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mcv3tqmhtw4blc3pmtks-b0mcl54.pub.sfmc-content.com Open in urlscan Pro
13.110.204.31  Public Scan

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Submitted URL: https://click.medicareinfo.cigna.com/?qs=bb0ede1a6a7a927d966e3063cd4b117dce5b1728424e14ddb4da5533c8ac6367390d18a542dcd1d242f303fde08d...
Effective URL: https://mcv3tqmhtw4blc3pmtks-b0mcl54.pub.sfmc-content.com/gokv2uvcdng?Contact_ID=65AA3FAF-0FD1-4DA6-90E0-DD94FBC2F0C9&EmailAddress=albrigl@ccf.org
Submission: On October 14 via api from US — Scanned from DE

Form analysis 1 forms found in the DOM

<form id="smartcapture-block-szgvl13pfyk" class="smartcapture-content-wrapper fuelux" novalidate="novalidate">
  <style id="smartcapture-styles-szgvl13pfyk">
    #smartcapture-block-szgvl13pfyk {
      background-color: transparent;
      margin-top: 0px;
      margin-right: 0px;
      margin-bottom: 0px;
      margin-left: 0px;
      padding-top: 0px;
      padding-right: 0px;
      padding-bottom: 0px;
      padding-left: 0px;
      text-align: center;
    }

    #smartcapture-block-szgvl13pfyk .smartcapture-controls {
      padding-bottom: 10px;
    }

    #smartcapture-block-szgvl13pfyk .smartcapture-controls .sc-formfield-label,
    #smartcapture-block-szgvl13pfyk .smartcapture-controls .sc-formfield-label label,
    #smartcapture-block-szgvl13pfyk .smartcapture-controls .sc-formfield-input label {
      color: #000000;
      font-family: Arial, Helvetica, sans-serif;
      font-size: 16px;
    }

    #smartcapture-block-szgvl13pfyk input[type="radio"],
    #smartcapture-block-szgvl13pfyk input[type="checkbox"] {
      margin: 0 0.4em 3px 0;
      vertical-align: middle;
    }

    #smartcapture-block-szgvl13pfyk input[type="text"],
    #smartcapture-block-szgvl13pfyk input[type="email"],
    #smartcapture-block-szgvl13pfyk input[type="number"] {
      width: 200px;
    }

    #smartcapture-block-szgvl13pfyk .sc-button {
      background-color: #009DDC;
      border-color: #009DDC;
      border-radius: 3px;
      border-style: solid;
      -webkit-border-radius: 3px;
      -moz-border-radius: 3px;
      color: #FFFFFF;
      font-family: Arial, Helvetica, sans-serif;
      font-size: 16px;
      line-height: normal;
      padding: 10px;
    }

    #smartcapture-block-szgvl13pfyk .smartcapture-submit-button-wrapper {
      padding-bottom: 10px;
      text-align: center;
    }

    #smartcapture-block-szgvl13pfyk .date-dropdown-select-boxes input {
      display: none;
    }

