forms.axahealth.co.uk
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91.207.38.27
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Submitted URL: https://axapppcorporates.login.prescience.cloud/
Effective URL: https://forms.axahealth.co.uk/templates/axapppcs/seo/emailPage
Submission: On August 31 via automatic, source certstream-suspicious
Effective URL: https://forms.axahealth.co.uk/templates/axapppcs/seo/emailPage
Submission: On August 31 via automatic, source certstream-suspicious
Form analysis 1 forms found in the DOM
POST https://forms.axahealth.co.uk/templates/axapppcs/seo/emailPage
<form id="form" method="post" action="https://forms.axahealth.co.uk/templates/axapppcs/seo/emailPage" enctype="multipart/form-data">
<div>
<input type="hidden" name="id" value="1630389970yhUpFT6ZvOvTOCVuLu5WW7"><input type="hidden" name="entryID" value=""><input type="hidden" name="moduleID" value="">
<input type="hidden" name="formSubmit" value="true">
</div>
<div class="section">
<h3>Query details</h3>
<div id="first_name_panel" class="panel">
<label for="first_name">Your first name <span class="mandatory">*</span>
</label>
<input type="text" name="first_name" id="first_name" alt="Please enter your first name" value="" maxlength="100" autocomplete="nope" class="outline">
</div>
<div id="last_name_panel" class="panel">
<label for="last_name">Your surname <span class="mandatory">*</span>
</label>
<input type="text" name="last_name" id="last_name" alt="Please enter your surname" value="" maxlength="100" autocomplete="nope" class="outline">
</div>
<div id="policyholder_panel" class="panel">
<label for="policyholder"> Are you a policyholder? <span class="mandatory">*</span>
</label>
<select name="policyholder" id="policyholder" class="outline apply-toogle">
<option value="">Please select</option>
<option value="Yes">Yes</option>
<option value="No">No</option>
</select>
</div>
<div id="policyholder_option_no" class="toogled policyholder" style="display: none;">
<div id="contact_category_panel" class="panel">
<label for="contact_category"> To help us direct your query to the correct department, please select the contact category which best describes you <span class="mandatory">*</span>
</label>
<select name="contact_category" id="contact_category" class="outline apply-toogle">
<option value="">Please select</option>
<option value="Prospective new member">Prospective new member</option>
<option value="GP">GP</option>
<option value="Specialist">Specialist</option>
<option value="Relative to a policyholder">Relative to a policyholder</option>
<option value="Power of attorney to a policyholder">Power of attorney to a policyholder</option>
<option value="Secretary / PA to a policyholder">Secretary / PA to a policyholder</option>
<option value="Hospital">Hospital</option>
<option value="Dentist">Dentist</option>
<option value="Broker">Broker</option>
<option value="Company Admin">Company Admin</option>
<option value="Company doctor">Company doctor</option>
<option value="Other">Other</option>
</select>
</div>
<div id="contact_category_option_other" class="toogled contact_category" style="display: none;">
<div id="contact_category_other_panel" class="panel">
<label for="contact_category_other">If other please provide details here <span class="mandatory">*</span>
</label>
<input type="text" name="contact_category_other" id="contact_category_other" alt="Please enter details if other" value="" maxlength="100" autocomplete="nope" class="outline">
</div>
</div>
</div>
<div id="membership_number_panel" class="panel">
<label for="membership_number" style="position: relative;">Membership number <a href="#" class="help-link">Help</a>
<div class="tooltip js" style="display: none;"><span class="marker"></span>
<h3>Help<a class="close">x</a></h3>
<div class="content">Your membership number is made up of a series of numbers with a letter at the end e.g. <strong>1234567a</strong> If your membership number does not end with a letter, please refer to our <strong>FAQs</strong> on how to
contact us</div>
</div>
</label>
<input type="text" name="membership_number" id="membership_number" alt="Please enter your membership number" value="" maxlength="100" autocomplete="nope" class="outline">
</div>
<div id="email_panel" class="panel">
<label for="email">Email address <span class="mandatory">*</span>
</label>
<input type="text" name="email" id="email" alt="Please enter your email address" value="" maxlength="100" autocomplete="nope" class="outline">
</div>
<div id="telephone_panel" class="panel">
<label for="telephone">Your full contact telephone number </label>
<input type="text" name="telephone" id="telephone" alt="Please enter your full contact telephone number" value="" maxlength="100" autocomplete="nope" class="outline">
</div>
<div id="query_type_panel" class="panel">
<label for="query_type"> Type of enquiry <span class="mandatory">*</span>
</label>
<select name="query_type" id="query_type" class="outline">
<option value="Question">Question</option>
<option value="Complaint">Complaint</option>
</select>
</div>
