- スキャンID：
- 7ae98dd9-84da-4e88-abaf-bfaf7a3ce754終了
- 送信済みURL：
- https://groupbenefitsplace.com/
- レポート終了日：
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| 名前 | 規模 |
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| $ | function |
| jQuery | function |
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HTML
未加工のHTMLページ本文
<!DOCTYPE html><html><head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1">
<title>American Employee Services</title>
<style type="text/css">
input:required:invalid, input:focus:invalid {
background-image: url(/images/invalid.png);
background-position: right top;
background-repeat: no-repeat;
}
input:required:valid {
background-image: url(/images/valid.png);
background-position: right top;
background-repeat: no-repeat;
}
</style>
<link href="css/style-ltc.css" rel="stylesheet">
<script type="text/javascript" src="https://ajax.googleapis.com/ajax/libs/jquery/1.6.2/jquery.min.js"></script>
<script type="text/javascript" src="js/jquery.maskedinput-1.3.min.js"></script>
<script type="text/javascript" src="js/phonemask.js"></script>
<script type="text/javascript" charset="utf-8">
jQuery(function($) {
$.mask.definitions['~']='[+-]';
$('#date').mask('99/99/9999');
});
</script>
</head>
<body>
<div class="color-border">
</div>
<div id="maincontainer">
<div id="topsection"><img src="images/head.jpg" alt="American Employee Services" align="left" style="width:100%; max-width:750px; height:auto;"></div>
<div style="clear:both;"></div>
<div id="contentwrapper">
<div id="contentcolumn">
<div class="innertube">
<div class="wrapper">
<div id="main" style="padding:0 0 0 0;" class="clearfix">
<!-- Form -->
<form action="quote.php" method="post" enctype="application/x-www-form-urlencoded" id="contact-form">
<input type="hidden" name="s" value="AES">
<input type="hidden" name="a" value="AES">
<h2>Long Term Care Insurance - Information Request</h2>
<h4>Please complete the form below and our representative will contact you.<br> <span style="color:#F00">* indicates required fields</span> </h4>
<div class="form-row">
<div class="column-half">
<label>
<span><h5>*</h5> First Name:</span>
<input placeholder="Please enter your first name" type="text" tabindex="1" name="first_name" data-validate="required" required="" autofocus="">
</label>
</div>
<div class="column-half">
<label>
<span><h5>*</h5> Last Name:</span>
<input placeholder="Please enter your last name" type="text" tabindex="2" name="last_name" data-validate="required" required="">
</label>
</div>
</div>
<div class="form-row">
<div class="column-half">
<label>
<span><h5>*</h5> City:</span>
<input placeholder="Please enter your city" type="text" tabindex="3" name="city" required="">
</label>
</div>
<div class="column-half">
<label>
<span><h5>*</h5> State:</span>
<select name="Market" id="Market" type="select" tabindex="4" required="">
<option value="default">Choose...</option>
<option value="AL">Alabama</option>
<option value="AK">Alaska</option>
<option value="AZ">Arizona</option>
<option value="AR">Arkansas</option>
<option value="CA">California</option>
<option value="CO">Colorado</option>
<option value="CT">Connecticut</option>
<option value="DE">Delaware</option>
<option value="DC">District Of Columbia</option>
<option value="FL">Florida</option>
<option value="GA">Georgia</option>
<option value="HI">Hawaii</option>
<option value="ID">Idaho</option>
<option value="IL">Illinois</option>
<option value="IN">Indiana</option>
<option value="IA">Iowa</option>
<option value="KS">Kansas</option>
<option value="KY">Kentucky</option>
<option value="LA">Louisiana</option>
<option value="ME">Maine</option>
<option value="MD">Maryland</option>
<option value="MA">Massachusetts</option>
<option value="MI">Michigan</option>
<option value="MN">Minnesota</option>
<option value="MS">Mississippi</option>
<option value="MO">Missouri</option>
<option value="MT">Montana</option>
<option value="NE">Nebraska</option>
<option value="NV">Nevada</option>
<option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option>
<option value="NM">New Mexico</option>
<option value="NY">New York</option>
<option value="NC">North Carolina</option>
<option value="ND">North Dakota</option>
<option value="OH">Ohio</option>
<option value="OK">Oklahoma</option>
<option value="OR">Oregon</option>
<option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option>
<option value="SC">South Carolina</option>
<option value="SD">South Dakota</option>
<option value="TN">Tennessee</option>
<option value="TX">Texas</option>
<option value="UT">Utah</option>
<option value="VT">Vermont</option>
<option value="VA">Virginia</option>
<option value="WA">Washington</option>
<option value="WV">West Virginia</option>
<option value="WI">Wisconsin</option>
<option value="WY">Wyoming</option>
</select>
</label>
</div>
</div>
<div style="clear:both;"></div>
<div class="form-row">
<div class="column-half">
<label>
<span><h5>*</h5> Zip Code:</span>
<input placeholder="Please enter your zip" type="text" tabindex="5" name="zip" required="">
</label>
</div>
<div class="column-half">
<label>
<span><h5>*</h5> Age of Insured:</span>
<input placeholder="Please enter age" type="text" tabindex="6" name="age" required="">
</label>
</div>
</div>
<div style="clear:both;"></div>
<div class="form-row">
<div class="column-half">
<label>
<span><h5>*</h5> Email Address:</span>
<input placeholder="Please enter your email" type="email" tabindex="7" name="email" required="">
</label>
</div>
<div class="column-half">
<label>
<span><h5>*</h5>
Cell Phone:</span>
<input id="txtPhoneNumber" name="FancyPhoneNumber" tabindex="8" placeholder="(XXX) XXX-XXXX" type="text" required="">
</label>
</div>
</div>
<input id="txtHiddenPhoneNumber" name="PhoneNumber" type="hidden" value="">
<div>
<button name="submit" type="submit" id="contact-submit">Send</button>
</div>
</form>
<!-- /Form -->
</div>
</div>
<script src="js/scripts.js"></script>
</div>
</div>
</div>
<div id="footer">
<p><strong>AES - American Employee Services</strong></p>
<p>953 Pavilion Street Suite #3 Cincinnati, OH 45202 </p>
<p>Tol Free: 866-242-6940 | <a href="http://www.americaneducational.us/email.html">Unsubscribe your Email</a></p>
</div>
</div>
</body></html>