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Submitted URL: https://click.actmkt.com/s/055-4fc61c12-8fa1-4428-8584-03b6ce4bd449?enr=naahiaduabyaa4yahiac6abpabtaa3yaoiag2aboabvaa3yao...
Effective URL: https://form.jotform.com/231526842885061
Submission: On June 11 via manual from US — Scanned from DE
Effective URL: https://form.jotform.com/231526842885061
Submission: On June 11 via manual from US — Scanned from DE
Form analysis 1 forms found in the DOM
Name: form_231526842885061 — POST https://submit.jotform.com/submit/231526842885061
<form class="jotform-form" onsubmit="return typeof testSubmitFunction !== 'undefined' && testSubmitFunction();" action="https://submit.jotform.com/submit/231526842885061" method="post" name="form_231526842885061" id="231526842885061"
accept-charset="utf-8" autocomplete="on" novalidate="true"><input type="hidden" name="formID" value="231526842885061"><input type="hidden" id="JWTContainer" value=""><input type="hidden" id="cardinalOrderNumber" value=""><input type="hidden"
id="jsExecutionTracker" name="jsExecutionTracker" value="build-date-1717551381971=>init-started:1718129748658=>validator-called:1718129748676=>validator-mounted-true:1718129748676=>init-complete:1718129748682"><input type="hidden"
id="submitSource" name="submitSource" value="mounted"><input type="hidden" id="buildDate" name="buildDate" value="1717551381971">
<div id="formCoverLogo" style="margin-bottom:10px" class="form-cover-wrapper form-has-cover form-page-cover-image-align-center">
<div class="form-page-cover-image-wrapper" style="max-width:752px"><img src="https://www.jotform.com/uploads/katelint/form_files/Transparent%20Proaction%20Logo.647e3b54c15f63.83656379.png" class="form-page-cover-image" width="560" height="140"
aria-label="Form Logo" style="aspect-ratio:560/140"></div>
</div>
<div role="main" class="form-all">
<ul class="form-section page-section">
<li id="cid_1" class="form-input-wide" data-type="control_head" data-css-selector="id_1">
<div class="form-header-group header-large">
<div class="header-text httac htvam">
<h1 id="header_1" class="form-header" data-component="header">Get a Quote</h1>
</div>
</div>
</li>
<li id="cid_3" class="form-input-wide" data-type="control_head" data-css-selector="id_3">
<div class="form-header-group header-default">
<div class="header-text httac htvam">
<h2 id="header_3" class="form-header" data-component="header">Safeguarding Healthcare & Caregiving Businesses</h2>
<div id="subHeader_3" class="form-subHeader">ProAction Insurance has access to multiple markets and would love the opportunity to provide you with competitive rates to save you time and money! To receive a quote, simply fill in the
answers to the questions below. For faster service please call our office at (951)-898-9892 and one of our Healthcare Insurance Specialists will assist you. </div>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_fullname" id="id_5" data-css-selector="id_5"><label class="form-label form-label-top form-label-auto" id="label_5" for="first_5" aria-hidden="false"> Contact Name<span
class="form-required">*</span> </label>
<div id="cid_5" class="form-input-wide jf-required" data-layout="full">
<div data-wrapper-react="true"><span class="form-sub-label-container" style="vertical-align:top" data-input-type="first"><input type="text" id="first_5" name="q5_contactName[first]" class="form-textbox validate[required]"
data-defaultvalue="" autocomplete="section-input_5 given-name" size="10" data-component="first" aria-labelledby="label_5 sublabel_5_first" required="" value=""><label class="form-sub-label" for="first_5" id="sublabel_5_first"
style="min-height:13px">First Name</label></span><span class="form-sub-label-container" style="vertical-align:top" data-input-type="last"><input type="text" id="last_5" name="q5_contactName[last]"
class="form-textbox validate[required]" data-defaultvalue="" autocomplete="section-input_5 family-name" size="15" data-component="last" aria-labelledby="label_5 sublabel_5_last" required="" value=""><label class="form-sub-label"
for="last_5" id="sublabel_5_last" style="min-height:13px">Last Name</label></span></div>
</div>
</li>
<li class="form-line form-line-column form-col-1 jf-required" data-type="control_textbox" id="id_19" data-css-selector="id_19"><label class="form-label form-label-top" id="label_19" for="input_19" aria-hidden="false"> Company Name<span
class="form-required">*</span> </label>
<div id="cid_19" class="form-input-wide jf-required" data-layout="half"> <input type="text" id="input_19" name="q19_companyName19" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" style="width:310px"
size="310" data-component="textbox" aria-labelledby="label_19" required="" value=""> </div>
</li>
