carer.carerinsure.co.uk Open in urlscan Pro
185.147.208.82  Public Scan

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POST

<form method="POST">
  <div class="row mt-4">
    <div class="col-sm-12 col-md-4">
      <label for="title">Title</label>
    </div>
    <div class="col-sm-12 col-md-4">
      <select name="title" class="title form-select" id="title" style="">
        <option value="" disabled="" selected="">Please select a title</option>
        <option value="Miss">Miss</option>
        <option value="Mrs">Mrs</option>
        <option value="Ms">Ms</option>
        <option value="Mr">Mr</option>
        <option value="Mx">Mx</option>
      </select>
    </div>
  </div>
  <div class="row mt-4">
    <div class="col-sm-12 col-md-4">
      <label for="FirstName">First name</label>
    </div>
    <div class="col-sm-12 col-md-4">
      <input type="text" id="firstName" name="first-name" class="forenameCapitalization form-control" value="" style="">
    </div>
  </div>
  <div class="row mt-4">
    <div class="col-sm-12 col-md-4">
      <label for="surname">Surname</label>
    </div>
    <div class="col-sm-12 col-md-4">
      <input type="text" id="surname" name="surname" class="surnameCapitalization form-control" value="" style="">
    </div>
  </div>
  <div class="row mt-4">
    <div class="col-sm-12 col-md-4">
      <label for="email">Email <span class="tooltip-ex">
          <svg xmlns="http://www.w3.org/2000/svg" style="" width="22" height="22" fill="currentColor" class="bi bi-info-circle" viewBox="0 0 16 16">
            <path d="M8 15A7 7 0 1 1 8 1a7 7 0 0 1 0 14zm0 1A8 8 0 1 0 8 0a8 8 0 0 0 0 16z"></path>
            <path
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            </path>
          </svg>
          <span class="tooltip-ex-text"> This is where we will send your policy documents. </span>
        </span>
      </label>
    </div>
    <div class="col-sm-12 col-md-4">
      <input type="text" id="email" name="email" value="" class="form-control" style="">
    </div>
  </div>
  <div class="row mt-4">
    <div class="col-sm-12 col-md-4">
      <label for="phoneNumber">Phone number</label>
    </div>
    <div class="col-sm-12 col-md-4">
      <input type="text" id="phoneNumber" name="phone-number" value="" class="form-control" style="">
    </div>
  </div>
  <div class="row" id="addressSection">
    <div class="row" style="">
      <div class="col-m-12 col-md-4" id="displayAddressLabel" style="display: none;">
        <label>Address</label>
      </div>
      <div class="col-m-12 col-md-4" id="hiddenAddressLabel" style="display: none;">
        <label id="addressSubTitleLabelTwo">Address</label>
      </div>
      <div class="col-sn-12 col-md-4" id="addressRows" style="display: none;">
        <div class="row">
          <div class="col-sm-12">
            <input type="text" id="addressLineOne" name="address-line-one" value="" class="form-control" placeholder="Address line one" style="">
          </div>
        </div>
        <div class="row" id="addressLineTwoContainer">
          <div class="col-sm-12 mt-4">
            <input type="text" id="addressLineTwo" name="address-line-two" value="" class="form-control" placeholder="Address line two">
          </div>
        </div>
        <div class="row">
          <div class="col-sm-12 mt-4" id="postTownContainer">
            <input type="text" id="postTown" name="post-town" value="" class="form-control" placeholder="Town/city" style="">
          </div>
        </div>
        <div class="row">
          <div class="col-sm-12 mt-4" id="postCodeContainer">
            <input type="text" id="postcode" name="postcode" value="" class="form-control" placeholder="Postcode" style="">
          </div>
        </div>
      </div>
    </div>
  </div>
  <div class="row mt-4" id="addressContainer">
    <div class="col-m-12 col-md-4">
      <label id="addressSubTitleLabel">Address</label>
    </div>
    <div class="col-sm-12 col-md-4 autocomplete-container" id="autocompleteContainer">
      <input type="search" id="txt_search" name="address-input" class="form-control" placeholder="Type an address..." autocomplete="off" autocapitalize="off" autocorrect="off" spellcheck="false">
      <div id="suggestion_list" class="suggestions-dropdown"></div>
    </div>
  </div>
  <div class="row mt-3" id="enterAddressContainer">
    <div class="col-sm-12 col-md-4"></div>
    <div class="col-sm-12 col-md-4">
      <div class="row">
        <div class="col-sm-12">
          <label class="form-check-label" for="enterAddress">
            <input type="checkbox" id="enterAddress" name="input-address" class="form-check-input"> Enter address manually </label>
        </div>
      </div>
    </div>
  </div>
  <div class="mt-3" id="addressNote">
    <div class="row">
      <div class="col-sm-12 col-md-4">
      </div>
      <div class="col-sm-12 col-md-4 small">
        <p><strong>Please note</strong>:<br>1. We are unable to cover anyone who resides in the Channel Islands.<br>2. If you reside on the Isle of Man, please contact us for a quote.</p>
      </div>
    </div>
  </div>
  <div class="row mt-4">
    <div class="col-sm-12 col-md-4">
      <label for="dateOfBirth">Date of birth</label>
    </div>
    <div class="col-sm-12 col-md-4">
      <div class="row">
        <div class="col">
          <input type="text" class="form-control" name="date-of-birth-day" id="dateOfBirthDay" maxlength="2" placeholder="DD" value="" style="">
        </div>
        <div class="col">
          <input type="text" class="form-control" name="date-of-birth-month" id="dateOfBirthMonth" maxlength="2" placeholder="MM" value="" style="">
        </div>
        <div class="col">
          <input type="text" class="form-control" name="date-of-birth-year" id="dateOfBirthYear" maxlength="4" placeholder="YYYY" value="" style="">
        </div>
      </div>
    </div>
  </div>
  <div class="row mt-4">
    <div class="col-sm-12 col-md-4">
      <label for="policyStartDateDay">Policy start date</label>
    </div>
    <div class="col-sm-12 col-md-4">
      <div class="row">
        <div class="col">
          <input type="text" class="form-control" name="policy-start-date-day" id="policyStartDateDay" maxlength="2" placeholder="DD" value="" style="">
        </div>
        <div class="col">
          <input type="text" class="form-control" name="policy-start-date-month" id="policyStartDateMonth" maxlength="2" placeholder="MM" value="" style="">
        </div>
        <div class="col">
          <input type="text" class="form-control" name="policy-start-date-year" id="policyStartDateYear" maxlength="4" placeholder="YYYY" value="" style="">
        </div>
      </div>
    </div>
  </div>
  <div class="row mt-4">
    <div class="col-sm-12 col-md-4">
      <label for="title">How did you hear about Carer Insure?</label>
    </div>
    <div class="col-sm-12 col-md-4">
      <select name="heard-from" class="title form-select" id="heardFrom" style="">
        <option value="" readonly="">Please select an option</option>
        <option value="Agency Introduction">Agency Introduction</option>
        <option value="Employer">Employer</option>
        <option value="Friend/Family">Friend/Family</option>
        <option value="Nannytax">Nannytax</option>
        <option value="Online Search">Online Search</option>
        <option value="Other">Other</option>
        <option value="Previous Client">Previous Client</option>
        <option value="Social Media">Social Media</option>
        <option value="Stafftax">Stafftax</option>
      </select>
    </div>
  </div>
  <div class="d-flex justify-content-end mt-4 mb-4">
    <div class="indexSubmitBtn mt-4">
      <button id="submitButton" name="submit" class="btn btn-custom inline mt-4">Next</button>
    </div>
  </div>
</form>

