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Submitted URL: https://www.ac-ins.com/uirForms/commons/C/?id=6748&eid=58801356292&qid=2
Effective URL: https://www.ac-ins.com/uirForms/UIRProc/index_new.php?id=6748&eid=58801356292&qid=2
Submission: On September 20 via manual from SG — Scanned from DE
Effective URL: https://www.ac-ins.com/uirForms/UIRProc/index_new.php?id=6748&eid=58801356292&qid=2
Submission: On September 20 via manual from SG — Scanned from DE
Form analysis 1 forms found in the DOM
POST WebForm_Proc_B_UIR.php
<form action="WebForm_Proc_B_UIR.php" method="post" id="frmMain" class="form" onsubmit="return verifyOnSubmit()">
<input type="hidden" id="CampaignID" name="CampaignID" value="6748">
<input type="hidden" id="Leadsid" name="Leadsid" value="58801356292">
<input type="hidden" id="email" name="email" value="serge.david@brighthousefinancial.com">
<input type="hidden" id="CampaignType" name="CampaignType" value="1">
<input type="hidden" id="UpdatedEmail" name="UpdatedEmail" value="0">
<table id="tbl_form" border="0" width="100%" frame="void" rules="none" cellpadding="2" cellspacing="0">
<tbody>
<tr>
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: Arial, Verdana, Sans-Serif; font-weight: bold; font-size: 11px;" valign="top">First Name<span style="color: red">*</span></td>
<td style="font-weight: normal; font-size: 11px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;"><span id="spnFirstName"><input name="firstname" type="text" tabindex="1" size="20" maxlength="30"
value="Serge" id="firstname">
</span></td>
</tr>
<tr>
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: Arial, Verdana, Sans-Serif; font-weight: bold; font-size: 11px;" valign="top">Last Name<span style="color: red">*</span></td>
<td style="font-weight: normal; font-size: 11px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;"><span id="spnLastName"><input name="lastname" type="text" tabindex="2" size="20" maxlength="30"
value="David" id="lastname">
</span></td>
</tr>
<tr>
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: Arial, Verdana, Sans-Serif; font-weight: bold; font-size: 11px;" valign="top">Company</td>
<td style="font-weight: normal; font-size: 11px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;"><span id="spnAddress2"><b><strong><input name="company" type="text" tabindex="4" size="20" maxlength="60" value="BRIGHTHOUSE FINANCIAL">
</strong></b></span></td>
</tr>
<!-- ********************************************************** -->
<!-- State Drop Down Control... -->
<tr>
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: Arial, Verdana, Sans-Serif; font-weight: bold; font-size: 11px;" valign="top"> State<span style="color: red">*</span></td>
<td height="25" style="font-weight: normal; font-size: 11px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<span id="spn_State">
<select id="state" name="state" size="1" tabindex="6">
<option value="">Select State</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC" selected="selected">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
<option value="PR">Puerto Rico</option>
</select>
</span>
</td>
</tr>
<!-- END State Drop Down Control... -->
<!-- ********************************************************** -->
<!-- ********************************************************** -->
<!-- The rest of the Form BEFORE the Products section ... -->
<tr id="tr_Email">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: Arial, Verdana, Sans-Serif; font-weight: bold; font-size: 11px;" valign="top"> Email</td>
<td style="font-weight: normal; font-size: 11px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<span id="spn_Email" style="font-weight: bold; font-size: 11px; vertical-align: middle; font-family: Arial, Verdana, Sans-Serif; text-align: left">serge.david@brighthousefinancial.com</span>
<br>
<span id="spn_UpdateEmail" style="font-weight: bold; font-size: 10px; vertical-align: middle; font-family: Arial, Verdana, Sans-Serif; text-align: right"> (To update your email address,
<a href="/UpdP/ChangeEmailAddr.php?id=6748&eid=58801356292"><strong>CLICK HERE</strong></a>)</span>
</td>
</tr>
<tr>
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: Arial, Verdana, Sans-Serif; font-weight: bold; font-size: 11px;" valign="top">Phone<span style="color: red">*</span></td>
<td style="font-weight: normal; font-size: 11px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;"><span id="spn_phone"><input name="phone" type="text" tabindex="9" size="20" maxlength="20"
value="9809495537" id="phone" onkeydown="javascript:backspacerDOWN(this,event);" onkeyup="javascript:backspacerUP(this,event);">
</span></td>
</tr>
<tr>
