ciru.unitedsecurityins.com
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52.173.28.95
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URL:
https://ciru.unitedsecurityins.com/
Submission: On July 03 via api from US — Scanned from DE
Submission: On July 03 via api from US — Scanned from DE
Form analysis
1 forms found in the DOMPOST
<form method="post">
<div class="d-flex flex-column justify-content-center clearfix">
<div class="body-box col-12">
<h3 class="mt-2">Complaints Resolution Form</h3>
<span class="text-muted">Please complete this form and a member of our team will be in contact with you within one business day.</span>
<div class="row">
<div class="col-md-6">
<label class="col-12" for="FirstName">First Name<span> *</span></label>
<input type="text" maxlength="64" class="form-control" required="" data-val="true" data-val-required="The FirstName field is required." id="FirstName" name="FirstName" value="">
</div>
<div class="col-md-6">
<label class="col-12" for="LastName">Last Name<span> *</span></label>
<input type="text" maxlength="64" class="form-control" required="" data-val="true" data-val-required="The LastName field is required." id="LastName" name="LastName" value="">
</div>
</div>
<div class="row">
<div class="col-md-12">
<label class="col-12" for="Language">Language<span> *</span></label>
<div class="form-check form-check-inline mt-1">
<input class="form-check-input" type="radio" value="English" name="Language" required="">
<label class="form-check-label"> English </label>
</div>
<div class="form-check form-check-inline mt-1">
<input class="form-check-input" type="radio" value="Spanish" name="Language" required="">
<label class="form-check-label"> Spanish </label>
</div>
<div class="form-check form-check-inline mt-1">
<input id="other" class="form-check-input" type="radio" value="Other" name="Language" required="">
<label class="form-check-label"> Other </label>
</div>
</div>
</div>
<div id="LanguageOther" class="row" style="display:none">
<div class="col-md-12">
<label class="col-12" for="LanguageOther">Other Language<span> *</span></label>
<input id="InputLanguageOther" type="text" class="form-control" maxlength="20" name="LanguageOther" value="">
</div>
</div>
<div class="row">
<div class="col-md-12">
<label class="col-12" for="PolicyClaimNumber">Claim or Policy Number</label>
<input type="text" maxlength="20" class="form-control" id="PolicyClaimNumber" name="PolicyClaimNumber" value="">
</div>
</div>
<div class="row">
<div class="col-md-12">
<label class="col-12" for="PhoneNumber">Cell Phone Number<span> *</span></label>
<input type="text" class="jqPhoneMask form-control" maxlength="14" placeholder="(___) ___-____" data-val="true" data-val-phone="The PhoneNumber field is not a valid phone number." data-val-required="The PhoneNumber field is required."
id="PhoneNumber" name="PhoneNumber" value="">
<span class="field-validation-valid" data-valmsg-for="PhoneNumber" data-valmsg-replace="true"></span>
</div>
</div>
<div class="row">
<div class="col-md-12">
<label class="col-12" for="AuthorizedToText">Do you authorize us to text you?<span> *</span></label>
<div class="form-check form-check-inline mt-1">
<input class="form-check-input" type="radio" value="true" name="AuthorizedToText">
<label class="form-check-label"> Yes </label>
</div>
<div class="form-check form-check-inline mt-1">
<input class="form-check-input" type="radio" value="false" name="AuthorizedToText">
<label class="form-check-label"> No </label>
</div>
</div>
</div>
<div class="row">
<div class="col-md-12">
<label class="col-12" for="Complaint">Please list Concern (max 2000 characters):<span> *</span></label>
<textarea maxlength="2000" class="form-control" style="height: 11.5em;" required="" data-val="true" data-val-length="The field Complaint must be a string with a maximum length of 2000." data-val-length-max="2000"
data-val-required="The Complaint field is required." id="Complaint" name="Complaint"></textarea>
</div>
</div>
<div class="row">
<div class="col-md-12">
<input type="submit" value="Submit" class="btn btn-primary mt-1">
</div>
</div>
</div>
</div>
<input name="__RequestVerificationToken" type="hidden" value="CfDJ8ELKEj36kfhAjqVxa2nRw7cWn3a8Vfsmga8PgLRhY-LdDcfXxODn58LOyMkOw5IgnAkCVgEUQa2CNj8mwR7crDGOg37OSkDc2To__hwOIgm1d19YKkHEQ6_-A8RiXY9BTwlXgIbo51l1Wzj9Jc_nprE">
</form>
Text Content
COMPLAINTS RESOLUTION FORM Please complete this form and a member of our team will be in contact with you within one business day. First Name * Last Name * Language * English Spanish Other Other Language * Claim or Policy Number Cell Phone Number * Do you authorize us to text you? * Yes No Please list Concern (max 2000 characters): *