www.magnacare.com
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urlscan Pro
2606:4700:20::681a:108
Public Scan
Submitted URL: http://www.magnacare.com/
Effective URL: https://www.magnacare.com/
Submission: On March 29 via manual from US — Scanned from DE
Effective URL: https://www.magnacare.com/
Submission: On March 29 via manual from US — Scanned from DE
Form analysis 8 forms found in the DOM
GET https://www.magnacare.com/
<form role="search" method="get" class="search-form form" action="https://www.magnacare.com/">
<label for="form-search-input" class="sr-only">Search for</label>
<div class="input-group">
<input type="search" id="form-search-input" class="form-control" placeholder="Search MagnaCare.com" value="" name="s" title="Search for:">
<span class="input-group-btn">
<button type="submit" class="btn btn-default"><i class="fa fa-search icon-search"></i></button>
</span>
</div>
</form><form>
<div>
<div class="nf-before-form-content"><nf-section>
<div class="nf-form-fields-required"> </div>
</nf-section></div>
<div class="nf-form-content "><nf-rows-wrap>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-13-container" class="nf-field-container firstname-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-13-wrap" class="field-wrap firstname-wrap" data-field-id="13">
<div class="nf-field-label">
<label for="nf-field-13" id="nf-label-field-13" class=""> First Name <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-13" name="fname" autocomplete="given-name" placeholder="First Name*" aria-invalid="false" aria-describedby="nf-error-13"
aria-labelledby="nf-label-field-13" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-13" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-14-container" class="nf-field-container lastname-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-14-wrap" class="field-wrap lastname-wrap" data-field-id="14">
<div class="nf-field-label">
<label for="nf-field-14" id="nf-label-field-14" class=""> Last Name <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-14" name="lname" autocomplete="family-name" placeholder="Last Name*" aria-invalid="false" aria-describedby="nf-error-14"
aria-labelledby="nf-label-field-14" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-14" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-15-container" class="nf-field-container textbox-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-15-wrap" class="field-wrap textbox-wrap" data-field-id="15">
<div class="nf-field-label">
<label for="nf-field-15" id="nf-label-field-15" class=""> Company <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" placeholder="Company*" id="nf-field-15" name="company" aria-invalid="false" aria-describedby="nf-error-15" aria-labelledby="nf-label-field-15"
aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-15" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-16-container" class="nf-field-container email-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-16-wrap" class="field-wrap email-wrap" data-field-id="16">
<div class="nf-field-label">
<label for="nf-field-16" id="nf-label-field-16" class=""> Work Email <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="email" value="" class="ninja-forms-field nf-element" id="nf-field-16" name="email" autocomplete="email" placeholder="Work Email*" aria-invalid="false" aria-describedby="nf-error-16"
aria-labelledby="nf-label-field-16" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-16" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-17-container" class="nf-field-container phone-container label-hidden textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-17-wrap" class="field-wrap phone-wrap textbox-wrap" data-field-id="17">
<div class="nf-field-label">
<label for="nf-field-17" id="nf-label-field-17" class=""> Phone </label>
</div>
<div class="nf-field-element">
<input type="tel" value="" class="ninja-forms-field nf-element" id="nf-field-17" name="phone" autocomplete="tel" placeholder="Phone" aria-invalid="false" aria-describedby="nf-error-17" aria-labelledby="nf-label-field-17">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-17" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-89-container" class="nf-field-container number-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-89-wrap" class="field-wrap number-wrap" data-field-id="89">
<div class="nf-field-label">
<label for="nf-field-89" id="nf-label-field-89" class=""> Number of Employees </label>
</div>
<div class="nf-field-element">
<input id="nf-field-89" name="nf-field-89" aria-invalid="false" aria-describedby="nf-error-89" class="ninja-forms-field nf-element" aria-labelledby="nf-label-field-89" type="number" value="" min="" max="" step="1"