<div id="query_panel" class="panel">
<label for="query">Your question <span class="mandatory">*</span>
</label>
<textarea name="query" id="query" rows="10" cols="50" class="outline"></textarea>
</div>
</div>
<div class="section">
<h3 style="position: relative;">Upload documents<a href="#" class="help-link">Help</a>
<div class="tooltip js" style="display: none;"><span class="marker"></span>
<h3>Help<a class="close">x</a></h3>
<div class="content">
<p>To upload documents:</p>
<ul>
<li>First, click the white 'Upload a document' button.</li>
<li>Click ‘Browse’ and locate the document from your files. This will add the document.</li>
<li>If the document has a valid size, name and file format, a green tick will appear.</li>
<li>You can attach more documents by clicking the 'Upload another document' button and repeating the process.</li>
</ul>
<p> Once you've attached everything you wish to send to us, click the red 'Submit' button. </p>
<p> You'll receive an email confirming receipt of your documents, and a contact reference number for you to quote if you need to refer to the message. </p>
<p>
<strong>Document not accepted?</strong>
</p>
<p> If your document isn’t accepted, a message will appear to let you know why. </p>
<ul>
<li>If it's too large, you'll need to split it into smaller files, save it in a lower quality, or save it in a different file format. The largest we can accept is 15MB.</li>
<li>If the name contains special characters that we cannot accept, you'll need to rename the document using standard alphanumeric characters.</li>
<li>If the file format is one that we cannot accept, you'll need to save it in a different format.</li>
</ul> Accepted file formats: PDF, Word, Excel, Powerpoint, JPG, PNG, BMP, GIF, TIFF, ODP, ODS, ODT, RTF, TXT.
</div>
</div>
</h3>
<div id="upload-fields" class="upload-fields j-s">
<button id="upload-fields_attach_file" class="button button-white button-attach" type="button">Upload a document</button>
</div>
<div class="disclaimer">
<ul>
<li>There is a <strong>15MB</strong> upload limit</li>
<li>We cannot accept credit or debit card details online</li>
</ul>
</div>
</div>
<div class="section">
<h3>Login information</h3>
<div>
<p> To ensure you're the only person who can access this information, we don't store your memorable word in our systems, so we're unable to remind you of your login details. </p>
</div>
<div id="memorable_panel" class="panel">
<label for="memorable" style="position: relative;">Memorable word <span class="mandatory">*</span>
<a href="#" class="help-link">Help</a>
<div class="tooltip js" style="display: none;"><span class="marker"></span>
<h3>Help<a class="close">x</a></h3>
<div class="content">Your memorable word needs to be between 8 – 20 characters long.</div>
</div>
</label>
<input type="password" name="memorable" id="memorable" alt="Please enter a memorable word" value="" maxlength="100" autocomplete="nope" class="outline js_validate_memorable">
</div>
<div id="memorable_confirm_panel" class="panel">
<label for="memorable_confirm">Confirm memorable word <span class="mandatory">*</span>
</label>
<input type="password" name="memorable_confirm" id="memorable_confirm" alt="Please confirm your memorable word" value="" maxlength="100" autocomplete="nope" class="outline js_validate_memorable">
</div>
<div id="memorable_reminder_panel" class="panel">
<label for="memorable_reminder" style="position: relative;">Memorable word reminder <span class="mandatory">*</span>
<a href="#" class="help-link">Help</a>
<div class="tooltip js" style="display: none;"><span class="marker"></span>
<h3>Help<a class="close">x</a></h3>
<div class="content">Please ensure that your reminder does not contain your memorable word in anyway. We will provide this information as a prompt to help you to log into the message centre. E.g.<br>
<strong>Memorable word:</strong> St John's<br>
<strong>Memorable word reminder:</strong> Name of my first school
</div>
</div>
</label>
<input type="text" name="memorable_reminder" id="memorable_reminder" alt="Please entre a memorable word reminder" value="" maxlength="100" autocomplete="nope" class="outline">
</div>
<div id="dob_panel" class="panel date-field">
<label for="dob_day">Your date of birth <span class="mandatory">*</span></label>
<span class="date-container" id="dob_container"><input type="text" name="dob" id="dob" class="outline date-picker gldp-el" autocomplete="off" gldp-id="gldp-301239465"><span class="date-picker-trigger"></span><span gldp-el="gldp-301239465"
class="gldp-default" style="display: none; z-index: 1000; width: 240px; top: 24px; position: absolute; left: 0px;"><span class="core border monyear"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px;"><a class="prev-arrow">◄</a></span><span class="core border monyear title"
style="width: 171.429px; height: 30px; line-height: 30px; border-top-width: 0px; margin-left: 0px;"><span><select style="width: auto; padding: 2px; margin-top: 2px; float: none;">
<option value="0">Jan</option>
<option value="1">Feb</option>
<option value="2">Mar</option>
<option value="3">Apr</option>