Text Content

 * 1
   
   Your Details

 * 2
   
   Declarations

 * 3
   
   Your Quote

We provide a non-advised service and will give you key information on the
features as well as the limitations/exclusions of the policy. This will help you
make an informed decision about our products and services. Full details will be
made available to you throughout the quotation. If you have questions about the
policy terms and conditions, please call our team.

The personal data you provide us within this form will be retained to provide
you with information about your quote. Our Privacy Notice lets you know how we
look after your data.

Please complete the following details.


YOUR DETAILS

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Title
Please select a title Miss Mrs Ms Mr Mx
First name

Surname

Email This is where we will send your policy documents.

Phone number

Address
Address

Address

Enter address manually

Please note:
1. We are unable to cover anyone who resides in the Channel Islands.
2. If you reside on the Isle of Man, please contact us for a quote.

Date of birth

Policy start date

How did you hear about Carer Insure?
Please select an option Agency IntroductionEmployerFriend/FamilyNannytaxOnline
SearchOtherPrevious ClientSocial MediaStafftax
Next

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Carer Insure is a trading name of Enable Limited who are an Appointed
Representative of Fish Administration Limited. Fish Administration Limited is
authorised and regulated by the Financial Conduct Authority, registered in
England and Wales under Company Registration Number 4214119. Registered Office;
Rossington's Business Park, West Carr Road, Retford, Nottinghamshire, DN22 7SW.
Enable Limited is registered in England and Wales under Company Registration
Number 04552449. Registered Office; 7th Floor, Telecom House, 125-135 Preston
Road, Brighton, England, BN1 6AF. Enable Limited's Firm Reference Number in
respect of Insurance activities is 468897 and Fish Administration Limited's Firm
Reference Number is 310172. These details can be checked on the Financial
Conduct Authority Register by visiting the FCA's Website at www.fca.org.uk or by
contacting the FCA on 0800 111 6768.