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<!doctype html>
<html lang="en">
<head>
<meta charset="utf-8">
<meta name="viewport" content="width=device-width, initial-scale=1">
<title>Medicare - Get In Touch Form</title>
<link href="https://cdn.jsdelivr.net/npm/bootstrap@5.3.2/dist/css/bootstrap.min.css" rel="stylesheet">
<style>
body { background-color: #f7fbff; }
.contact-card { border-radius: 12px; box-shadow: 0 4px 20px rgba(0,0,0,0.08); overflow: hidden; }
.btn-brand { background-color: #0d6efd; color: #fff; border: none; }
.btn-brand:hover { background-color: #0b5ed7; }
.note { font-size: 0.9rem; color: #6c757d; }
</style>
</head>
<body>
<section class="py-5">
<div class="container">
<div class="row justify-content-center">
<div class="col-lg-8">
<div class="card contact-card p-4">
<h3 class="mb-4 text-center">GET IN TOUCH</h3>
<form id="contactForm" class="needs-validation" novalidate>
<div class="row g-3">
<div class="col-md-6">
<label for="firstName" class="form-label">First Name</label>
<input type="text" class="form-control" id="firstName" placeholder="First Name" required>
<div class="invalid-feedback">Please enter your first name.</div>
</div>
<div class="col-md-6">
<label for="lastName" class="form-label">Last Name</label>
<input type="text" class="form-control" id="lastName" placeholder="Last Name" required>
<div class="invalid-feedback">Please enter your last name.</div>
</div>
<div class="col-md-6">
<label for="phone" class="form-label">Phone Number</label>
<input type="tel" class="form-control" id="phone" placeholder="Phone Number" required>
<div class="invalid-feedback">Please enter your phone number.</div>
</div>
<div class="col-md-6">
<label for="dob" class="form-label">DOB</label>
<input type="text" class="form-control" id="dob" placeholder="dd/mm/yyyy" required>
<div class="invalid-feedback">Please enter your date of birth.</div>
</div>
<div class="col-md-6">
<label for="state" class="form-label">State</label>
<input type="text" class="form-control" id="state" placeholder="State" required>
<div class="invalid-feedback">Please enter your state.</div>
</div>
<div class="col-md-6">
<label for="zip" class="form-label">Zip Code</label>
<input type="text" class="form-control" id="zip" placeholder="Zip Code" required>
<div class="invalid-feedback">Please enter your zip code.</div>
</div>
<div class="col-12">
<label for="trustedUrl" class="form-label">Trusted Form URL</label>
<input type="url" class="form-control" id="trustedUrl" value="https://cert.trustedform.com/759961edb557c4e18d1d9b8fce5390ac1e3ce2d7" readonly>
</div>
<div class="col-12">
<div class="form-check">
<input class="form-check-input" type="checkbox" id="agree" required>
<label class="form-check-label" for="agree">I agree.</label>
<div class="invalid-feedback">You must agree before submitting.</div>
</div>
</div>
<div class="col-12">
<p class="note mt-3">
This is a solicitation for insurance. Your contact information will be provided to a licensed sales agent.<br><br>
They may enroll you into a Medicare Advantage, Part D, or Medicare Supplement Insurance plan.<br><br>
You agree to receive automated marketing messages via email, text, or calls. Carrier charges may apply.<br><br>
Your consent does not impact eligibility or services. You may change preferences by contacting us at <strong>+1(754)250-0386</strong>.
</p>
</div>
<div class="col-12 text-center">
<button type="submit" class="btn btn-brand px-5">Submit</button>
</div>
</div>
</form>
<div id="formAlert" class="alert alert-success mt-3 d-none" role="alert">
Thank you! Your information has been submitted.
</div>
</div>
</div>
</div>
</div>
</section>
<script src="https://cdn.jsdelivr.net/npm/bootstrap@5.3.2/dist/js/bootstrap.bundle.min.js"></script>
<script>
(function () {
'use strict';
var forms = document.querySelectorAll('.needs-validation');
Array.prototype.slice.call(forms).forEach(function (form) {
form.addEventListener('submit', function (event) {
if (!form.checkValidity()) {
event.preventDefault();
event.stopPropagation();
} else {
event.preventDefault();
var alert = document.getElementById('formAlert');
alert.classList.remove('d-none');
form.reset();
form.classList.remove('was-validated');
setTimeout(function(){ alert.classList.add('d-none'); }, 4000);
}
form.classList.add('was-validated');
}, false);
});
})();
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</body>
</html>