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Submitted URL: http://r.emg.thgins.com/mk/cl/f/CaSkrMoNsszw3uopKGZTnm5VgZIMnaE4dKGl_XSJxCLMipsZAdosYxHsr54nQNFcWEhttZwVOeGWNSoJkEoOV_Jf...
Effective URL: https://share.hsforms.com/18ABwtS_eRTm-WngvXg5lwwccpkj?utm_source=sendinblue&utm_campaign=WE%20want%20your%20smoker%20clie...
Submission: On August 31 via api from US — Scanned from DE
Effective URL: https://share.hsforms.com/18ABwtS_eRTm-WngvXg5lwwccpkj?utm_source=sendinblue&utm_campaign=WE%20want%20your%20smoker%20clie...
Submission: On August 31 via api from US — Scanned from DE
Form analysis 1 forms found in the DOM
<form id="hs-form-f00070b5-2fde-4539-be5a-782f5e0e65c3-1812a0c2-103d-41a7-91d9-f928f3495bf0" class="hs-form-f00070b5-2fde-4539-be5a-782f5e0e65c3 hs-form hs-form_theme-canvas hs-form_free" data-instance-id="1812a0c2-103d-41a7-91d9-f928f3495bf0"
data-form-id="f00070b5-2fde-4539-be5a-782f5e0e65c3" data-portal-id="20748403" lang="en" data-hs-cf-bound="true">
<div class="hs-form__pagination-content-container">
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-email hs-email"><label id="email-label" for="email-input" class="hs-form__field__label hs-form__field__label--required" data-required="true"><span>Email</span></label><input id="email-input"
class="hs-form__field__input" type="email" name="email" required="" autocomplete="email" inputmode="email" aria-invalid="false" aria-labelledby="email-label" aria-describedby="email-description" aria-required="true" value=""></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-firstname hs-firstname"><label id="firstname-label" for="firstname-input" class="hs-form__field__label hs-form__field__label--required" data-required="true"><span>First name</span></label><input
id="firstname-input" class="hs-form__field__input" type="text" name="firstname" required="" autocomplete="given-name" inputmode="text" aria-invalid="false" aria-labelledby="firstname-label" aria-describedby="firstname-description"
aria-required="true" value=""></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-lastname hs-lastname"><label id="lastname-label" for="lastname-input" class="hs-form__field__label hs-form__field__label--required" data-required="true"><span>Last name</span></label><input
id="lastname-input" class="hs-form__field__input" type="text" name="lastname" required="" autocomplete="family-name" inputmode="text" aria-invalid="false" aria-labelledby="lastname-label" aria-describedby="lastname-description"
aria-required="true" value=""></div>
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</div>
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</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-phone hs-phone"><label id="phone-label" for="phone-input" class="hs-form__field__label hs-form__field__label--required" data-required="true"><span>Phone number</span></label>
<div class="hs-form__field__phone"><input id="phone-input" class="hs-form__field__input" type="tel" name="phone" required="" autocomplete="tel" inputmode="tel" aria-invalid="false" aria-labelledby="phone-label"
aria-describedby="phone-description" aria-required="true" value=""></div>
</div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-company hs-company"><label id="company-label" for="company-input" class="hs-form__field__label" data-required="false"><span>Company name</span></label><input id="company-input"
class="hs-form__field__input" type="text" name="company" autocomplete="organization" inputmode="text" aria-invalid="false" aria-labelledby="company-label" aria-describedby="company-description" aria-required="false" value=""></div>
</div>
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</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-message hs-message"><label id="message-label" for="message-input" class="hs-form__field__label" data-required="false"><span>Message</span></label><textarea id="message-input"