<li class="form-line form-line-column form-col-2" data-type="control_email" id="id_7" data-css-selector="id_7"><label class="form-label form-label-top" id="label_7" for="input_7" aria-hidden="false"> DBA ( if applicable) </label>
<div id="cid_7" class="form-input-wide" data-layout="half"> <input type="email" id="input_7" name="q7_dba" class="form-textbox validate[Email]" data-defaultvalue="" autocomplete="section-input_7 email" style="width:310px" size="310"
data-component="email" aria-labelledby="label_7" value=""> </div>
</li>
<li class="form-line jf-required" data-type="control_address" id="id_8" data-compound-hint=",,,,Please Select,,Please Select," data-css-selector="id_8"><label class="form-label form-label-top form-label-auto" id="label_8"
for="input_8_addr_line1" aria-hidden="false"> Business Address<span class="form-required">*</span> </label>
<div id="cid_8" class="form-input-wide jf-required" data-layout="full">
<div summary="" class="form-address-table jsTest-addressField">
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_8_addr_line1" name="q8_businessAddress[addr_line1]" class="form-textbox validate[required] form-address-line" data-defaultvalue="" autocomplete="section-input_8 address-line1" data-component="address_line_1"
aria-labelledby="label_8 sublabel_8_addr_line1" required="" value="" maxlength="100"><label class="form-sub-label" for="input_8_addr_line1" id="sublabel_8_addr_line1" style="min-height:13px">Street Address</label></span></span>
</div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_8_addr_line2" name="q8_businessAddress[addr_line2]" class="form-textbox form-address-line" data-defaultvalue="" autocomplete="section-input_8 address-line2" data-component="address_line_2"
aria-labelledby="label_8 sublabel_8_addr_line2" required="" value="" maxlength="100"><label class="form-sub-label" for="input_8_addr_line2" id="sublabel_8_addr_line2" style="min-height:13px">Street Address Line
2</label></span></span></div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-city-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_8_city" name="q8_businessAddress[city]" class="form-textbox validate[required] form-address-city" data-defaultvalue="" autocomplete="section-input_8 address-level2" data-component="city"
aria-labelledby="label_8 sublabel_8_city" required="" value="" maxlength="60"><label class="form-sub-label" for="input_8_city" id="sublabel_8_city" style="min-height:13px">City</label></span></span><span
class="form-address-line form-address-state-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_8_state" name="q8_businessAddress[state]"
class="form-textbox validate[required] form-address-state" data-defaultvalue="" autocomplete="section-input_8 address-level1" data-component="state" aria-labelledby="label_8 sublabel_8_state" required="" value=""
maxlength="60"><label class="form-sub-label" for="input_8_state" id="sublabel_8_state" style="min-height:13px">State / Province</label></span></span></div>
<div class="form-address-line-wrapper jsTest-address-line-wrapperField"><span class="form-address-line form-address-zip-line jsTest-address-lineField "><span class="form-sub-label-container" style="vertical-align:top"><input type="text"
id="input_8_postal" name="q8_businessAddress[postal]" class="form-textbox validate[required] form-address-postal" data-defaultvalue="" autocomplete="section-input_8 postal-code" data-component="zip"
aria-labelledby="label_8 sublabel_8_postal" required="" value="" maxlength="20"><label class="form-sub-label" for="input_8_postal" id="sublabel_8_postal" style="min-height:13px">Postal / Zip Code</label></span></span></div>
</div>
</div>
</li>
<li class="form-line form-line-column form-col-1 jf-required" data-type="control_email" id="id_9" data-css-selector="id_9"><label class="form-label form-label-top" id="label_9" for="input_9" aria-hidden="false"> Email<span
class="form-required">*</span> </label>
<div id="cid_9" class="form-input-wide jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="email" id="input_9" name="q9_email" class="form-textbox validate[required, Email]"
data-defaultvalue="" autocomplete="section-input_9 email" style="width:310px" size="310" data-component="email" aria-labelledby="label_9 sublabel_input_9" required="" value=""><label class="form-sub-label" for="input_9"
id="sublabel_input_9" style="min-height:13px">example@example.com</label></span> </div>
</li>
<li class="form-line form-line-column form-col-2 jf-required" data-type="control_phone" id="id_10" data-css-selector="id_10"><label class="form-label form-label-top" id="label_10" for="input_10_full"> Phone Number<span
class="form-required">*</span> </label>
<div id="cid_10" class="form-input-wide jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="tel" id="input_10_full" name="q10_phoneNumber[full]" data-type="mask-number"