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: Arial, Verdana, Sans-Serif; font-weight: bold; font-size: 11px;" valign="top">Cell Phone</td>
<td style="font-weight: normal; font-size: 11px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;"><span id="spnCellPhone"><input name="cellphone" type="text" tabindex="10" size="20" maxlength="20" value=""
id="cellphone">
</span></td>
</tr>
<!-- ************************************************************************** -->
<!-- Interest Level Drop Down Control -->
<tr id="tr_InterestLevel">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: Arial, Verdana, Sans-Serif; font-weight: bold; font-size: 11px;" valign="top">Interest Level<span style="color: red">*</span></td>
<td style="font-weight: normal; font-size: 11px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<select id="interestLevel" name="interestLevel">
<option value="">--Please Select--</option>
<option value="Contact Me Now">Contact Me Now</option>
<option value="Need More Information">Need More Information</option>
<option value="Just Looking">Just Looking</option>
</select>
</td>
</tr>
<tr>
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: Arial, Verdana, Sans-Serif; font-weight: bold; font-size: 11px;" valign="top">Are you recruiting nationally?<span style="color: red">*</span></td>
<td style="font-weight: normal; font-size: 11px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left;">
<select id="recruitingNationally" name="recruitingNationally">
<option value="">--Please Select--</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
<option value="Maybe">Maybe</option>
</select>
</td>
</tr>
<tr>
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: Arial, Verdana, Sans-Serif; font-weight: bold; font-size: 11px;" valign="top"> Comments:</td>
<td style="font-weight: normal; font-size: 11px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left">
<textarea name="comment" rows="2" cols="25" tabindex="<br />
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1" id="comment"></textarea>
</td>
</tr>
<tr id="tr_RowSpacer3">
<td id="td_RowCellSpacer3Left"> </td>
<td id="td_RowCellSpacer3Right" style="font-weight: normal; font-size: 11px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: left"> </td>
</tr>
<!--
<tr id="tr_OptIn">
<td align="left" style="vertical-align: text-top; width: 25%; text-align: left; font-family: Arial, Verdana, Sans-Serif; font-weight: bold; font-size: 11px;" valign="top">
<td id="td_RowCellOptIn" style="font-weight: normal; font-size: 11px; vertical-align: text-top; font-family: Arial, Verdana, Sans-Serif; text-align: center">
<span id="spn_Optin"><strong><font face="Arial" size="1">
I agree to receive future mailing<input type="checkbox" id="Optin" name="Optin" value="1" checked="checked" tabindex="<br />
<b>Notice</b>: Undefined variable: tabindex in <b>/var/www/html/09_Clients/uirForms/UIRProc/SSI_Templates/WebForm_B_UIR/FormSection_B.php</b> on line <b>141</b><br />
2" />
</font></strong></span>
</td>
</tr>
-->
<tr>
<td></td>
<td> <input type="submit" id="Submit" name="Submit" value="Submit" class="btn tertiary" tabindex="<br />
<b>Notice</b>: Undefined variable: tabindex in <b>/var/www/html/09_Clients/uirForms/UIRProc/SSI_Templates/WebForm_B_UIR/FormSection_B.php</b> on line <b>149</b><br />
3"></td>
</tr>
</tbody>
</table>
<!--<div id="div_LastMessageAndSubmit">
<p style="text-align: center" id="p_Submit">
<input type="image" border="0" src="/uirForms/UIRProc/SSI_Templates/WebForm_B/images/submit.png" width="262" height="40" name="Submit" id="Submit" tabindex="<br />
<b>Notice</b>: Undefined variable: tabindex in <b>/var/www/html/09_Clients/uirForms/UIRProc/SSI_Templates/WebForm_B_UIR/FormSection_B.php</b> on line <b>155</b><br />
3" />
</p>
<p style="margin-top: 0; margin-bottom: 0" align="center"> </p>
</div>-->
</form>Text Content
Recruiting producers that actually place business is a challenge. Generate Quality Leads with our Exclusive List of Subscribers. We'll help you get business placed - not just contracted! Are you: Looking to Recruit More Producers? Looking to Generate Quality Leads? If you answered YES then Complete the Form NOW or give us a call at 702-458-9833 ext 101! Hurry... our schedule books fast! Recruit More Nationally Today Get Our Full List of Referrals by Completing the Form Please Complete the Form Now for More Information! * Required Fields First Name* Last Name* Company State* Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Email serge.david@brighthousefinancial.com (To update your email address, CLICK HERE) Phone* Cell Phone Interest Level* --Please Select-- Contact Me Now Need More Information Just Looking Are you recruiting nationally?* --Please Select-- Yes No Maybe Comments: Click Here for Our Spam & Privacy Policy