injuryhelpdesk.net Open in urlscan Pro
23.92.22.51  Public Scan

Form analysis
1 forms found in the DOM

POST /autoaccident/step/2

<form class="path_form " method="post" action="/autoaccident/step/2" novalidate="novalidate">
  <input type="hidden" name="_token" value="DAbQVz5oNZdNkAKqqnoR8E0Tht7WKPs47eKZMnsL">
  <input type="hidden" name="step" value="1">
  <input type="hidden" name="page_id" value="1">
  <input type="hidden" name="path_id" value="22">
  <input type="hidden" name="last_step" value="5">
  <input type="hidden" name="theme_id" value="82">
  <input type="hidden" name="register" value="">
  <!--        <input type="hidden" name="cr_sequence" id="cr_sequence" value="">-->
  <!--            <textarea name="cr_sequence" id="cr_sequence" value=""></textarea>-->
  <h3 class="d-block d-md-block text-center pb-2">Sign Up Below To Use Our</h3>
  <center>
    <h3 class="CTA-highlight">INJURY COMPENSATION CALCULATOR!</h3>
  </center>
  <div class="row">
    <div class="col-md-6" id="first_name">
      <div class="form-group row question item_container item_2_container step_1_item_2" id="item_2_container">
        <div class="col">
          <label id="item_2_label" for="item_2" class="">First Name</label>
          <input type="text" name="cr_question_2" class="form-control form_input question_2 " id="item_2" required="" data-msg="This field is required" value="">
          <div class="cr_validation_icon"></div>
          <div class="cr_validation_error_message"></div>
        </div>
      </div>
    </div>
    <div class="col-md-6" id="last_name">
      <div class="form-group row question item_container item_3_container step_1_item_3" id="item_3_container">
        <div class="col">
          <label id="item_3_label" for="item_3" class="">Last Name</label>
          <input type="text" name="cr_question_3" class="form-control form_input question_3 " id="item_3" required="" data-msg="This field is required" value="">
          <div class="cr_validation_icon"></div>
          <div class="cr_validation_error_message"></div>
        </div>
      </div>
    </div>
  </div>
  <script>
    //select question row, move it to a new column
    $('#item_2_container').appendTo('#first_name');
    $('#item_3_container').appendTo('#last_name');
  </script>
  <div class="form-group row question item_container item_94_container step_1_item_5" id="item_94_container">
    <div class="col">
      <label id="item_94_label" for="item_94" class="">Delivery Address <script>
          var addressFilled = false;
          var placeSearch, autocomplete;
          var cr_items = {
            street_number: 'item_7',
            route: 'item_7',
            locality: 'item_10',
            administrative_area_level_1: 'item_11',
            /*sublocality_level_1: 'item_19',*/
            postal_code: 'item_8'
          };
          var componentForm = {
            street_number: 'short_name',
            route: 'long_name',
            locality: 'long_name',
            administrative_area_level_1: 'short_name',
            /*sublocality_level_1: 'long_name',*/
            postal_code: 'short_name'
          };

          function initAutocomplete() {
            autocomplete = new google.maps.places.Autocomplete(document.getElementById('item_94'), {
              types: ['geocode'],
              componentRestrictions: {
                country: "us"
              }
            });
            autocomplete.setFields(['address_component']);
            autocomplete.addListener('place_changed', fillInAddress);
          }

