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1 forms found in the DOM

POST submit.php

<form action="submit.php" method="post" id="offer_form">
  <input type="hidden" name="page" value="1">
  <input type="hidden" name="aid" value="1">
  <input type="hidden" name="offer_id" value="290">
  <input type="hidden" name="subid" value="">
  <input type="hidden" name="subid2" value="">
  <div class="input-row" id="treated">
    <label>Were you treated by a Medical Professional?</label>
    <select name="treated" style="display: none;">
      <option value=""></option>
      <option value="N">No</option>
      <option value="Y">Yes</option>
    </select>
    <div class="nice-select" tabindex="0"><span class="current"></span>
      <ul class="list">
        <li data-value="" class="option selected"></li>
        <li data-value="N" class="option">No</li>
        <li data-value="Y" class="option">Yes</li>
      </ul>
    </div>
  </div>
  <div class="input-row" id="injured">
    <label>Were you or a loved one injured in accident that was not your fault?</label>
    <select name="injured" style="display: none;">
      <option value=""></option>
      <option value="N">No</option>
      <option value="Y">Yes</option>
    </select>
    <div class="nice-select" tabindex="0"><span class="current"></span>
      <ul class="list">
        <li data-value="" class="option selected"></li>
        <li data-value="N" class="option">No</li>
        <li data-value="Y" class="option">Yes</li>
      </ul>
    </div>
  </div>
  <div class="input-row" id="hospitalized">
    <label>Did the accident require hospitalization or medical treatment?</label>
    <select name="hospitalized" style="display: none;">
      <option value=""></option>
      <option value="N">No</option>
      <option value="Y">Yes</option>
    </select>
    <div class="nice-select" tabindex="0"><span class="current"></span>
      <ul class="list">
        <li data-value="" class="option selected"></li>
        <li data-value="N" class="option">No</li>
        <li data-value="Y" class="option">Yes</li>
      </ul>
    </div>
  </div>
  <div class="input-row" id="has_lawyer">
    <label>Do you currently have a lawyer representing your injury claim?</label>
    <select name="has_lawyer" style="display: none;">
      <option value=""></option>
      <option value="N">No</option>
      <option value="Y">Yes</option>
    </select>
    <div class="nice-select" tabindex="0"><span class="current"></span>
      <ul class="list">
        <li data-value="" class="option selected"></li>
        <li data-value="N" class="option">No</li>
        <li data-value="Y" class="option">Yes</li>
      </ul>
    </div>
  </div>
  <div class="input-row" id="accident_type">
    <label>What type of accident occurred?</label>
    <select name="accident_type" style="display: none;">
      <option value=""></option>
      <option value="1">Auto Accident</option>
      <option value="2">Motorcycle Accident</option>
      <option value="3">Truck Accident</option>
      <option value="4">Medical Malpractice</option>
      <option value="5">Work Injury</option>
      <option value="6">Slip and Fall</option>
      <option value="7">Product Liability</option>
      <option value="8">Dog Bite</option>
    </select>
    <div class="nice-select" tabindex="0"><span class="current"></span>
      <ul class="list">
        <li data-value="" class="option selected"></li>
        <li data-value="1" class="option">Auto Accident</li>
        <li data-value="2" class="option">Motorcycle Accident</li>
        <li data-value="3" class="option">Truck Accident</li>
        <li data-value="4" class="option">Medical Malpractice</li>
        <li data-value="5" class="option">Work Injury</li>
        <li data-value="6" class="option">Slip and Fall</li>
        <li data-value="7" class="option">Product Liability</li>
        <li data-value="8" class="option">Dog Bite</li>
      </ul>
    </div>
  </div>
  <div class="input-row">
    <label>What was the date of your accident?</label>
    <input type="date" name="accident_date" id="accident_date">
  </div>
  <div class="input-row wide">
    <div class="input-wrapper">
      <textarea placeholder="Please Describe What Happened" name="description" id="description"></textarea>
    </div>
  </div>
  <div class="input-row wide">
    <input type="submit" value="Do I Qualify?">
  </div>
</form>

Text Content

ACCIDENT INJURY REPORT

“Get Paid for your Injuries!”


GET A FREE CASE EVALUATION TODAY

Were you treated by a Medical Professional? No Yes
 * 
 * No
 * Yes

Were you or a loved one injured in accident that was not your fault? No Yes
 * 
 * No
 * Yes

Did the accident require hospitalization or medical treatment? No Yes
 * 
 * No
 * Yes

Do you currently have a lawyer representing your injury claim? No Yes
 * 
 * No
 * Yes

What type of accident occurred? Auto Accident Motorcycle Accident Truck Accident
Medical Malpractice Work Injury Slip and Fall Product Liability Dog Bite
 * 
 * Auto Accident
 * Motorcycle Accident
 * Truck Accident
 * Medical Malpractice
 * Work Injury
 * Slip and Fall
 * Product Liability
 * Dog Bite

What was the date of your accident?



RESOURCES

 * Auto Accident
 * Motorcycle Accident
 * Truck Accident
 * Medical Malpractice
 * Work Injury
 * Slip and Fall
 * Product Liability
 * Dog Bite

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