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52.85.61.90  Public Scan

Form analysis
1 forms found in the DOM

Name: surveyForm — POST

<form name="surveyForm" action="" method="post" enctype="multipart/form-data" novalidate="" data-survey-page-form="">
  <div class="questions clearfix">
    <div class="question-row clearfix 
                   ">
      <div data-question-type="open_ended_single" data-rq-question-type="open_ended" class="question-container
    
        
        
    
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        <div id="question-field-179523817" data-qnumber="1" data-qdispnumber="1" data-question-id="179523817" class=" question-open-ended-single qn question single question-required">
          <h3 class="screenreader-only">Question Title</h3>
          <div class=" question-fieldset question-legend">
            <h4 id="question-title-179523817" class=" question-title-container ">
              <span class="required-asterisk notranslate"> * </span>
              <span class="question-number notranslate"> 1<span class="question-dot">.</span>
              </span>
              <span class="user-generated notranslate
                "> Please enter the plan reference number located at the bottom left-hand corner of the letter you received.</span>
            </h4>
            <div class="question-body clearfix notranslate ">
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                <div class="question-body open-ended-single"><input aria-labelledby="question-title-179523817" id="179523817" aria-required="true" data-sm-open-single="true" maxlength="20000" class="wds-input wds-input--lg qt-input_text text"
                    name="179523817" size="50" value=""></div>
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    </div>
    <div class="question-row clearfix 
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      <div data-question-type="single_choice_menu" data-rq-question-type="dropdown" class="question-container
    
        
        
    
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        <div id="question-field-179523856" data-qnumber="2" data-qdispnumber="2" data-question-id="179523856" class=" question-single-choice-select qn question menu">
          <h3 class="screenreader-only">Question Title</h3>
          <fieldset class=" question-fieldset">
            <legend class="question-legend">
              <h4 id="question-title-179523856" class="
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                <span class="required-asterisk notranslate"> * </span>
                <span class="question-number notranslate"> 2<span class="question-dot">.</span>
                </span>
                <span class="user-generated notranslate
                "> Which state do you live in?</span>
              </h4>
            </legend>
            <div class="question-body clearfix notranslate ">
              <select id="179523856" name="179523856" aria-labelledby="question-title-179523856" class="select no-touch" data-sm-select="">
                <option value=""></option>
                <option value="1302862471" class="user-generated"> Arizona </option>
                <option value="1302862472" class="user-generated"> California </option>
                <option value="1302862473" class="user-generated"> Colorado </option>
                <option value="1302862474" class="user-generated"> Connecticut </option>
                <option value="1302862476" class="user-generated"> Florida </option>
                <option value="1302862477" class="user-generated"> Georgia </option>
                <option value="1302862478" class="user-generated"> Iowa </option>
                <option value="1302862479" class="user-generated"> Indiana </option>
                <option value="1302862480" class="user-generated"> Kentucky </option>
                <option value="1302862481" class="user-generated"> Louisiana </option>
                <option value="1302862482" class="user-generated"> Maine </option>
                <option value="1302862483" class="user-generated"> Missouri </option>
                <option value="1302862484" class="user-generated"> Montana </option>
                <option value="1302862485" class="user-generated"> New Hampshire </option>
                <option value="1302862486" class="user-generated"> New Jersey </option>
                <option value="1302862487" class="user-generated"> Nevada </option>
                <option value="1302862488" class="user-generated"> New York </option>
                <option value="1302862489" class="user-generated"> Ohio </option>
                <option value="1302862491" class="user-generated"> Tennessee </option>
                <option value="1302862492" class="user-generated"> Texas </option>
                <option value="1302862493" class="user-generated"> Virginia </option>
                <option value="1302862494" class="user-generated"> Washington </option>
                <option value="1302862495" class="user-generated"> Wisconsin </option>
                <option value="1302862496" class="user-generated"> My state isn't listed </option>
              </select>
            </div>
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      </div>
    </div>
    <div class="question-row clearfix 
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      <div data-question-type="presentation_descriptive_text" data-rq-question-type="presentation_text" class="question-container
    
        
        
    
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        <div id="question-field-179523857" data-qnumber="3" data-qdispnumber="" data-question-id="179523857" class=" question-presentation-text qn question descriptive_text">
          <div class="question-body-font-theme question-presentation-text user-generated">
            <span class="user-generated notranslate
                ">
              <div style="text-align: center;">We value your opinion. Call us today to give additional feedback:<br>833-565-0103 TTY 711, 8am-11pm EST Mon-Fri</div>
            </span>
          </div>
        </div>
      </div>
    </div>
  </div>
  <div class="survey-submit-actions center-text clearfix">
    <button type="submit" data-submit-page-button="" class="btn small next-button survey-page-button user-generated notranslate"> Next </button>
  </div>
  <input type="hidden" id="survey_data" name="survey_data"
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  <input type="hidden" data-response-quality="" id="response_quality_data" name="response_quality_data" value="{}">
  <input type="hidden" id="is_previous" name="is_previous" value="false">
  <input type="hidden" id="is_changing_language" name="is_changing_language" value="">
  <input type="hidden" id="disable_survey_buttons_on_submit" name="disable_survey_buttons_on_submit" value="">
</form>

Text Content

 * English
 * Español

English

 
2% of survey complete.


QUESTION TITLE

* 1. PLEASE ENTER THE PLAN REFERENCE NUMBER LOCATED AT THE BOTTOM LEFT-HAND
CORNER OF THE LETTER YOU RECEIVED.




QUESTION TITLE

* 2. WHICH STATE DO YOU LIVE IN?

Arizona California Colorado Connecticut Florida Georgia Iowa Indiana Kentucky
Louisiana Maine Missouri Montana New Hampshire New Jersey Nevada New York Ohio
Tennessee Texas Virginia Washington Wisconsin My state isn't listed
We value your opinion. Call us today to give additional feedback:
833-565-0103 TTY 711, 8am-11pm EST Mon-Fri
Next

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