class="mask-phone-number form-textbox validate[required, Fill Mask]" data-defaultvalue="" autocomplete="section-input_10 tel-national" style="width:310px" data-masked="true" placeholder="(000) 000-0000" data-component="phone"
aria-labelledby="label_10 sublabel_10_masked" required="" value="" inputmode="text" maskvalue="(###) ###-####"><label class="form-sub-label" for="input_10_full" id="sublabel_10_masked" style="min-height:13px">Please enter a valid phone
number.</label></span> </div>
</li>
<li class="form-line jf-required" data-type="control_checkbox" id="id_16" data-css-selector="id_16"><label class="form-label form-label-top form-label-auto" id="label_16" aria-hidden="false"> Coverage Considerations (select all that apply)<span
class="form-required">*</span> </label>
<div id="cid_16" class="form-input-wide jf-required" data-layout="full">
<div class="form-single-column" role="group" aria-labelledby="label_16" data-component="checkbox"><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input type="checkbox" aria-describedby="label_16"
class="form-checkbox validate[required]" id="input_16_0" name="q16_coverageConsiderations[]" value="Workers' Compensation" required=""><label id="label_input_16_0" for="input_16_0">Workers' Compensation</label></span><span
class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input type="checkbox" aria-describedby="label_16" class="form-checkbox validate[required]" id="input_16_1" name="q16_coverageConsiderations[]"
value="General Liability" required=""><label id="label_input_16_1" for="input_16_1">General Liability</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input type="checkbox"
aria-describedby="label_16" class="form-checkbox validate[required]" id="input_16_2" name="q16_coverageConsiderations[]" value="Professional Liability" required=""><label id="label_input_16_2" for="input_16_2">Professional
Liability</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input type="checkbox" aria-describedby="label_16" class="form-checkbox validate[required]" id="input_16_3"
name="q16_coverageConsiderations[]" value="Business Personal Property (BPP)" required=""><label id="label_input_16_3" for="input_16_3">Business Personal Property (BPP)</label></span><span class="form-checkbox-item"
style="clear:left"><span class="dragger-item"></span><input type="checkbox" aria-describedby="label_16" class="form-checkbox validate[required]" id="input_16_4" name="q16_coverageConsiderations[]" value="Hired Non-Owned Auto"
required=""><label id="label_input_16_4" for="input_16_4">Hired Non-Owned Auto</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input type="checkbox" aria-describedby="label_16"
class="form-checkbox validate[required]" id="input_16_5" name="q16_coverageConsiderations[]" value="Employment Practices Liability (EPL)" required=""><label id="label_input_16_5" for="input_16_5">Employment Practices Liability
(EPL)</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input type="checkbox" aria-describedby="label_16" class="form-checkbox validate[required]" id="input_16_6"
name="q16_coverageConsiderations[]" value="Cyber Liability" required=""><label id="label_input_16_6" for="input_16_6">Cyber Liability</label></span><span class="form-checkbox-item" style="clear:left"><span
class="dragger-item"></span><input type="checkbox" aria-describedby="label_16" class="form-checkbox validate[required]" id="input_16_7" name="q16_coverageConsiderations[]" value="Surety/Dishonesty Bond" required=""><label
id="label_input_16_7" for="input_16_7">Surety/Dishonesty Bond</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input type="checkbox" aria-describedby="label_16"
class="form-checkbox validate[required]" id="input_16_8" name="q16_coverageConsiderations[]" value="Home Care Organization Bond" required=""><label id="label_input_16_8" for="input_16_8">Home Care Organization Bond</label></span>
</div>
</div>
</li>
<li class="form-line jf-required" data-type="control_datetime" id="id_18" data-css-selector="id_18"><label class="form-label form-label-top form-label-auto" id="label_18" for="lite_mode_18" aria-hidden="false"> Renewal/Effective Date <span
class="form-required">*</span> </label>
<div id="cid_18" class="form-input-wide jf-required" data-layout="half">
<div data-wrapper-react="true">
<div style="display:none"><span class="form-sub-label-container" style="vertical-align:top"><input type="tel" class="form-textbox validate[required, limitDate]" id="month_18" name="q18_renewaleffectiveDate[month]" size="2"
data-maxlength="2" data-age="" maxlength="2" value="" required="" autocomplete="off" aria-labelledby="label_18 sublabel_18_month" inputmode="numeric"><span class="date-separate" aria-hidden="true"> -</span><label