    #smartcapture-block-szgvl13pfyk .date-dropdown-select-boxes .select {
      max-height: 28em;
      max-width: 6em;
      overflow: auto;
    }
  </style>
  <table cellpadding="0" cellspacing="0" width="100%" role="presentation" style="min-width: 100%; " class="stylingblock-content-wrapper">
    <tbody>
      <tr>
        <td class="stylingblock-content-wrapper camarker-inner">
          <div class="smartcapture-controls">
            <div class="sc-formfield-label"></div>
            <div class="sc-formfield-input-wrapper">
              <div class="sc-formfield-input"><label><input type="checkbox" name="Promotional_Optin_Ind" data-field-type="Boolean">&nbsp;Promotional Messages</label></div>
            </div>
          </div>
        </td>
      </tr>
    </tbody>
  </table>
  <table cellpadding="0" cellspacing="0" width="100%" role="presentation" style="min-width: 100%; " class="stylingblock-content-wrapper">
    <tbody>
      <tr>
        <td class="stylingblock-content-wrapper camarker-inner">
          <div class="smartcapture-controls">
            <div class="sc-formfield-label"></div>
            <div class="sc-formfield-input-wrapper">
              <div class="sc-formfield-input"><label><input type="checkbox" name="Global_Opt_Out" data-field-type="Boolean">&nbsp;Opt-out of all communications</label></div>
            </div>
          </div>
        </td>
      </tr>
    </tbody>
  </table>
  <table cellpadding="0" cellspacing="0" width="100%" role="presentation" style="min-width: 100%; " class="stylingblock-content-wrapper">
    <tbody>
      <tr>
        <td class="stylingblock-content-wrapper camarker-inner">
          <div class="smartcapture-controls">
            <div class="sc-formfield-label"><label for="EmailAddress"></label></div>
            <div class="sc-formfield-input"><input type="hidden" name="EmailAddress" value="albrigl@ccf.org" data-field-type="EmailAddress" data-validation="email"></div>
          </div>
        </td>
      </tr>
    </tbody>
  </table>
  <table cellpadding="0" cellspacing="0" width="100%" role="presentation" style="min-width: 100%; " class="stylingblock-content-wrapper">
    <tbody>
      <tr>
        <td class="stylingblock-content-wrapper camarker-inner">
          <div class="smartcapture-controls">
            <div class="sc-formfield-label"><label for="Contact_ID"></label></div>
            <div class="sc-formfield-input"><input type="hidden" name="Contact_ID" value="65AA3FAF-0FD1-4DA6-90E0-DD94FBC2F0C9" data-field-type="Text"></div>
          </div>
        </td>
      </tr>
    </tbody>
  </table>
  <div class="smartcapture-submit-button-wrapper">
    <button type="submit" class="sc-button">Submit</button>
  </div>
  <script id="smartcapture-script-szgvl13pfyk">
    var scFormLoaded = function() {
      window.ScForm.init({
        "gearID": "szgvl13pfyk",
        "smartCaptureFormID": 19,
        "sourceKey": "E30D7062-95FA-483E-B634-06773A47BE44",
        "source": "dataExtension",
        "triggeredSend": "",
        "confirmationMessage": "<div style=\"text-align: center;\">\n\tThank you for your submission.</div>",
        "buttonText": "Submit",
        "formStyling": {
          "background-color": "transparent",
          "margin-top": "0px",
          "margin-right": "0px",
          "margin-bottom": "0px",
          "margin-left": "0px",
          "padding-top": "0px",
          "padding-right": "0px",
          "padding-bottom": "0px",
          "padding-left": "0px",
          "text-align": "center"
        },
        "fieldStyling": {
          "width": "200px"
        },
        "buttonStyling": {
          "background-color": "#009DDC",
          "border-color": "#009DDC",
          "border-radius": "3px",
          "border-style": "solid",
          "-webkit-border-radius": "3px",
          "-moz-border-radius": "3px",
          "color": "#FFFFFF",
          "font-family": "Arial, Helvetica, sans-serif",
          "font-size": "16px",
          "line-height": "normal",
          "padding": "10px"
        },
        "onSubmitGotoUrlType": 2
      });
    };
    window.appDomain = window.appDomain || '' || 'mc.s12.exacttarget.com';
    window.contentDetail = window.contentDetail || {
      "isSite": true,
      "mid": 534004190,
      "eid": 534004190,
      "pageID": 37,
      "siteID": 170894,
      "isMobile": "false"
    };
    if (!window.ScForm || !window.ScForm.init) {
      var head = document.getElementsByTagName('head')[0];
      var id = 'smartcapture-formjs-script';
      var script = document.getElementById(id);
      var domain = window.appDomain;
      var el;
      if (!script) {
        if (domain) {
          domain = '//' + domain;
        }
        el = document.createElement('script');
        el.async = true;
        el.id = id;
        el.src = domain + '/CloudPages/lib/smartcapture-formjs.js';
        el.onload = scFormLoaded;
        head.appendChild(el);
      } else {
        if (script.addEventListener) {
          script.addEventListener('load', scFormLoaded);
        } else if (script.attachEvent) {
          script.attachEvent('onload', scFormLoaded);
        }
      }
    } else {
      scFormLoaded();
    }
  </script>
</form>

Text Content

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