placeholder="Number of Employees/Members*">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-89" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-18-container" class="nf-field-container textarea-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-18-wrap" class="field-wrap textarea-wrap" data-field-id="18">
<div class="nf-field-label">
<label for="nf-field-18" id="nf-label-field-18" class=""> Comments / Questions <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<textarea id="nf-field-18" name="nf-field-18" aria-invalid="false" aria-describedby="nf-error-18" class="ninja-forms-field nf-element" placeholder="Comments/Questions*" aria-labelledby="nf-label-field-18"
aria-required="true" required=""></textarea>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-18" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-19-container" class="nf-field-container submit-container label-above textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-19-wrap" class="field-wrap submit-wrap textbox-wrap" data-field-id="19">
<div class="nf-field-label"></div>
<div class="nf-field-element">
<input id="nf-field-19" class="ninja-forms-field btn btn-default nf-element " type="submit" value="SUBMIT">
</div>
<div class="nf-error-wrap"></div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-19" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
</nf-rows-wrap></div>
<div class="nf-after-form-content"><nf-section>
<div id="nf-form-errors-3" class="nf-form-errors" role="alert"><nf-errors></nf-errors></div>
<div class="nf-form-hp"><nf-section>
<label id="nf-label-field-hp-3" for="nf-field-hp-3" aria-hidden="true"> If you are a human seeing this field, please leave it empty. <input id="nf-field-hp-3" name="nf-field-hp" class="nf-element nf-field-hp" type="text" value=""
aria-labelledby="nf-label-field-hp-3">
</label>
</nf-section></div>
</nf-section></div>
</div>
</form><form>
<div>
<div class="nf-before-form-content"><nf-section>
<div class="nf-form-fields-required"> </div>
</nf-section></div>
<div class="nf-form-content "><nf-rows-wrap>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-13_1-container" class="nf-field-container firstname-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-13_1-wrap" class="field-wrap firstname-wrap" data-field-id="13_1">
<div class="nf-field-label">
<label for="nf-field-13_1" id="nf-label-field-13_1" class=""> First Name <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-13_1" name="fname" autocomplete="given-name" placeholder="First Name*" aria-invalid="false" aria-describedby="nf-error-13_1"
aria-labelledby="nf-label-field-13_1" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-13_1" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-14_1-container" class="nf-field-container lastname-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-14_1-wrap" class="field-wrap lastname-wrap" data-field-id="14_1">
<div class="nf-field-label">
<label for="nf-field-14_1" id="nf-label-field-14_1" class=""> Last Name <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-14_1" name="lname" autocomplete="family-name" placeholder="Last Name*" aria-invalid="false" aria-describedby="nf-error-14_1"
aria-labelledby="nf-label-field-14_1" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-14_1" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-15_1-container" class="nf-field-container textbox-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-15_1-wrap" class="field-wrap textbox-wrap" data-field-id="15_1">
<div class="nf-field-label">
<label for="nf-field-15_1" id="nf-label-field-15_1" class=""> Company <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" placeholder="Company*" id="nf-field-15_1" name="company" aria-invalid="false" aria-describedby="nf-error-15_1" aria-labelledby="nf-label-field-15_1"
aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-15_1" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-16_1-container" class="nf-field-container email-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-16_1-wrap" class="field-wrap email-wrap" data-field-id="16_1">
<div class="nf-field-label">
<label for="nf-field-16_1" id="nf-label-field-16_1" class=""> Work Email <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="email" value="" class="ninja-forms-field nf-element" id="nf-field-16_1" name="email" autocomplete="email" placeholder="Work Email*" aria-invalid="false" aria-describedby="nf-error-16_1"
aria-labelledby="nf-label-field-16_1" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-16_1" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-17_1-container" class="nf-field-container phone-container label-hidden textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-17_1-wrap" class="field-wrap phone-wrap textbox-wrap" data-field-id="17_1">
<div class="nf-field-label">
<label for="nf-field-17_1" id="nf-label-field-17_1" class=""> Phone </label>
</div>
<div class="nf-field-element">
