awaltakaful.drip.id
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188.114.96.3
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URL:
https://awaltakaful.drip.id/
Submission: On June 07 via api from US — Scanned from NL
Submission: On June 07 via api from US — Scanned from NL
Form analysis 1 forms found in the DOM
POST
<form method="POST" id="form-init">
<div class="px-6 py-3 bg-white">
<div class="mb-3 "><label class="block text-md font-semibold text-gray-700 mb-3 flex" for="">Nama <span class="true text-red-400 ml-1">*</span></label> <input name="name" required=""
class="focus:outline-none focus:ring-2 focus:ring-green-500 focus:border-transparent block appearance-none p-3 w-full max-w-full mb-1 text-base leading-normal bg-white text-gray-800 border-none ring-1 ring-gray-300 rounded" type="text"
placeholder="Nama Lengkap"></div>
</div>
<div class="px-6 py-3 bg-white">
<div class="mb-3 "><label class="block text-md font-semibold text-gray-700 mb-3 flex" for="">Email <span class="true text-red-400 ml-1">*</span></label> <input name="email" required=""
class="focus:outline-none focus:ring-2 focus:ring-green-500 focus:border-transparent block appearance-none p-3 w-full max-w-full mb-1 text-base leading-normal bg-white text-gray-800 border-none ring-1 ring-gray-300 rounded" type="text"
placeholder="Alamat Email"></div>
</div>
<div class="px-6 py-3">
<div class="mb-3"><label class="block text-md font-semibold text-gray-700 mb-3 flex" for="">No.WA <span class="text-red-400 ml-1 true">*</span></label>
<div class="flex" v-if="selected_dial_code"><select
class="focus:outline-none focus:ring-2 focus:ring-green-500 focus:border-transparent rounded-r-none appearance-none p-3 mb-1 text-base leading-normal bg-white text-gray-800 border-none ring-1 ring-gray-300 rounded">
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</select> <input name="phone" required=""
class="focus:outline-none focus:ring-2 focus:ring-green-500 focus:border-transparent block rounded-l-none appearance-none p-3 w-full max-w-full mb-1 text-base leading-normal bg-white text-gray-800 border-none ring-1 ring-gray-300 rounded"
type="text" placeholder="Nomor Whatsapp"></div>
</div>
</div>
<div class="px-0 py-0"><iframe class="w-full" id="youtube_9" frameborder="0" allowfullscreen="" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share"
referrerpolicy="strict-origin-when-cross-origin" title="E-Policy Asuransi Takaful Keluarga" width="640" height="360"
src="https://www.youtube.com/embed/BVGo0Y-jitA?playsinline=1&enablejsapi=1&origin=https%3A%2F%2Fawaltakaful.drip.id&widgetid=1" style="height: 439px;"></iframe> </div>
<div class="px-6 py-3">
<div>
<a href="https://bioqu.id/Takafuldanapendidikan" target="_blank" class="bg-green-500 w-full cursor-pointer text-lg mt-1 inline-flex items-center justify-center px-6 py-3 border border-transparent rounded-md shadow-sm text-base font-semibold text-white"><div class=""><div><svg xmlns="http://www.w3.org/2000/svg" class="h-6 w-6" fill="none" viewBox="0 0 24 24" stroke="currentColor"><path stroke-linecap="round" stroke-linejoin="round" stroke-width="2" d="M13 9l3 3m0 0l-3 3m3-3H8m13 0a9 9 0 11-18 0 9 9 0 0118 0z"></path></svg></div> </div> <span class="ml-1">KLIK DISINI</span></a>
</div>
</div>
<div class="px-6 py-3">
<div class="mb-4"><label class="block text-md font-semibold text-gray-700 mb-3 flex" for="">Jenis Kelamin<span class="text-red-400 ml-1 true">*</span></label>
<div class="grid grid-cols-1 sm:grid-cols-2"><label><input type="radio" required="" value="Laki-Laki"> Laki-Laki </label><label><input type="radio" required="" value="Perempuan"> Perempuan </label></div>
</div>
</div>
<div class="px-6 py-3">
<div class="mb-3"><label class="block text-md font-semibold text-gray-700 mb-3 flex" for="">Upload File <span class="hidden text-red-400 ml-1">*</span></label> <input
class="focus:outline-none focus:ring-2 focus:ring-green-500 focus:border-transparent block appearance-none p-3 w-full max-w-full mb-1 text-base leading-normal bg-white text-gray-800 border-none ring-1 ring-gray-300 rounded" type="file"></div>
