ref.amaxinsurance.com Open in urlscan Pro
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Form analysis
1 forms found in the DOM

POST /Customer/SaveReferral

<form action="/Customer/SaveReferral" class="custom-form padding-bottom-80" id="form" method="post" novalidate="novalidate">
  <div class="row mt-4">
    <div class="col-md-6 col-sm-12">
      <h3>Your Information</h3>
      <div class="form-group">
        <label>Name</label>
        <input class="form-control" data-val="true" data-val-required="Enter Your Name" id="CustomerName" name="CustomerName" placeholder="Name" type="text" value="">
        <div class="error">
          <span class="field-validation-valid" data-valmsg-for="CustomerName" data-valmsg-replace="true"></span>
        </div>
      </div>
      <div class="form-group">
        <label>Email</label>
        <input class="form-control" data-val="true" data-val-regex="E-mail is not valid" data-val-regex-pattern="^([0-9a-zA-Z]([-.\w]*[0-9a-zA-Z])*@([0-9a-zA-Z][-\w]*[0-9a-zA-Z]\.)+[a-zA-Z]{2,9})$" id="CustomerEmail" name="CustomerEmail"
          placeholder="Email" type="text" value="" data-val-email="E-mail is not valid">
        <div class="error">
          <span class="field-validation-valid" data-valmsg-for="CustomerEmail" data-valmsg-replace="true"></span>
        </div>
      </div>
      <div class="form-group">
        <label>Phone Number</label>
        <input class="form-control" data-val="true" data-val-minlength="Please enter valid phone number." data-val-minlength-min="10" data-val-regex="Please enter valid phone number." data-val-regex-pattern="([0-9]+)"
          data-val-required="Enter Phone Number" id="CustomerPhone" maxlength="10" name="CustomerPhone" placeholder="Phone Number" type="text" value="">
        <div class="error">
          <span class="field-validation-valid" data-valmsg-for="CustomerPhone" data-valmsg-replace="true"></span>
        </div>
      </div>
      <div class="form-group">
        <label>Zip Code</label>
        <input class="form-control" data-val="true" data-val-regex="Enter valid zip Code." data-val-regex-pattern="([0-9]+)" id="Zip" name="ZipCode" type="text" value="">
        <div class="error">
          <span class="field-validation-valid" data-valmsg-for="ZipCode" data-valmsg-replace="true"></span>
        </div>
      </div>
    </div>
    <div class="col-md-6 col-sm-12">
      <h3>Who Would You Like to Refer?</h3>
      <div class="form-group">
        <label>Name</label>
        <input class="form-control" data-val="true" data-val-required="Enter Referral's Name" id="RefName" name="RefName" placeholder="Name" type="text" value="">
        <div class="error">
          <span class="field-validation-valid" data-valmsg-for="RefName" data-valmsg-replace="true"></span>
        </div>
      </div>
      <div class="form-group">
        <label>Email</label>
        <input class="form-control" data-val="true" data-val-regex="E-mail is not valid" data-val-regex-pattern="^([0-9a-zA-Z]([-.\w]*[0-9a-zA-Z])*@([0-9a-zA-Z][-\w]*[0-9a-zA-Z]\.)+[a-zA-Z]{2,9})$"
          data-val-remote="This email address is already referred." data-val-remote-additionalfields="*.RefEmail" data-val-remote-url="/Validation/ValidateEmail" id="RefEmail" name="RefEmail" placeholder="Email" type="text" value=""
          data-val-email="E-mail is not valid">
        <div class="error">
          <span class="field-validation-valid" data-valmsg-for="RefEmail" data-valmsg-replace="true"></span>
        </div>
      </div>
      <div class="form-group">
        <label>Phone Number</label>
        <input class="form-control" data-val="true" data-val-minlength="Please enter valid phone number." data-val-minlength-min="10" data-val-regex="Please enter valid phone number." data-val-regex-pattern="([0-9]+)"
          data-val-remote="This phone number is already referred." data-val-remote-additionalfields="*.RefPhone" data-val-remote-url="/Validation/ValidatePhone" data-val-required="Enter Phone Number" id="RefPhone" maxlength="10" name="RefPhone"
          placeholder="Phone Number" type="text" value="">
        <div class="error">
          <span class="field-validation-valid" data-valmsg-for="RefPhone" data-valmsg-replace="true"></span>
        </div>
      </div>
    </div>
    <div class="col-12">
    </div>
    <div class="col-sm-12 text-center">
      <button type="submit" value="Add" name="type" class="btn btn-danger">Submit</button>
      <button type="submit" value="AddMore" name="type" class="btn btn-danger">Save and Add More</button>
    </div>
  </div>
  <input name="__RequestVerificationToken" type="hidden" value="CfDJ8G2cegxO4Q1IgM_RwoaSryHsy9fWqCov7_IXYEfRoX2zz-k7OAPI01n7xWEl30nvO6ugR-quu68MwhFQbDqqaFUtAdyrI9in_5plBFLtxIclo0ht4JjdgKLw3fzHWYL9opauqU_LesfTN5y8Z4sjPiw">
</form>

Text Content

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 * Home
 * Refer A Friend
 * Agent


MAX REWARDS REFERRAL PROGRAM


REFER A FRIEND FOR
A CHANCE TO WIN


HOW TO ENTER

 1. Refer a friend or family member with the form below.
 2. Eligible referrals must receive an auto quote from A-MAX.
 3. Follow us on Facebook @amaxinsurance and check your email to see if you win.

Each week, A-MAX will randomly select winners. Eligible winners will be
contacted by phone or email and provided instructions on claiming their prize.

Refer a Friend Request a Quote


REFER A FRIEND


YOUR INFORMATION

Name

Email

Phone Number

Zip Code



WHO WOULD YOU LIKE TO REFER?

Name

Email

Phone Number


Submit Save and Add More

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