www.employeenavigator.com Open in urlscan Pro
45.60.45.174  Public Scan

Form analysis
1 forms found in the DOM

POST /benefits/Account/Register/Register

<form action="/benefits/Account/Register/Register" class="form" data-ajax="true" data-ajax-begin="signup_on_begin" data-ajax-cache="true" data-ajax-failure="signup_on_error" data-ajax-method="Post" data-ajax-mode="replace"
  data-ajax-success="register_on_success" data-ajax-update="#wrapper" method="post" role="form" novalidate="novalidate">
  <div class="col-md-12">
    <h3>First, let's find your company record</h3>
    <br>
    <div class="form-group">
      <label class="text-primary control-label" for="FirstName">First Name</label>
      <div class="controls">
        <input class="form-control" data-val="true" data-val-required="*" id="FirstName" name="FirstName" type="text" value="">
        <span class="text-danger field-validation-valid" data-valmsg-for="FirstName" data-valmsg-replace="true"></span>
      </div>
    </div>
    <div class="form-group">
      <label class="text-primary control-label" for="LastName">Last Name</label>
      <div class="controls">
        <input class="form-control" data-val="true" data-val-required="*" id="LastName" name="LastName" type="text" value="">
        <span class="text-danger field-validation-valid" data-valmsg-for="LastName" data-valmsg-replace="true"></span>
      </div>
    </div>
    <div class="form-group">
      <label class="text-primary control-label" for="CompanyIdentifier">Company Identifier</label>
      <br><em><small class="label-plain text-muted">(provided by HR)</small></em>
      <div class="controls">
        <input class="form-control" data-val="true" data-val-required="*" id="CompanyIdentifier" name="CompanyIdentifier" type="text" value="">
        <span class="text-danger field-validation-valid" data-valmsg-for="CompanyIdentifier" data-valmsg-replace="true"></span>
      </div>
    </div>
    <div class="form-group">
      <label class="text-primary">PIN</label>
      <br>
      <em><small class="text-muted">(Last 4 Digits of SSN / ID)</small></em>
      <div class="controls">
        <input class="form-control" data-val="true" data-val-length="*" data-val-length-max="4" data-val-length-min="4" data-val-required="*" id="Last4OfSSN" maxlength="4" name="Last4OfSSN" type="text" value="">
        <span class="text-danger field-validation-valid" data-valmsg-for="Last4OfSSN" data-valmsg-replace="true"></span>
      </div>
    </div>
    <div class="form-group">
      <label class="text-primary control-label" for="BirthDate">Birth Date</label>
      <br><em><small class="text-muted">(mm/dd/yyyy)</small></em>
      <div class="controls">
        <input class="form-control" data-val="true" data-val-date="mm/dd/yyyy" data-val-required="*" id="BirthDate" name="BirthDate" type="text" value="">
        <span class="text-danger field-validation-valid" data-valmsg-for="BirthDate" data-valmsg-replace="true"></span>
      </div>
    </div>
    <div class="form-group">
      <div class="controls">
        <input id="btn_next" type="submit" value="Next »" class="btn btn-success" style="width:100%">
      </div>
    </div>
  </div>
  <input name="__RequestVerificationToken" type="hidden" value="CfDJ8CsHE4gye_NOv773ujGViWHhTweL-_2V4NdvXRzTJxzat7H2ZKQTH_n6P4fA9b1CyIUiq-73e2FUY8rCd3MXqA10VhYSvzT1-Ju1TLBnA4Q5r4K3ppwLoVaV9pkhPtslSAWYwW7-gHs_RPnCAIspiM8">
</form>

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VERIFY YOUR ACCOUNT


FIRST, LET'S FIND YOUR COMPANY RECORD


First Name

Last Name

Company Identifier
(provided by HR)

PIN
(Last 4 Digits of SSN / ID)

Birth Date
(mm/dd/yyyy)