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preferpay.commercebank.com Open in urlscan Pro
12.167.75.50  Public Scan

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URL: https://preferpay.commercebank.com/?key=d023f666293c4206b08267122a9935a6875f05df87294a14a0c125afdbc6a652&cid=0646995
Submission: On December 07 via manual from US — Scanned from US

Form analysis 1 forms found in the DOM

<form autocomplete="off" class="cb-row auth-container ng-untouched ng-pristine ng-invalid" novalidate=""><!---->
  <div class="ng-container"><!----><!----><!----><form-date _nghost-c5="">
      <div _ngcontent-c5="" class="cb-form-group cb-col-md-6 cb-col-xs-12 ng-untouched ng-pristine ng-invalid"><label _ngcontent-c5="" class="cb-form-control-label">Guarantor Date of Birth</label>
        <div _ngcontent-c5="" class="cb-row">
          <div _ngcontent-c5="" class="cb-col-sm-5 cb-col-xs-12">
            <div _ngcontent-c5="" class="cb-select"><select _ngcontent-c5="" autocomplete="off" class="cb-form-control ng-untouched ng-pristine ng-invalid" formcontrolname="Month" name="Month" tabindex="0" id="guarantor_date_of_birth_month">
                <option _ngcontent-c5="" disabled="disabled" value="">Month</option><!---->
                <option _ngcontent-c5="" value="1: 0">January (1)</option>
                <option _ngcontent-c5="" value="2: 1">February (2)</option>
                <option _ngcontent-c5="" value="3: 2">March (3)</option>
                <option _ngcontent-c5="" value="4: 3">April (4)</option>
                <option _ngcontent-c5="" value="5: 4">May (5)</option>
                <option _ngcontent-c5="" value="6: 5">June (6)</option>
                <option _ngcontent-c5="" value="7: 6">July (7)</option>
                <option _ngcontent-c5="" value="8: 7">August (8)</option>
                <option _ngcontent-c5="" value="9: 8">September (9)</option>
                <option _ngcontent-c5="" value="10: 9">October (10)</option>
                <option _ngcontent-c5="" value="11: 10">November (11)</option>
                <option _ngcontent-c5="" value="12: 11">December (12)</option>
              </select></div>
          </div>
          <div _ngcontent-c5="" class="cb-clearfix pad-top cb-hidden-sm-up"></div>
          <div _ngcontent-c5="" class="cb-col-sm-3 cb-col-xs-6">
            <div _ngcontent-c5="" class="cb-select disabled"><select _ngcontent-c5="" autocomplete="off" class="cb-form-control ng-untouched ng-pristine" formcontrolname="Day" name="Day" tabindex="0" disabled="" id="guarantor_date_of_birth_day">
                <option _ngcontent-c5="" disabled="disabled" value="">Day</option><!---->
              </select></div>
          </div>
          <div _ngcontent-c5="" class="cb-col-sm-4 cb-col-xs-6"><input _ngcontent-c5="" autocomplete="off" class="cb-form-control ng-untouched ng-pristine ng-invalid" formcontrolname="Year" name="Year" placeholder="YYYY" tabindex="0" type="text"
              id="guarantor_date_of_birth_year"></div>
        </div><!---->
        <div _ngcontent-c5="" class="placeholder"></div><!----><!---->
      </div>
    </form-date><!----><!----><!----><!----></div>
  <div class="ng-container adjust-auth-field"><!----><!----><!----><!----><!----><form-alphanumeric _nghost-c7="">
      <div _ngcontent-c7="" class="cb-form-group cb-col-md-6 cb-col-xs-12 ng-untouched ng-pristine ng-invalid"><label _ngcontent-c7="" class="cb-form-control-label" for="alphanumeric">Guarantor Zip Code</label><input _ngcontent-c7=""
          autocomplete="off" class="cb-form-control ng-untouched ng-pristine ng-invalid" formcontrolname="alphanumeric" maxlength="50" name="alphanumeric" tabindex="0" type="text" id="guarantor_zip_code"><!---->
        <div _ngcontent-c7="" class="placeholder"></div><!----><!---->
      </div>
    </form-alphanumeric><!----><!----></div>
  <div class="ng-container"><!----><!----><!----><!----><form-numeric _nghost-c6="">
      <div _ngcontent-c6="" class="cb-form-group cb-col-md-6 cb-col-xs-12 ng-untouched ng-pristine ng-invalid"><label _ngcontent-c6="" class="cb-form-control-label" for="numeric">Last Four Digits of Guarantor Phone Number</label><input
          _ngcontent-c6="" autocomplete="off" class="cb-form-control ng-untouched ng-pristine ng-invalid" formcontrolname="numeric" maxlength="17" name="numeric" tabindex="0" type="text" id="last_four_digits_of_guarantor_phone_number"><!---->
        <div _ngcontent-c6="" class="placeholder"></div><!----><!---->
      </div>
    </form-numeric><!----><!----><!----></div><!---->
  <div class="cb-row margin-top cb-col-xs-12">
    <div class="cb-col-md-3 cb-col-xs-12 right"><button class="cb-btn-lg cb-btn-primary cb-btn-block" id="continueButton" tabindex="0" type="submit"><!----><span>Continue</span><!----></button></div>
  </div>
</form>

Text Content

AVERA HEALTH REFUNDS

POWERED BY PREFERPAY®


LET'S GET STARTED

Please enter the following information to confirm your identity.

Guarantor Date of Birth
MonthJanuary (1)February (2)March (3)April (4)May (5)June (6)July (7)August
(8)September (9)October (10)November (11)December (12)

Day


Guarantor Zip Code

Last Four Digits of Guarantor Phone Number

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