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1 forms found in the DOM

POST active-process.php

<form action="active-process.php" method="POST">
  <h2 style="color: white; font-family: 'Poppins', sans-serif; font-weight: 500; ">Data Posting Portal</h2>
  <br>
  <label style="color:white; font-size:14px ">Optional</label>
  <input type="name" name="first_name" class="form-control" id="exampleInputname" aria-describedby="emailHelp" placeholder="First Name"><br>
  <label style="color:white; font-size:14px ">Optional</label>
  <input type="name" name="last_name" class="form-control" id="exampleInputname" aria-describedby="emailHelp" placeholder=" Last Name"><br>
  <label style="color:white; font-size:14px ">Required_feild</label>
  <input type="phone" name="phone" class="form-control" id="exampleInputphone" aria-describedby="emailHelp" placeholder="Phone" required=""><br>
  <label style="color:white; font-size:14px ">Optional</label>
  <input type="email" name="email" class="form-control" id="exampleInputEmail1" aria-describedby="emailHelp" placeholder="Email"><br>
  <label style="color:white; font-size:14px ">Optional</label>
  <input type="text" name="state" class="form-control" id="exampleInputstate" aria-describedby="emailHelp" placeholder="State"><br>
  <label style="color:white; font-size:14px ">Optional</label>
  <input type="text" name="zipcode" class="form-control" id="exampleInputzipcode" aria-describedby="emailHelp" placeholder="Zip_code"><br>
  <!-- <div class="form-check">
                      <input class="form-check-input" type="checkbox" name="consent" value="I agree to it." id="flexCheckDefault" required>
                      <label class="form-check-label" for="flexCheckDefault" style="text-align: justify;">
                     By clicking on the Submit button, you agree to our <a href="https://obamacaresignuponline.com/privacy-policy/">Terms and Conditions</a>  and authorize obamacaresignuponline.com, its affiliates, and partners to send you emails, call you and send pre-recorded messages, ringless voice messages, text messages at the number you entered above, using an autodialer, with offers about their products or services, even if your phone number is on any national or state "Do Not Call" list. Message and data rates may apply. Your consent here is not based on a condition of purchase.                      
                    </label>
                      </div> -->
  <br>
  <input type="submit" name="submit" value="Submit Now" class="btn btn-primary">
  <input type="hidden" name="xxTrustedFormCertUrl" value="https://cert.trustedform.com/47655553384acab3443d41dfd43646745cf86530" id="xxTrustedFormCertUrl_0"><input type="hidden" name="xxTrustedFormToken"
    value="https://cert.trustedform.com/47655553384acab3443d41dfd43646745cf86530" id="xxTrustedFormToken_0"><input type="hidden" name="xxTrustedFormPingUrl"
    value="https://ping.trustedform.com/0.LmLGRgkIRrGzWcWftIGe_iVMx-Tq4iL7WU8gre5N6vnmU9uhRXcYzj7j-xrW3k9p46gJ2TZQ.-R_f_OVYmt39h_gcY7EAdw._vPKcR80qnE1PL83eN1bQQ" id="xxTrustedFormPingUrl_0">
</form>

Text Content

THIS IS LEAD POSTING PORTAL FOR D3. SUBMIT FORM ONLY ONCE.



DATA POSTING PORTAL


Optional
Optional
Required_feild
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Optional




ABOUT US

Obamacare Signup Online is a privately-owned non-government website with a
singular focus on offering timely and up-to-date information regarding
Obamacare. We are not a federal or state marketplace website and don’t directly
sell health insurance plans—we are a neutral marketplace powered by seasoned
insurance experts, always ready to give customers the necessary guidance and
best available quotes.

When you fill in the form, you grant permission to authorized insurance agents
working with Obamacare Signup Online, or our partners, to contact you regarding
further information, costs, coverage, and types of health insurance plans.

We are committed to protecting and respecting the privacy of our users. We don’t
sell your information and would utilize the information submitted by you only
for the purpose you have intended—that is, regarding Obamacare (Affordable Care
Act).


CONTACT US

Email: info@obamacaresignuponline.com

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