          function fillInAddress() {
            var place = autocomplete.getPlace();
            for (var component in cr_items) {
              document.getElementById(cr_items[component]).value = '';
              // document.getElementById(cr_items[component]).disabled = false;
            }
            //console.log(place.address_components);
            for (var i = 0; i < place.address_components.length; i++) {
              var addressType = place.address_components[i].types[0];
              if (componentForm[addressType]) {
                var val = place.address_components[i][componentForm[addressType]];
                if (addressType === 'street_number' || addressType === 'route') {
                  var address = document.getElementById(cr_items[addressType]).value;
                  if (address) {
                    document.getElementById(cr_items[addressType]).value = address + ' ' + val;
                    addressFilled = true;
                  } else {
                    document.getElementById(cr_items[addressType]).value = val;
                  }
                } else {
                  document.getElementById(cr_items[addressType]).value = val;
                }
                console.log(cr_items[addressType]);
              }
            }
            for (var component in cr_items) {
              if (document.getElementById(cr_items[component]).value === '') {
                console.log(cr_items[component] + ' is blank');
                $('#' + cr_items[component] + '_container').addClass('force-show');
              }
              // document.getElementById(cr_items[component]).disabled = false;
            }
          }
          // Bias the autocomplete object to the user's geographical location,
          // as supplied by the browser's 'navigator.geolocation' object.
          function geolocate() {
            if (navigator.geolocation) {
              navigator.geolocation.getCurrentPosition(function(position) {
                var geolocation = {
                  lat: position.coords.latitude,
                  lng: position.coords.longitude
                };
                var circle = new google.maps.Circle({
                  center: geolocation,
                  radius: position.coords.accuracy
                });
                autocomplete.setBounds(circle.getBounds());
              });
            }
          }
          $('#item_94').blur(function() {
            if (addressFilled) {
              console.log('address filled');
            } else {
              console.log('address not filled');
              $(this).val('');
            }
          });
        </script>
        <script>
          let google_script_loaded = false
          $('#item_94').on('keyup', function(e) {
            if (!google_script_loaded) {
              let addValue = $(this).val();
              if (addValue.length > 3) {
                const script = document.createElement('script');
                script.id = '__script__id__';
                script.type = 'text/javascript';
                script.async = true;
                script.src = 'https://maps.googleapis.com/maps/api/js?key=AIzaSyCVEwOAcInt-jKfHajXYFXj79gREww5Nfs&libraries=places&callback=initAutocomplete';
                document.head.append(script);
                google_script_loaded = true;
              }
            }
          })
        </script>
        <style>
          .address_field {
            overflow: hidden;
            height: 0;
            margin-bottom: 0;
          }