<option value="4">May</option>
<option value="5">Jun</option>
<option value="6">Jul</option>
<option value="7" selected="selected">Aug</option>
<option value="8">Sep</option>
<option value="9">Oct</option>
<option value="10">Nov</option>
<option value="11">Dec</option>
</select><select style="width: auto; padding: 2px; margin-top: 2px; float: none;">
<option value="1900">1900</option>
<option value="1901">1901</option>
<option value="1902">1902</option>
<option value="1903">1903</option>
<option value="1904">1904</option>
<option value="1905">1905</option>
<option value="1906">1906</option>
<option value="1907">1907</option>
<option value="1908">1908</option>
<option value="1909">1909</option>
<option value="1910">1910</option>
<option value="1911">1911</option>
<option value="1912">1912</option>
<option value="1913">1913</option>
<option value="1914">1914</option>
<option value="1915">1915</option>
<option value="1916">1916</option>
<option value="1917">1917</option>
<option value="1918">1918</option>
<option value="1919">1919</option>
<option value="1920">1920</option>
<option value="1921">1921</option>
<option value="1922">1922</option>
<option value="1923">1923</option>
<option value="1924">1924</option>
<option value="1925">1925</option>
<option value="1926">1926</option>
<option value="1927">1927</option>
<option value="1928">1928</option>
<option value="1929">1929</option>
<option value="1930">1930</option>
<option value="1931">1931</option>
<option value="1932">1932</option>
<option value="1933">1933</option>
<option value="1934">1934</option>
<option value="1935">1935</option>
<option value="1936">1936</option>
<option value="1937">1937</option>
<option value="1938">1938</option>
<option value="1939">1939</option>
<option value="1940">1940</option>
<option value="1941">1941</option>
<option value="1942">1942</option>
<option value="1943">1943</option>
<option value="1944">1944</option>
<option value="1945">1945</option>
<option value="1946">1946</option>
<option value="1947">1947</option>
<option value="1948">1948</option>
<option value="1949">1949</option>
<option value="1950">1950</option>
<option value="1951">1951</option>
<option value="1952">1952</option>
<option value="1953">1953</option>
<option value="1954">1954</option>
<option value="1955">1955</option>
<option value="1956">1956</option>
<option value="1957">1957</option>
<option value="1958">1958</option>
<option value="1959">1959</option>
<option value="1960">1960</option>
<option value="1961">1961</option>
<option value="1962">1962</option>
<option value="1963">1963</option>
<option value="1964">1964</option>
<option value="1965">1965</option>
<option value="1966">1966</option>
<option value="1967">1967</option>
<option value="1968">1968</option>
<option value="1969">1969</option>
<option value="1970">1970</option>
<option value="1971">1971</option>
<option value="1972">1972</option>
<option value="1973">1973</option>
<option value="1974">1974</option>
<option value="1975">1975</option>
<option value="1976">1976</option>
<option value="1977">1977</option>
<option value="1978">1978</option>
<option value="1979">1979</option>
<option value="1980">1980</option>
<option value="1981">1981</option>
<option value="1982">1982</option>
<option value="1983">1983</option>
<option value="1984">1984</option>
<option value="1985">1985</option>
<option value="1986">1986</option>
<option value="1987">1987</option>
<option value="1988">1988</option>
<option value="1989">1989</option>
<option value="1990">1990</option>
<option value="1991">1991</option>
<option value="1992">1992</option>
<option value="1993">1993</option>
<option value="1994">1994</option>
<option value="1995">1995</option>
<option value="1996">1996</option>
<option value="1997">1997</option>
<option value="1998">1998</option>
<option value="1999">1999</option>
<option value="2000">2000</option>
<option value="2001">2001</option>
<option value="2002">2002</option>
<option value="2003">2003</option>
<option value="2004">2004</option>
<option value="2005">2005</option>
<option value="2006">2006</option>
<option value="2007">2007</option>
<option value="2008">2008</option>
<option value="2009">2009</option>
<option value="2010">2010</option>
<option value="2011">2011</option>
<option value="2012">2012</option>
<option value="2013">2013</option>
<option value="2014">2014</option>
<option value="2015">2015</option>
<option value="2016">2016</option>
<option value="2017">2017</option>
<option value="2018">2018</option>
<option value="2019">2019</option>
<option value="2020">2020</option>
<option value="2021" selected="selected">2021</option>
<option value="2022">2022</option>
