-6"><button type="button" x-show="!completed" x-on:click.prevent="await forward"
class="cursor-pointer w-full flex justify-center items-center bg-primary disabled:opacity-50 text-white no-underline font-semibold shadow-md text-lg rounded-md my-2 h-16">Next</button>
<div class="flex justify-center items-center mt-2"><span class="inline-flex items-center rounded-md bg-green-100 px-2.5 py-0.5 text-sm font-medium text-green-800"><svg class="-ml-0.5 mr-1.5 h-2 w-2 text-green-400" fill="currentColor"
viewBox="0 0 8 8">
<circle cx="4" cy="4" r="3"></circle>
</svg> Your data is securely encrypted</span></div>
</div>
</div><template x-if="urlData?.first_name == null && urlData?.last_name == null">
<div x-cloak="" data-step="6" x-show="step == 6" x-transition:enter.duration.450ms="">
<div class="font-bold text-lg lg:text-xl my-2 py-0 not-prose">
<p>What's your name?</p>
</div>
<div class="validate">
<div class="not-prose"><input type="text" @pageshow.window="leadFields.first_name = $el.value" name="fname" id="fname" data-validation="["required", "onlyLetters", "minLength:2"]"
@keyup.enter="!completed && await forward" autocomplete="given-name" class="valid mb-2 block w-full shadow-sm rounded-md border-gray-300 p-6 text-sm lg:text-base placeholder:text-slate-500 placeholder:text-base"
placeholder="Enter Your First Name" x-model.debounce.600="leadFields.first_name" required="" autofocus=""> <input type="text" @pageshow.window="leadFields.last_name = $el.value" name="lname" id="lname"
data-validation="["required", "onlyLetters", "minLength:2"]" @keyup.enter="!completed && await forward" autocomplete="family-name"
class="valid mt-2 block w-full shadow-sm rounded-md border-gray-300 p-6 text-sm lg:text-base placeholder:text-slate-500 placeholder:text-base" placeholder="Enter Your Last Name" x-model="leadFields.last_name" required=""
autofocus=""> <small class="hidden error-text"></small></div>
</div>
<div class="not-prose mt-6"><button type="button" x-show="!completed" x-on:click.prevent="await forward"
class="cursor-pointer w-full flex justify-center items-center bg-primary disabled:opacity-50 text-white no-underline font-semibold shadow-md text-lg rounded-md my-2 h-16">Next</button>
<div class="flex justify-center items-center mt-2"><span class="inline-flex items-center rounded-md bg-green-100 px-2.5 py-0.5 text-sm font-medium text-green-800"><svg class="-ml-0.5 mr-1.5 h-2 w-2 text-green-400" fill="currentColor"
viewBox="0 0 8 8">
<circle cx="4" cy="4" r="3"></circle>
</svg> Your data is securely encrypted</span></div>
</div>
</div>
</template>
<div data-step="6" x-show="step == 6" x-transition:enter.duration.450ms="" style="display: none;">
<div class="font-bold text-lg lg:text-xl my-2 py-0 not-prose">
<p>What's your name?</p>
</div>
<div class="validate">
<div class="not-prose"><input type="text" @pageshow.window="leadFields.first_name = $el.value" name="fname" id="fname" data-validation="["required", "onlyLetters", "minLength:2"]"
@keyup.enter="!completed && await forward" autocomplete="given-name" class="valid mb-2 block w-full shadow-sm rounded-md border-gray-300 p-6 text-sm lg:text-base placeholder:text-slate-500 placeholder:text-base"
placeholder="Enter Your First Name" x-model.debounce.600="leadFields.first_name" required="" autofocus=""> <input type="text" @pageshow.window="leadFields.last_name = $el.value" name="lname" id="lname"
data-validation="["required", "onlyLetters", "minLength:2"]" @keyup.enter="!completed && await forward" autocomplete="family-name"
class="valid mt-2 block w-full shadow-sm rounded-md border-gray-300 p-6 text-sm lg:text-base placeholder:text-slate-500 placeholder:text-base" placeholder="Enter Your Last Name" x-model="leadFields.last_name" required="" autofocus="">
<small class="hidden error-text"></small></div>
</div>
<div class="not-prose mt-6"><button type="button" x-show="!completed" x-on:click.prevent="await forward"
class="cursor-pointer w-full flex justify-center items-center bg-primary disabled:opacity-50 text-white no-underline font-semibold shadow-md text-lg rounded-md my-2 h-16">Next</button>
<div class="flex justify-center items-center mt-2"><span class="inline-flex items-center rounded-md bg-green-100 px-2.5 py-0.5 text-sm font-medium text-green-800"><svg class="-ml-0.5 mr-1.5 h-2 w-2 text-green-400" fill="currentColor"
viewBox="0 0 8 8">
<circle cx="4" cy="4" r="3"></circle>
</svg> Your data is securely encrypted</span></div>
</div>
</div><template x-if="urlData?.date_of_birth == null && urlData?.display_date_of_birth == null">
<div x-cloak="" data-step="7" x-show="step == 7" x-transition:enter.duration.450ms="">
<div class="font-bold text-lg lg:text-xl my-2 py-0 not-prose">
<p>Enter your D.O.B.</p>
</div>
<div class="validate">
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<div class="not-prose mt-6"><button type="button" x-show="!completed" x-on:click.prevent="await forward"
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<div class="flex justify-center items-center mt-2"><span class="inline-flex items-center rounded-md bg-green-100 px-2.5 py-0.5 text-sm font-medium text-green-800"><svg class="-ml-0.5 mr-1.5 h-2 w-2 text-green-400" fill="currentColor"
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</svg> Your data is securely encrypted</span></div>
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<div data-step="7" x-show="step == 7" x-transition:enter.duration.450ms="" style="display: none;">
<div class="font-bold text-lg lg:text-xl my-2 py-0 not-prose">
<p>Enter your D.O.B.</p>
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<div class="validate">
<div class="not-prose"><input type="text" @pageshow.window="leadFields.display_date_of_birth = $el.value" name="date_of_birth" id="date_of_birth" x-mask="99/99/9999" data-validation="["required"]"
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<div class="not-prose mt-6"><button type="button" x-show="!completed" x-on:click.prevent="await forward"
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viewBox="0 0 8 8">
<circle cx="4" cy="4" r="3"></circle>
</svg> Your data is securely encrypted</span></div>
</div>
</div>
</div>
</div>
<div class="p-4">
<a href="#" x-show="step != firstStep && !completed" @click.prevent="back()" class="cursor-pointer w-1/2 flex justify-center items-center bg-slate-400 text-white no-underline font-semibold shadow-md text-lg rounded-md my-2 py-2" style="display: none;">Back</a>
</div>
</div>
<div class="hidden"><input type="hidden" x-init="extraFields.household_size = '1'" name="extraFields.household_size" x-model="extraFields.household_size" value="1"></div><input type="hidden" name="jornaya_leadid" id="jornaya_leadid"
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value="https://ping.trustedform.com/0.5ymoseiLsI4QV7rmmXYLn0Y2ggDPoR1preMdXJnYM0LZzfqhOlHIx6meJHjk8e9bPWd1aMw.k0mjiSvy91nXYt3CGDXkOQ.PjHl3th3CFpptKVSzxThyQ" id="xxTrustedFormPingUrl_0">
</form>Text Content
Nationwide ObamaCare
AMERICANS IN QUEBEC CAN NOW EASILY GET HEALTHCARE COVERAGE!
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*Pricing of $59/month is based off a 26-year-old male living in Miami, FL
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