class="hs-form__field__input" name="message" aria-invalid="false" aria-labelledby="message-label" aria-describedby="message-description" aria-required="false"></textarea></div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-information_you_are_requesting__choose_all_that_apply__ hs-information_you_are_requesting__choose_all_that_apply__"><label id="information_you_are_requesting__choose_all_that_apply__-label"
for="information_you_are_requesting__choose_all_that_apply__-input" class="hs-form__field__label hs-form__field__label--required" data-required="true"><span>Information you are requesting? Choose all that apply.:</span></label>
<div style="display: flex; flex-grow: 1; align-items: flex-start; justify-content: flex-start; flex-direction: row;">
<div class="hs-form__field__options__container" role="group" aria-invalid="false" aria-labelledby="information_you_are_requesting__choose_all_that_apply__-label"
aria-describedby="information_you_are_requesting__choose_all_that_apply__-description">
<div style="align-self: flex-start; flex: 0 1 auto;"><label id="information_you_are_requesting__choose_all_that_apply__-label-1" class="hs-form__field__label hs-form__field__checkbox__label"><input
id="information_you_are_requesting__choose_all_that_apply__-input-1" class="hs-form__field__input hs-form__field__checkbox__input" type="checkbox"
name="information_you_are_requesting__choose_all_that_apply__-New Final Expense" aria-invalid="false" aria-labelledby="information_you_are_requesting__choose_all_that_apply__-label-1"
aria-describedby="information_you_are_requesting__choose_all_that_apply__-description" aria-required="false" aria-checked="false" value="New Final Expense"><span class="hs-form__field__checkbox__label-span">New Final
Expense</span></label></div>
<div style="align-self: flex-start; flex: 0 1 auto;"><label id="information_you_are_requesting__choose_all_that_apply__-label-2" class="hs-form__field__label hs-form__field__checkbox__label"><input
id="information_you_are_requesting__choose_all_that_apply__-input-2" class="hs-form__field__input hs-form__field__checkbox__input" type="checkbox"
name="information_you_are_requesting__choose_all_that_apply__-RX Discount Drug Card" aria-invalid="false" aria-labelledby="information_you_are_requesting__choose_all_that_apply__-label-2"
aria-describedby="information_you_are_requesting__choose_all_that_apply__-description" aria-required="false" aria-checked="false" value="RX Discount Drug Card"><span class="hs-form__field__checkbox__label-span">RX Discount
Drug Card</span></label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__group">
<div class="hs-form__field-row">
<div class="hs-form__field-row__column">
<div class="hs-form__field hs-form__field-what_product_s__do_you_sell__choose_all_that_apply__ hs-what_product_s__do_you_sell__choose_all_that_apply__"><label id="what_product_s__do_you_sell__choose_all_that_apply__-label"
for="what_product_s__do_you_sell__choose_all_that_apply__-input" class="hs-form__field__label hs-form__field__label--required" data-required="true"><span>What product(s) do you sell? Choose all that apply.:</span></label>
<div style="display: flex; flex-grow: 1; align-items: flex-start; justify-content: flex-start; flex-direction: row;">
<div class="hs-form__field__options__container" role="group" aria-invalid="false" aria-labelledby="what_product_s__do_you_sell__choose_all_that_apply__-label"
aria-describedby="what_product_s__do_you_sell__choose_all_that_apply__-description">
<div style="align-self: flex-start; flex: 0 1 auto;"><label id="what_product_s__do_you_sell__choose_all_that_apply__-label-1" class="hs-form__field__label hs-form__field__checkbox__label"><input
id="what_product_s__do_you_sell__choose_all_that_apply__-input-1" class="hs-form__field__input hs-form__field__checkbox__input" type="checkbox" name="what_product_s__do_you_sell__choose_all_that_apply__-Health/Under 65"
aria-invalid="false" aria-labelledby="what_product_s__do_you_sell__choose_all_that_apply__-label-1" aria-describedby="what_product_s__do_you_sell__choose_all_that_apply__-description" aria-required="false" aria-checked="false"
value="Health/Under 65"><span class="hs-form__field__checkbox__label-span">Health/Under 65</span></label></div>