          .address_field.force-show {
            overflow: none;
            height: auto;
            margin-bottom: 1rem;
          }
        </style>
      </label>
      <input type="text" name="cr_question_94" class="form-control form_input question_94 " id="item_94" placeholder="Enter Location" required="" data-msg="This field is required" value="">
      <div class="cr_validation_icon"></div>
      <div class="cr_validation_error_message"></div>
    </div>
  </div>
  <div class="form-group row question item_container item_7_container step_1_item_6 address_field" id="item_7_container">
    <div class="col">
      <label id="item_7_label" for="item_7" class="">Street</label>
      <input type="text" name="cr_question_7" class="form-control form_input question_7 " id="item_7" required="" data-msg="This field is required" value="">
      <div class="cr_validation_icon"></div>
      <div class="cr_validation_error_message"></div>
    </div>
  </div>
  <div class="form-group row question item_container item_10_container step_1_item_7 address_field" id="item_10_container">
    <div class="col">
      <label id="item_10_label" for="item_10" class="">City</label>
      <input type="text" name="cr_question_10" class="form-control form_input question_10 " id="item_10" required="" data-msg="This field is required" value="">
      <div class="cr_validation_icon"></div>
      <div class="cr_validation_error_message"></div>
    </div>
  </div>
  <div class="form-group row question item_container item_11_container step_1_item_8 address_field" id="item_11_container">
    <div class="col">
      <label id="item_11_label" for="item_11" class="">State</label>
      <input type="text" name="cr_question_11" class="form-control form_input question_11  check_conditionals" id="item_11" minlength="2" maxlength="2" required="" data-msg="This field is required" value="">
      <div class="cr_validation_icon"></div>
      <div class="cr_validation_error_message"></div>
    </div>
  </div>
  <div class="form-group row question item_container item_8_container step_1_item_9 address_field" id="item_8_container">
    <div class="col">
      <label id="item_8_label" for="item_8" class="">Zip Code</label>
      <input type="text" name="cr_question_8" class="form-control form_input question_8 " id="item_8" minlength="5" maxlength="5" required="" data-msg="This field is required" value="">
      <div class="cr_validation_icon"></div>
      <div class="cr_validation_error_message"></div>
    </div>
  </div>
  <script>
    $(document).ready(function() {
      $('input#item_8').mask('99999');
    });
  </script>
  <div class="row">
    <div class="col-md-6" id="email">
      <div class="form-group row question item_container item_4_container step_1_item_12" id="item_4_container">
        <div class="col">
          <label id="item_4_label" for="item_4" class="">Email Address</label>
          <input type="email" name="cr_question_4" class="form-control form_input question_4 " id="item_4" required="" data-msg="This field is required" value="">
          <div class="cr_validation_icon"></div>
          <div class="cr_validation_error_message"></div>
        </div>
      </div>
    </div>
    <div class="col-md-6" id="phone">
      <div class="form-group row question item_container item_5_container step_1_item_13" id="item_5_container">
        <div class="col">
          <label id="item_5_label" for="item_5" class="">Phone Number (Must Be Correct)</label>
          <input type="tel" name="cr_question_5" class="form-control form_input question_5 " id="item_5" maxlength="10" required="" data-msg="Please enter a valid phone number, digits only, no spaces or special characters." value="">
          <div class="cr_validation_icon"></div>
          <div class="cr_validation_error_message"></div>
        </div>
      </div>
    </div>
  </div>
  <script>
    //select question row, move it to a new column
    $('#item_4_container').appendTo('#email');
    $('#item_5_container').appendTo('#phone');
  </script>
  <div class="form-group row question item_container item_9_container step_1_item_11" id="item_9_container">
    <div class="col">
      <label id="item_9_label" for="item_9" class="">Date of Birth</label>
      <div class="row date_selector">
        <div class="col-xs-6 col-6">
          <select class="form-control form_input date-month question_9" required="" data-msg="This field is required" name="part-9_month">
            <option value="">Month</option>
            <option value="01">January</option>
            <option value="02">February</option>
            <option value="03">March</option>
            <option value="04">April</option>
            <option value="05">May</option>
            <option value="06">June</option>
            <option value="07">July</option>
            <option value="08">August</option>
            <option value="09">September</option>
            <option value="10">October</option>
            <option value="11">November</option>
            <option value="12">December</option>
          </select>
        </div>
        <div class="col-xs-3 col-3">
          <select class="form-control form_input date-day question_9" required="" data-msg="This field is required" name="part-9_day">
            <option value="">Day</option>
            <option value="01">1</option>
            <option value="02">2</option>
            <option value="03">3</option>
            <option value="04">4</option>
            <option value="05">5</option>
            <option value="06">6</option>
            <option value="07">7</option>
            <option value="08">8</option>
            <option value="09">9</option>
            <option value="10">10</option>
            <option value="11">11</option>
            <option value="12">12</option>
            <option value="13">13</option>
            <option value="14">14</option>
            <option value="15">15</option>
            <option value="16">16</option>
            <option value="17">17</option>
            <option value="18">18</option>
            <option value="19">19</option>
            <option value="20">20</option>
            <option value="21">21</option>
            <option value="22">22</option>
            <option value="23">23</option>
            <option value="24">24</option>
            <option value="25">25</option>
            <option value="26">26</option>
            <option value="27">27</option>
            <option value="28">28</option>