class="form-sub-label" for="month_18" id="sublabel_18_month" style="min-height:13px">Month</label></span><span class="form-sub-label-container" style="vertical-align:top"><input type="tel"
class="form-textbox validate[required, limitDate]" id="day_18" name="q18_renewaleffectiveDate[day]" size="2" data-maxlength="2" data-age="" maxlength="2" value="" required="" autocomplete="off"
aria-labelledby="label_18 sublabel_18_day" inputmode="numeric"><span class="date-separate" aria-hidden="true"> -</span><label class="form-sub-label" for="day_18" id="sublabel_18_day"
style="min-height:13px">Day</label></span><span class="form-sub-label-container" style="vertical-align:top"><input type="tel" class="form-textbox validate[required, limitDate]" id="year_18" name="q18_renewaleffectiveDate[year]"
size="4" data-maxlength="4" data-age="" maxlength="4" value="" required="" autocomplete="off" aria-labelledby="label_18 sublabel_18_year"><label class="form-sub-label" for="year_18" id="sublabel_18_year"
style="min-height:13px">Year</label></span></div><span class="form-sub-label-container" style="vertical-align:top"><input type="text" class="form-textbox validate[required, limitDate, validateLiteDate]" id="lite_mode_18" size="12"
data-maxlength="12" data-age="" value="" required="" data-format="mmddyyyy" data-seperator="-" placeholder="MM-DD-YYYY" data-placeholder="MM-DD-YYYY" autocomplete="off" aria-labelledby="label_18 sublabel_18_litemode"
inputmode="numeric"><img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Pick a Date" id="input_18_pick" src="https://cdn.jotfor.ms/images/calendar.png" data-component="datetime" aria-hidden="true" data-allow-time="No"
data-version="v2"><label class="form-sub-label" for="lite_mode_18" id="sublabel_18_litemode" style="min-height:13px">Date</label></span>
</div>
</div>
</li>
<li class="form-line" data-type="control_button" id="id_2" data-css-selector="id_2">
<div id="cid_2" class="form-input-wide" data-layout="full">
<div data-align="auto" class="form-buttons-wrapper form-buttons-auto jsTest-button-wrapperField">
<div class="submitBrandingWrapper" style="flex-direction: column;"><button id="input_2" type="submit" class="form-submit-button submit-button jf-form-buttons jsTest-submitField" data-component="button" data-content=""
aria-live="polite">Submit</button><a target="_blank" href="https://www.jotform.com/?utm_source=powered_by_jotform&utm_medium=banner&utm_term=231526842885061&utm_content=powered_by_jotform_text&utm_campaign=powered_by_jotform_signup_hp" class="jf-branding" style="display: inline-block; opacity: 0.8; -webkit-font-smoothing: antialiased; color: rgb(0, 0, 0); font-family: Inter, sans-serif; font-size: 12px; padding-top: 10px; margin-left: -5px;">Powered by <b>Jotform</b></a>
</div>
</div>
</div>
</li>
<li style="display:none">Should be Empty: <input type="text" name="website" value=""></li>
</ul>
</div>
<script>
JotForm.showJotFormPowered = "old_footer";
</script>
<script>
JotForm.poweredByText = "Powered by Jotform";
</script><input type="hidden" class="simple_spc" id="simple_spc" name="simple_spc" value="231526842885061-231526842885061">
<script type="text/javascript">
var all_spc = document.querySelectorAll("form[id='231526842885061'] .si" + "mple" + "_spc");
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all_spc[i].value = "231526842885061-231526842885061";
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<input type="hidden" name="event_id" value="1718129748658_231526842885061_c41uJ0J"><input type="hidden" name="timeToSubmit" value="3">
</form>Text Content
* GET A QUOTE * SAFEGUARDING HEALTHCARE & CAREGIVING BUSINESSES ProAction Insurance has access to multiple markets and would love the opportunity to provide you with competitive rates to save you time and money! To receive a quote, simply fill in the answers to the questions below. For faster service please call our office at (951)-898-9892 and one of our Healthcare Insurance Specialists will assist you. * Contact Name* First NameLast Name * Company Name* * DBA ( if applicable) * Business Address* Street Address Street Address Line 2 CityState / Province Postal / Zip Code * Email* example@example.com * Phone Number* Please enter a valid phone number. * Coverage Considerations (select all that apply)* Workers' CompensationGeneral LiabilityProfessional LiabilityBusiness Personal Property (BPP)Hired Non-Owned AutoEmployment Practices Liability (EPL)Cyber LiabilitySurety/Dishonesty BondHome Care Organization Bond * Renewal/Effective Date * -Month -DayYear Date * SubmitPowered by Jotform * Should be Empty: June‹› 2024«» June 2024TodaySMTWTFS26272829303112345678910111213141516171819202122232425262728293012345678910111213