<div style="align-self: flex-start; flex: 0 1 auto;"><label id="what_product_s__do_you_sell__choose_all_that_apply__-label-2" class="hs-form__field__label hs-form__field__checkbox__label"><input
id="what_product_s__do_you_sell__choose_all_that_apply__-input-2" class="hs-form__field__input hs-form__field__checkbox__input" type="checkbox" name="what_product_s__do_you_sell__choose_all_that_apply__-Medicare/65 and over"
aria-invalid="false" aria-labelledby="what_product_s__do_you_sell__choose_all_that_apply__-label-2" aria-describedby="what_product_s__do_you_sell__choose_all_that_apply__-description" aria-required="false" aria-checked="false"
value="Medicare/65 and over"><span class="hs-form__field__checkbox__label-span">Medicare/65 and over</span></label></div>
<div style="align-self: flex-start; flex: 0 1 auto;"><label id="what_product_s__do_you_sell__choose_all_that_apply__-label-3" class="hs-form__field__label hs-form__field__checkbox__label"><input
id="what_product_s__do_you_sell__choose_all_that_apply__-input-3" class="hs-form__field__input hs-form__field__checkbox__input" type="checkbox" name="what_product_s__do_you_sell__choose_all_that_apply__-Other:"
aria-invalid="false" aria-labelledby="what_product_s__do_you_sell__choose_all_that_apply__-label-3" aria-describedby="what_product_s__do_you_sell__choose_all_that_apply__-description" aria-required="false" aria-checked="false"
value="Other:"><span class="hs-form__field__checkbox__label-span">Other</span></label></div>
<div style="align-self: flex-start; flex: 0 1 auto;"><label id="what_product_s__do_you_sell__choose_all_that_apply__-label-4" class="hs-form__field__label hs-form__field__checkbox__label"><input
id="what_product_s__do_you_sell__choose_all_that_apply__-input-4" class="hs-form__field__input hs-form__field__checkbox__input" type="checkbox" name="what_product_s__do_you_sell__choose_all_that_apply__-Life"
aria-invalid="false" aria-labelledby="what_product_s__do_you_sell__choose_all_that_apply__-label-4" aria-describedby="what_product_s__do_you_sell__choose_all_that_apply__-description" aria-required="false" aria-checked="false"
value="Life"><span class="hs-form__field__checkbox__label-span">Life</span></label></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="hs-form__row">
<div id="hsRecaptchaTarget">
<div class="grecaptcha-badge" data-style="inline" style="width: 256px; height: 60px; box-shadow: gray 0px 0px 5px;">
<div class="grecaptcha-logo"><iframe title="reCAPTCHA"
src="https://www.google.com/recaptcha/enterprise/anchor?ar=1&k=6Ld_ad8ZAAAAAAqr0ePo1dUfAi0m4KPkCMQYwPPm&co=aHR0cHM6Ly9zaGFyZS5oc2Zvcm1zLmNvbTo0NDM.&hl=en&v=3TZgZIog-UsaFDv31vC4L9R_&size=invisible&badge=inline&cb=g61f2fv1m5qr"
width="256" height="60" role="presentation" name="a-1re8udw7kxde" frameborder="0" scrolling="no"
sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"></iframe></div>
<div class="grecaptcha-error"></div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div><iframe style="display: none;"></iframe>
</div>
</div>
</div>
<div class="hs-form__row">
<div class="hs-form__actions"><button type="submit" name="Submit" class="hs-form__actions__submit">Submit</button></div>
</div>
<div class="hs-form__row">
<div class="hs-form__virality-link"><img src="https://js.hsforms.net/sproket.png" class="hs-form__virality-link__sproket" alt=""><span class="hs-form__virality-link__text"><span>Create your own
</span><a target="_blank" rel="noopener noreferrer" href="https://app.hubspot.com/signup-hubspot/marketing?hubs_medium=virality&hubs_campaign=hubspot-forms-virality&hubs_id=forms-branding-control&hubs_source=share.hsforms.com&intent=marketingFreeForms&opt_sidebar=forms" class="hs-form__virality-link__text__link"><span>free form with HubSpot</span></a></span>
</div>
</div>
</form>Text Content
Skip to form Email First name Last name Phone number Company name Message Information you are requesting? Choose all that apply.: New Final Expense RX Discount Drug Card What product(s) do you sell? Choose all that apply.: Health/Under 65 Medicare/65 and over Other Life Submit Create your own free form with HubSpot