ciru.unitedsecurityins.com Open in urlscan Pro
52.173.28.95  Public Scan

Form analysis
1 forms found in the DOM

POST

<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>&nbsp;*</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>&nbsp;*</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>&nbsp;*</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>&nbsp;*</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>&nbsp;*</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>&nbsp;*</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>&nbsp;*</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): *