</div>
<div class="px-6 py-3 bg-white">
<div class="mb-4 pr-6"><label class="block text-md font-semibold text-gray-700 mb-3 flex" for="">Isi Pesan<span class="text-red-400 ml-1 true">*</span></label> <textarea required="" style="width : 500px"
class="focus:outline-none focus:ring-2 focus:ring-green-500 focus:border-transparent block appearance-none p-3 max-w-full mb-1 text-base leading-normal bg-white text-gray-800 border-none ring-1 ring-gray-300 rounded"
placeholder="Masukan Pesan"></textarea></div>
</div>
<div class="px-6 py-3 bg-white">
<div class="mb-3 "><label class="block text-md font-semibold text-gray-700 mb-3 flex" for="">Tangga Lahir <span class="hidden text-red-400 ml-1">*</span></label> <input name="date"
class="focus:outline-none focus:ring-2 focus:ring-green-500 focus:border-transparent block appearance-none p-3 w-full max-w-full mb-1 text-base leading-normal bg-white text-gray-800 border-none ring-1 ring-gray-300 rounded" type="date"></div>
</div>
<div class="px-6 py-3">
<div class="my-3">
<h2 id="summary-heading" class="text-lg font-medium text-gray-900">Rincian Transaksi</h2>
<div class="mx-auto mt-3">
<div role="list" class="text-sm font-medium text-gray-900 divide-y divide-gray-200"> </div>
</div>
<dl class="text-sm font-medium text-gray-900 space-y-6">
<div class="flex items-center justify-between border-t border-gray-200 pt-6" style="border-top : 1px solid #e0e0e0">
<dt class="text-base">Total</dt>
<dd class="text-base">Rp.0</dd>
</div>
</dl>
</div>
</div>
<div class="px-6 py-3">
<div class="my-3">
<div>
<h2 class="text-lg font-medium text-gray-900 mb-3">Metode Pembayaran</h2>
</div>
</div>
</div>
<div class="px-6 py-3">
<div class="border border-dashed p-3 text-center">
<p class="text-gray-400">No items found</p>
</div>
</div>
<div class="px-6 py-3">
<div class="relative w-full">
<div class="space-y-1"><label class="block text-md font-semibold text-gray-700 mb-3 flex" for="">Kecamatan<span class="text-red-400 ml-1 true">*</span></label> <input
class="focus:outline-none focus:ring-2 focus:ring-green-500 focus:border-transparent block appearance-none p-3 w-full max-w-full mb-1 text-base leading-normal bg-white text-gray-800 border-none ring-1 ring-gray-300 rounded" type="text"
autocomplete="off" placeholder="Ketik Kecamatan Anda" id="custom-multiselect"></div>
</div>
</div>
<div class="px-6 py-3 bg-white">
<div class="mb-3 "><label class="block text-md font-semibold text-gray-700 mb-3 flex" for="">Tanggal Lahir <span class="hidden text-red-400 ml-1">*</span></label> <input name="birthday"
class="focus:outline-none focus:ring-2 focus:ring-green-500 focus:border-transparent block appearance-none p-3 w-full max-w-full mb-1 text-base leading-normal bg-white text-gray-800 border-none ring-1 ring-gray-300 rounded" type="date"></div>
</div>
</form>Text Content
Nama * Email * No.WA * + 345+1+1242+1246+1264+1268+1284+1340+1441+1473+1649+1664+1670+1671+1684+1758+1767+1784+1849+1868+1869+1876+1939+20+211+212+213+216+218+220+221+222+223+224+225+226+227+228+229+230+231+232+233+234+235+236+237+238+239+240+241+242+243+244+245+246+248+249+250+251+252+253+254+255+256+257+258+260+261+262+263+264+265+266+267+268+269+27+290+291+297+298+299+30+31+32+33+34+350+351+352+353+354+355+356+357+358+359+36+370+371+372+373+374+375+376+377+378+379+380+381+382+385+386+387+389+39+40+41+420+421+423+43+44+45+46+47+48+49+500+501+502+503+504+505+506+507+508+509+51+52+53+54+55+56+57+58+590+591+593+594+595+596+597+598+599+60+61+62+63+64+65+66+670+672+673+674+675+676+677+678+679+680+681+682+683+685+686+687+688+689+690+691+692+7+77+81+82+84+850+852+853+855+856+86+872+880+886+90+91+92+93+94+95+960+961+962+963+964+965+966+967+968+970+971+972+973+974+975+976+977+98+992+993+994+995+996+998 KLIK DISINI Jenis Kelamin* Laki-Laki Perempuan Upload File * Isi Pesan* Tangga Lahir * RINCIAN TRANSAKSI Total Rp.0 METODE PEMBAYARAN No items found Kecamatan* Tanggal Lahir *