</select></span></span><span class="core border monyear" style="width: 34.2857px; height: 30px; line-height: 30px; margin-left: 0px; border-width: 0px;"><a class="next-arrow">►</a></span><span class="core border dow"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1000;">Sun</span><span class="core border dow"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1001;">Mon</span><span class="core border dow"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1002;">Tue</span><span class="core border dow"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1003;">Wed</span><span class="core border dow"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1004;">Thu</span><span class="core border dow"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1005;">Fri</span><span class="core border dow"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1006;">Sat</span><span class="core border sun outday"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1007;">25</span><span class="core border mon outday"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1008;">26</span><span class="core border tue outday"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1009;">27</span><span class="core border wed outday"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1010;">28</span><span class="core border thu outday"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1011;">29</span><span class="core border fri outday"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1012;">30</span><span class="core border sat outday"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1013;">31</span><span class="core border sun"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1014;">1</span><span class="core border mon"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1015;">2</span><span class="core border tue"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1016;">3</span><span class="core border wed"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1017;">4</span><span class="core border thu"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1018;">5</span><span class="core border fri"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1019;">6</span><span class="core border sat"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1020;">7</span><span class="core border sun"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1021;">8</span><span class="core border mon"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1022;">9</span><span class="core border tue"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1023;">10</span><span class="core border wed"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1024;">11</span><span class="core border thu"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1025;">12</span><span class="core border fri"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1026;">13</span><span class="core border sat"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1027;">14</span><span class="core border sun"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1028;">15</span><span class="core border mon"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1029;">16</span><span class="core border tue"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1030;">17</span><span class="core border wed"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1031;">18</span><span class="core border thu"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1032;">19</span><span class="core border fri"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1033;">20</span><span class="core border sat"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1034;">21</span><span class="core border sun"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1035;">22</span><span class="core border mon"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1036;">23</span><span class="core border tue"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1037;">24</span><span class="core border wed"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1038;">25</span><span class="core border thu"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1039;">26</span><span class="core border fri"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1040;">27</span><span class="core border sat"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1041;">28</span><span class="core border sun"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1042;">29</span><span class="core border mon"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1043;">30</span><span class="core border selected"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1145;">31</span><span class="core border wed outday"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1045;">1</span><span class="core border thu outday"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1046;">2</span><span class="core border fri outday"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1047;">3</span><span class="core border sat outday"
style="width: 34.2857px; height: 30px; line-height: 30px; border-width: 0px; margin-left: 0px; margin-top: 0px; z-index: 1048;">4</span></span></span><input type="hidden" name="dob_day" id="dob_day" value=""><input type="hidden"
name="dob_month" id="dob_month" value=""><input type="hidden" name="dob_year" id="dob_year" value="">
</div>
</div>
<div class="section">
<input type="submit" value="Send" class="button">
</div>
</form>Text Content
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