<input type="tel" value="" class="ninja-forms-field nf-element" id="nf-field-17_1" name="phone" autocomplete="tel" placeholder="Phone" aria-invalid="false" aria-describedby="nf-error-17_1"
aria-labelledby="nf-label-field-17_1">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-17_1" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-89_1-container" class="nf-field-container number-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-89_1-wrap" class="field-wrap number-wrap" data-field-id="89_1">
<div class="nf-field-label">
<label for="nf-field-89_1" id="nf-label-field-89_1" class=""> Number of Employees </label>
</div>
<div class="nf-field-element">
<input id="nf-field-89_1" name="nf-field-89_1" aria-invalid="false" aria-describedby="nf-error-89_1" class="ninja-forms-field nf-element" aria-labelledby="nf-label-field-89_1" type="number" value="" min="" max="" step="1"
placeholder="Number of Employees/Members*">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-89_1" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-18_1-container" class="nf-field-container textarea-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-18_1-wrap" class="field-wrap textarea-wrap" data-field-id="18_1">
<div class="nf-field-label">
<label for="nf-field-18_1" id="nf-label-field-18_1" class=""> Comments / Questions <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<textarea id="nf-field-18_1" name="nf-field-18_1" aria-invalid="false" aria-describedby="nf-error-18_1" class="ninja-forms-field nf-element" placeholder="Comments/Questions*" aria-labelledby="nf-label-field-18_1"
aria-required="true" required=""></textarea>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-18_1" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-19_1-container" class="nf-field-container submit-container label-above textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-19_1-wrap" class="field-wrap submit-wrap textbox-wrap" data-field-id="19_1">
<div class="nf-field-label"></div>
<div class="nf-field-element">
<input id="nf-field-19_1" class="ninja-forms-field btn btn-default nf-element " type="submit" value="SUBMIT">
</div>
<div class="nf-error-wrap"></div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-19_1" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
</nf-rows-wrap></div>
<div class="nf-after-form-content"><nf-section>
<div id="nf-form-errors-3_1" class="nf-form-errors" role="alert"><nf-errors></nf-errors></div>
<div class="nf-form-hp"><nf-section>
<label id="nf-label-field-hp-3_1" for="nf-field-hp-3_1" aria-hidden="true"> If you are a human seeing this field, please leave it empty. <input id="nf-field-hp-3_1" name="nf-field-hp" class="nf-element nf-field-hp" type="text" value=""
aria-labelledby="nf-label-field-hp-3_1">
</label>
</nf-section></div>
</nf-section></div>
</div>
</form><form>
<div>
<div class="nf-before-form-content"><nf-section>
<div class="nf-form-fields-required"> </div>
</nf-section></div>
<div class="nf-form-content "><nf-rows-wrap>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-13_2-container" class="nf-field-container firstname-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-13_2-wrap" class="field-wrap firstname-wrap" data-field-id="13_2">
<div class="nf-field-label">
<label for="nf-field-13_2" id="nf-label-field-13_2" class=""> First Name <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-13_2" name="fname" autocomplete="given-name" placeholder="First Name*" aria-invalid="false" aria-describedby="nf-error-13_2"
aria-labelledby="nf-label-field-13_2" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-13_2" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-14_2-container" class="nf-field-container lastname-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-14_2-wrap" class="field-wrap lastname-wrap" data-field-id="14_2">
<div class="nf-field-label">
<label for="nf-field-14_2" id="nf-label-field-14_2" class=""> Last Name <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-14_2" name="lname" autocomplete="family-name" placeholder="Last Name*" aria-invalid="false" aria-describedby="nf-error-14_2"
aria-labelledby="nf-label-field-14_2" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-14_2" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-15_2-container" class="nf-field-container textbox-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-15_2-wrap" class="field-wrap textbox-wrap" data-field-id="15_2">
<div class="nf-field-label">
<label for="nf-field-15_2" id="nf-label-field-15_2" class=""> Company <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" placeholder="Company*" id="nf-field-15_2" name="company" aria-invalid="false" aria-describedby="nf-error-15_2" aria-labelledby="nf-label-field-15_2"
aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-15_2" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-16_2-container" class="nf-field-container email-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-16_2-wrap" class="field-wrap email-wrap" data-field-id="16_2">
<div class="nf-field-label">
<label for="nf-field-16_2" id="nf-label-field-16_2" class=""> Work Email <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="email" value="" class="ninja-forms-field nf-element" id="nf-field-16_2" name="email" autocomplete="email" placeholder="Work Email*" aria-invalid="false" aria-describedby="nf-error-16_2"
aria-labelledby="nf-label-field-16_2" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-16_2" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-17_2-container" class="nf-field-container phone-container label-hidden textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-17_2-wrap" class="field-wrap phone-wrap textbox-wrap" data-field-id="17_2">
<div class="nf-field-label">
<label for="nf-field-17_2" id="nf-label-field-17_2" class=""> Phone </label>
</div>
<div class="nf-field-element">
<input type="tel" value="" class="ninja-forms-field nf-element" id="nf-field-17_2" name="phone" autocomplete="tel" placeholder="Phone" aria-invalid="false" aria-describedby="nf-error-17_2"
aria-labelledby="nf-label-field-17_2">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-17_2" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-89_2-container" class="nf-field-container number-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-89_2-wrap" class="field-wrap number-wrap" data-field-id="89_2">
<div class="nf-field-label">
<label for="nf-field-89_2" id="nf-label-field-89_2" class=""> Number of Employees </label>
</div>
<div class="nf-field-element">
<input id="nf-field-89_2" name="nf-field-89_2" aria-invalid="false" aria-describedby="nf-error-89_2" class="ninja-forms-field nf-element" aria-labelledby="nf-label-field-89_2" type="number" value="" min="" max="" step="1"
placeholder="Number of Employees/Members*">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-89_2" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-18_2-container" class="nf-field-container textarea-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-18_2-wrap" class="field-wrap textarea-wrap" data-field-id="18_2">
<div class="nf-field-label">
<label for="nf-field-18_2" id="nf-label-field-18_2" class=""> Comments / Questions <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<textarea id="nf-field-18_2" name="nf-field-18_2" aria-invalid="false" aria-describedby="nf-error-18_2" class="ninja-forms-field nf-element" placeholder="Comments/Questions*" aria-labelledby="nf-label-field-18_2"
aria-required="true" required=""></textarea>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-18_2" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-19_2-container" class="nf-field-container submit-container label-above textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-19_2-wrap" class="field-wrap submit-wrap textbox-wrap" data-field-id="19_2">
<div class="nf-field-label"></div>
<div class="nf-field-element">
<input id="nf-field-19_2" class="ninja-forms-field btn btn-default nf-element " type="submit" value="SUBMIT">
</div>
<div class="nf-error-wrap"></div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-19_2" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
</nf-rows-wrap></div>
<div class="nf-after-form-content"><nf-section>
<div id="nf-form-errors-3_2" class="nf-form-errors" role="alert"><nf-errors></nf-errors></div>
<div class="nf-form-hp"><nf-section>
<label id="nf-label-field-hp-3_2" for="nf-field-hp-3_2" aria-hidden="true"> If you are a human seeing this field, please leave it empty. <input id="nf-field-hp-3_2" name="nf-field-hp" class="nf-element nf-field-hp" type="text" value=""
aria-labelledby="nf-label-field-hp-3_2">
</label>
</nf-section></div>
</nf-section></div>
</div>
</form><form>
<div>
<div class="nf-before-form-content"><nf-section>
<div class="nf-form-fields-required"> </div>
</nf-section></div>
<div class="nf-form-content "><nf-rows-wrap>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-13_3-container" class="nf-field-container firstname-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-13_3-wrap" class="field-wrap firstname-wrap" data-field-id="13_3">
<div class="nf-field-label">
<label for="nf-field-13_3" id="nf-label-field-13_3" class=""> First Name <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-13_3" name="fname" autocomplete="given-name" placeholder="First Name*" aria-invalid="false" aria-describedby="nf-error-13_3"
aria-labelledby="nf-label-field-13_3" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-13_3" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-14_3-container" class="nf-field-container lastname-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-14_3-wrap" class="field-wrap lastname-wrap" data-field-id="14_3">
