garantiepl.hankook.fr Open in urlscan Pro
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POST

<form method="post">
  <div class="row py-2 justify-content-center">
    <div class="col col-lg-2 text-center text-md-end pe-4">
      <img src="/build/images/superhero.png" class="img-fluid mt-5" alt="Assureclair">
    </div>
    <div class="col-12 col-md-8 col-lg-5 px-4 px-md-0">
      <div class="row mt-4">
        <div class="ms-1 fs-6 dark-grey-text" style="font-weight: 500">N° de contrat <em class="fs-6 red-text">*</em></div>
        <div><input type="text" name="reference" id="inputReference" class="form-control" required=""></div>
      </div>
      <div class="row mt-2">
        <div class="ms-1 fs-6 dark-grey-text" style="font-weight: 500">Prénom <em class="fs-6 red-text">*</em></div>
        <div><input type="text" name="firstname" id="inputFirstname" class="form-control" required=""></div>
      </div>
      <div class="row mt-2">
        <div class="ms-1 fs-6 dark-grey-text" style="font-weight: 500">Nom <em class="fs-6 red-text">*</em></div>
        <div><input type="text" name="lastname" id="inputLastname" class="form-control" required=""></div>
      </div>
      <div class="row mt-1 justify-content-between">
        <div class="col-12 fs-9 text-end">
          <span class="red-text">* Champs obligatoires</span>
        </div>
      </div>
      <input type="hidden" name="_csrf_token" value="087932d56d7103fef948.07ieiAwOuOGPlgq8e3wLWiZ8K3jKiS5zY5D_qUazEE4.gojYxm5Z-dn6zGXIIxNBL1A5QDak7nkqBPOV5BfZX3yV-8f5f33Om9nOMg">
      <div class="row mt-3 mb-5 px-2">
        <button class="btn btn-primary text-uppercase fw-bold py-2 fs-6" type="submit">Connexion</button>
      </div>
    </div>
  </div>
</form>

Text Content

SERVICE COMMERCIAL
0811 140 126
Service 0,06 € / min + prix appel
N° de contrat *

Prénom *

Nom *

* Champs obligatoires
Connexion
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