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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">
  <div class="row">
    <div class="col-6">
      <input type="text" id="name" name="name" placeholder="Full name">
    </div>
    <div class="col-6">
      <input type="email" id="email" name="email" placeholder="Email address">
    </div>
    <div class="col-6">
      <input type="text" id="dob" name="dob" placeholder="Your Date of Birth">
    </div>
    <div class="col-6">
      <input type="text" id="phone" name="phone_number" placeholder="Phone number">
    </div>
    <div class="col-6">
      <input type="text" id="state" name="state" placeholder="Your State">
    </div>
    <div class="col-6">
      <input type="text" id="city" name="city" placeholder="Your City">
    </div>
    <div class="col-12 mb-3">
      <textarea id="street" name="street" class="form-control" rows="5" placeholder="Your street"></textarea>
    </div>
    <input type="checkbox" name="agreement" value="1" style="height: 18px;width: 18px;margin: 4px 0px 0px 15px;">
    <div style="margin: -27px 50px 16px"> I agree , By submitting my cell phone number to receive automated sms/mms messages with more information or quote from U.SHA. 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>
    <div class="col-12 d-flex justify-content-center ">
      <button class="btn btn-primary" type="submit">Send</button>
    </div>
  </div>
</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

U.SHA
 * Home (current)
 * Terms Conditions (current)
 * Privacy Policy (current)


MARLON GARDNER

Hi My name is Marlon, I'm a Health advisor. I have access to all available plans
in the public and private market. Whatever your insurance needs i'll help you
find the plan that works best for you!


OUR EXPERTISE

CUSTOMIZED INSURANCE PLANS

Let me help you find the perfect insurance plan tailored to your specific needs
and budget. With access to all available plans in the public and private market,
I'll make sure you're covered for whatever life throws your way.

EXPERT HEALTH INSURANCE ADVICE

As a health advisor with extensive knowledge of the insurance industry, I can
guide you through the confusing world of health insurance. Together, we'll find
the best plan for your unique situation and ensure that you have comprehensive
coverage.

COMPREHENSIVE INSURANCE SERVICES

From health insurance to home insurance, I offer a wide range of insurance
services to provide complete protection for you and your family. Let me be your
trusted advisor in navigating the complex world of insurance and securing peace
of mind.


HOW TO REACH US

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


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