            <option value="29">29</option>
            <option value="30">30</option>
            <option value="31">31</option>
          </select>
        </div>
        <div class="col-xs-3 col-3">
          <select class="form-control form_input date-year question_9" required="" data-msg="This field is required" name="part-9_year">
            <option value="">Year</option>
            <option value="1924">1924</option>
            <option value="1925">1925</option>
            <option value="1926">1926</option>
            <option value="1927">1927</option>
            <option value="1928">1928</option>
            <option value="1929">1929</option>
            <option value="1930">1930</option>
            <option value="1931">1931</option>
            <option value="1932">1932</option>
            <option value="1933">1933</option>
            <option value="1934">1934</option>
            <option value="1935">1935</option>
            <option value="1936">1936</option>
            <option value="1937">1937</option>
            <option value="1938">1938</option>
            <option value="1939">1939</option>
            <option value="1940">1940</option>
            <option value="1941">1941</option>
            <option value="1942">1942</option>
            <option value="1943">1943</option>
            <option value="1944">1944</option>
            <option value="1945">1945</option>
            <option value="1946">1946</option>
            <option value="1947">1947</option>
            <option value="1948">1948</option>
            <option value="1949">1949</option>
            <option value="1950">1950</option>
            <option value="1951">1951</option>
            <option value="1952">1952</option>
            <option value="1953">1953</option>
            <option value="1954">1954</option>
            <option value="1955">1955</option>
            <option value="1956">1956</option>
            <option value="1957">1957</option>
            <option value="1958">1958</option>
            <option value="1959">1959</option>
            <option value="1960">1960</option>
            <option value="1961">1961</option>
            <option value="1962">1962</option>
            <option value="1963">1963</option>
            <option value="1964">1964</option>
            <option value="1965">1965</option>
            <option value="1966">1966</option>
            <option value="1967">1967</option>
            <option value="1968">1968</option>
            <option value="1969">1969</option>
            <option value="1970">1970</option>
            <option value="1971">1971</option>
            <option value="1972">1972</option>
            <option value="1973">1973</option>
            <option value="1974">1974</option>
            <option value="1975">1975</option>
            <option value="1976">1976</option>
            <option value="1977">1977</option>
            <option value="1978">1978</option>
            <option value="1979">1979</option>
            <option value="1980">1980</option>
            <option value="1981">1981</option>
            <option value="1982">1982</option>
            <option value="1983">1983</option>
            <option value="1984">1984</option>
            <option value="1985">1985</option>
            <option value="1986">1986</option>
            <option value="1987">1987</option>
            <option value="1988">1988</option>
            <option value="1989">1989</option>
            <option value="1990">1990</option>
            <option value="1991">1991</option>
            <option value="1992">1992</option>
            <option value="1993">1993</option>
            <option value="1994">1994</option>
            <option value="1995">1995</option>
            <option value="1996">1996</option>
            <option value="1997">1997</option>
            <option value="1998">1998</option>
            <option value="1999">1999</option>
            <option value="2000">2000</option>
            <option value="2001">2001</option>
            <option value="2002">2002</option>
            <option value="2003">2003</option>
            <option value="2004">2004</option>
            <option value="2005">2005</option>
            <option value="2006">2006</option>
            <option value="2007">2007</option>
            <option value="2008">2008</option>
            <option value="2009">2009</option>
            <option value="2010">2010</option>
            <option value="2011">2011</option>
            <option value="2012">2012</option>
            <option value="2013">2013</option>
            <option value="2014">2014</option>
            <option value="2015">2015</option>
            <option value="2016">2016</option>
            <option value="2017">2017</option>
            <option value="2018">2018</option>
            <option value="2019">2019</option>
            <option value="2020">2020</option>
            <option value="2021">2021</option>
            <option value="2022">2022</option>
            <option value="2023">2023</option>
            <option value="2024">2024</option>
            <option value="2025">2025</option>
            <option value="2026">2026</option>
            <option value="2027">2027</option>
            <option value="2028">2028</option>
            <option value="2029">2029</option>
          </select>
        </div>
        <input type="hidden" class="date-full form_input  check_conditionals" name="cr_question_9" id="question_9" value="">
      </div>
      <div class="cr_validation_icon"></div>
      <div class="cr_validation_error_message"></div>
    </div>
  </div>
  <script>
    $(document).ready(function() {
      $('input#item_5').mask('0000000000');
    });
  </script>
  <div class="form-group row question item_container item_228_container step_1_item_14 button bordered inline" id="item_228_container">
    <div class="col">
      <label id="item_228_label" for="item_228" class=""><strong>Were You involved in an auto accident in last 24 months?</strong>
        <strong></strong></label>
      <div class="radio_answers">
        <div class="form-check">
          <input name="cr_question_228" class="form-check-input question_228   check_conditionals" required="" data-msg="This field is required" type="radio" id="answer_10237" value="cr_answer_10237">
          <label class="form-check-label" for="answer_10237">Yes</label>
        </div>
        <div class="form-check">
