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Form analysis
2 forms found in the DOM

POST /create-contact.php

<form id="contact-form" class="contact__form" method="post" action="/create-contact.php">
  <input type="text" id="name" name="name" class="form-control mb-4 px-0" placeholder="Full name">
  <input type="email" id="email" name="email" class="form-control mb-4 px-0" placeholder="Email address">
  <input type="text" id="street" name="street" class="form-control mb-4 px-0" placeholder="Your street">
  <input type="text" id="city" name="city" class="form-control mb-4 px-0" placeholder="Your City">
  <input type="text" id="state" name="state" class="form-control mb-4 px-0" placeholder="Your State">
  <input type="text" id="dob" name="dob" class="form-control mb-4 px-0" placeholder="Your Date of Birth">
  <input type="text" id="phone" name="phone_number" class="form-control mb-4 px-0" placeholder="Phone number">
  <div>
    <input type="checkbox" name="agreement" value="1"> I agree , By submitting my cell phone number to receive automated sms/mms messages with more information or quote from JOSE GERMAN. Message frequency may vary. Reply STOP to cancel, Reply HELP
    for contact information. message and date rates may apply <a href="terms-conditions.html">Terms &amp; Conditions</a> | <a href="privacy-policy.html">Privacy Policy</a>
  </div>
  <button class="btn btn-primary" type="submit">Send</button>
</form>

POST /opt-contact.php

<form method="POST" action="/opt-contact.php">
  <div class="modal-body"><input type="text" class="form-control" placeholder="Phone" name="ph" required=""></div>
  <div class="modal-footer">
    <button type="button" class="btn btn-secondary closeModalButton">Close</button>
    <button type="submit" class="btn btn-primary">Submit</button>
  </div>
</form>

Text Content

JOSE GERMAN
 * Home
 * Terms Conditions
 * Privacy Policy


JOSE GERMAN




WHAT WE OFFER

I'm an Independent licensed health advisor in 29 states that provides the best
service possible when helping families and individuals know their options on
available healthcare plans and guide them to the most affordable choice that
also meets their health needs.



PERSONALIZED HEALTH INSURANCE PLANS

We offer personalized health insurance plans tailored to your specific needs and
budget. Our licensed advisors will guide you through the available options in 29
states, ensuring that you make the best choice for your health and finances.

AFFORDABLE HEALTHCARE SOLUTIONS

At JOSE GERMAN, we understand the importance of affordable healthcare for
families and individuals. That's why we specialize in finding the most
cost-effective options that still meet your health requirements. Let us help you
navigate the complex world of insurance.

EXPERT GUIDANCE ON HEALTHCARE PLANS

With our team of independent licensed advisors, you can trust JOSE GERMAN to
provide expert guidance on healthcare plans. We'll walk you through all
available options and help you find the ideal plan that meets both your health
needs and budget.
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TALK TO US

I agree , By submitting my cell phone number to receive automated sms/mms
messages with more information or quote from JOSE GERMAN. Message frequency may
vary. Reply STOP to cancel, Reply HELP for contact information. message and date
rates may apply Terms & Conditions | Privacy Policy
Send

JOSE GERMAN

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