          <input name="cr_question_228" class="form-check-input question_228   check_conditionals" required="" data-msg="This field is required" type="radio" id="answer_10238" value="cr_answer_10238">
          <label class="form-check-label" for="answer_10238">No</label>
        </div>
      </div>
      <div class="cr_validation_icon"></div>
      <div class="cr_validation_error_message"></div>
    </div>
  </div>
  <div class="form-group row question item_container item_229_container step_1_item_15 button bordered inline" id="item_229_container">
    <div class="col">
      <label id="item_229_label" for="item_229" class=""><strong>Did you require medical attention with-in 30 days of accident?</strong>
        <strong></strong></label>
      <div class="radio_answers">
        <div class="form-check">
          <input name="cr_question_229" class="form-check-input question_229   check_conditionals" required="" data-msg="This field is required" type="radio" id="answer_10283" value="cr_answer_10283">
          <label class="form-check-label" for="answer_10283">Yes</label>
        </div>
        <div class="form-check">
          <input name="cr_question_229" class="form-check-input question_229   check_conditionals" required="" data-msg="This field is required" type="radio" id="answer_10284" value="cr_answer_10284">
          <label class="form-check-label" for="answer_10284">No</label>
        </div>
      </div>
      <div class="cr_validation_icon"></div>
      <div class="cr_validation_error_message"></div>
    </div>
  </div>
  <div class="form-group row question item_container item_230_container step_1_item_16 button bordered inline" id="item_230_container">
    <div class="col">
      <label id="item_230_label" for="item_230" class=""><strong>Do you have an attorney?</strong>
        <strong></strong></label>
      <div class="radio_answers">
        <div class="form-check">
          <input name="cr_question_230" class="form-check-input question_230   check_conditionals" required="" data-msg="This field is required" type="radio" id="answer_10329" value="cr_answer_10329">
          <label class="form-check-label" for="answer_10329">Yes</label>
        </div>
        <div class="form-check">
          <input name="cr_question_230" class="form-check-input question_230   check_conditionals" required="" data-msg="This field is required" type="radio" id="answer_10330" value="cr_answer_10330">
          <label class="form-check-label" for="answer_10330">No</label>
        </div>
      </div>
      <div class="cr_validation_icon"></div>
      <div class="cr_validation_error_message"></div>
    </div>
  </div>
  <input type="hidden" name="cr_question_97" id="item_97" class="question_97 " value="">
  <div class="form-group row question item_container item_217_container step_1_item_18 mt-1" id="item_217_container">
    <div class="col">
      <label id="item_217_label" for="item_217" class=""></label>
      <div class="radio_answers">
        <div class="form-check">
          <input name="cr_question_217[]" class="form-check-input question_217  " required="" data-msg="This field is required" type="checkbox" id="answer_9736" value="cr_answer_9736">
          <label class="form-check-label" for="answer_9736">
            <p class="small">Check box to confirm your agreement with the <a href="https://injuryhelpdesk.net/privacy-policy-injury-help-desk.html" target="_blank" rel="noopener noreferrer" data-auth="NotApplicable">Privacy Policy</a> and
              <a href="https://injuryhelpdesk.net/terms-and-conditions-injury-help-desk.html" target="_blank" rel="noopener noreferrer" data-auth="NotApplicable">Terms of Service</a>, including mandatory arbitration.</p>
            <p class="small">By clicking Continue you agree to receive SMS text messages (msg &amp; data rates apply) and autodialed, prerecorded calls from Basco Property MGMT, LLC for each offer you select at the number you provided even if it is
              on a state or federal Do Not Call list. Reply STOP to cancel. Your agreement is not required to purchase or receive any goods or services. To receive information about this offer without receiving texts or calls, call
              <a href="tel:800-361-9757">800-361-9757</a>.</p>
          </label>
        </div>
      </div>
      <div class="cr_validation_icon"></div>
      <div class="cr_validation_error_message"></div>
    </div>
  </div>
  <div class="next_button row item_container item_6_container" style="display: none;">
    <div class="col">
      <button type="submit" id="" class="btn btn-primary">Continue</button>
    </div>
  </div>
  <div class="html row item_container item_231_container step_1_item_20">
    <div class="col">
      <center><button class="btn skip">Continue!</button></center>
      <script>
        $(document).on('click', '.skip', function(e) {
          e.preventDefault();
          var url = $(this).closest('form').attr('action');
          window.location = url;
        });
      </script>
    </div>
  </div>
  <input type="hidden" name="cr_question_83" id="item_83" class="question_83 " value="LF25">
  <input type="hidden" name="cr_question_98" id="item_98" class="question_98 " value="">
  <input type="hidden" name="cr_question_109" id="item_109" class="question_109 " value="">
  <input type="hidden" name="cr_question_110" id="item_110" class="question_110 " value="">
  <input type="hidden" name="cr_question_22" id="item_22" class="question_22 " value="B19B8206-5DA1-DBB2-C24F-D44D4001C908">
  <div class="html row item_container item_23_container step_1_item_26">
    <div class="col">
      <input id="leadid_token" name="universal_leadid" type="hidden" value="B19B8206-5DA1-DBB2-C24F-D44D4001C908">
      <script id="LeadiDscript_campaign" type="text/javascript" async="" src="//create.lidstatic.com/campaign/9d0c1f9c-a1d3-b3d7-5f4f-d24fba30fb8f.js?snippet_version=2"></script>
      <script id="LeadiDscript" type="text/javascript">
        (function() {
          var s = document.createElement('script');
          s.id = 'LeadiDscript_campaign';
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Text Content

Get Case Value


NO MATTER THE ACCIDENT, WE’VE GOT YOU COVERED.


SEEK MAXIMUM COMPENSATION FOR YOUR INJURY

FREE CLAIM REVIEW!

BY A LOCAL ATTORNEY


GET THE BEST AUTO ACCIDENT LEGAL REPRESENTERS TRY OUR
COMPENSATION CALCULATOR!

NO FEES UNLESS WE WIN!




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INJURY COMPENSATION CALCULATOR!

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