<div class="nf-field-label">
<label for="nf-field-14_3" id="nf-label-field-14_3" class=""> Last Name <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-14_3" name="lname" autocomplete="family-name" placeholder="Last Name*" aria-invalid="false" aria-describedby="nf-error-14_3"
aria-labelledby="nf-label-field-14_3" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-14_3" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-15_3-container" class="nf-field-container textbox-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-15_3-wrap" class="field-wrap textbox-wrap" data-field-id="15_3">
<div class="nf-field-label">
<label for="nf-field-15_3" id="nf-label-field-15_3" class=""> Company <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" placeholder="Company*" id="nf-field-15_3" name="company" aria-invalid="false" aria-describedby="nf-error-15_3" aria-labelledby="nf-label-field-15_3"
aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-15_3" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-16_3-container" class="nf-field-container email-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-16_3-wrap" class="field-wrap email-wrap" data-field-id="16_3">
<div class="nf-field-label">
<label for="nf-field-16_3" id="nf-label-field-16_3" class=""> Work Email <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="email" value="" class="ninja-forms-field nf-element" id="nf-field-16_3" name="email" autocomplete="email" placeholder="Work Email*" aria-invalid="false" aria-describedby="nf-error-16_3"
aria-labelledby="nf-label-field-16_3" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-16_3" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-17_3-container" class="nf-field-container phone-container label-hidden textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-17_3-wrap" class="field-wrap phone-wrap textbox-wrap" data-field-id="17_3">
<div class="nf-field-label">
<label for="nf-field-17_3" id="nf-label-field-17_3" class=""> Phone </label>
</div>
<div class="nf-field-element">
<input type="tel" value="" class="ninja-forms-field nf-element" id="nf-field-17_3" name="phone" autocomplete="tel" placeholder="Phone" aria-invalid="false" aria-describedby="nf-error-17_3"
aria-labelledby="nf-label-field-17_3">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-17_3" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-89_3-container" class="nf-field-container number-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-89_3-wrap" class="field-wrap number-wrap" data-field-id="89_3">
<div class="nf-field-label">
<label for="nf-field-89_3" id="nf-label-field-89_3" class=""> Number of Employees </label>
</div>
<div class="nf-field-element">
<input id="nf-field-89_3" name="nf-field-89_3" aria-invalid="false" aria-describedby="nf-error-89_3" class="ninja-forms-field nf-element" aria-labelledby="nf-label-field-89_3" type="number" value="" min="" max="" step="1"
placeholder="Number of Employees/Members*">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-89_3" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-18_3-container" class="nf-field-container textarea-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-18_3-wrap" class="field-wrap textarea-wrap" data-field-id="18_3">
<div class="nf-field-label">
<label for="nf-field-18_3" id="nf-label-field-18_3" class=""> Comments / Questions <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<textarea id="nf-field-18_3" name="nf-field-18_3" aria-invalid="false" aria-describedby="nf-error-18_3" class="ninja-forms-field nf-element" placeholder="Comments/Questions*" aria-labelledby="nf-label-field-18_3"
aria-required="true" required=""></textarea>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-18_3" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-19_3-container" class="nf-field-container submit-container label-above textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-19_3-wrap" class="field-wrap submit-wrap textbox-wrap" data-field-id="19_3">
<div class="nf-field-label"></div>
<div class="nf-field-element">
<input id="nf-field-19_3" class="ninja-forms-field btn btn-default nf-element " type="submit" value="SUBMIT">
</div>
<div class="nf-error-wrap"></div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-19_3" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
</nf-rows-wrap></div>
<div class="nf-after-form-content"><nf-section>
<div id="nf-form-errors-3_3" class="nf-form-errors" role="alert"><nf-errors></nf-errors></div>
<div class="nf-form-hp"><nf-section>
<label id="nf-label-field-hp-3_3" for="nf-field-hp-3_3" aria-hidden="true"> If you are a human seeing this field, please leave it empty. <input id="nf-field-hp-3_3" name="nf-field-hp" class="nf-element nf-field-hp" type="text" value=""
aria-labelledby="nf-label-field-hp-3_3">
</label>
</nf-section></div>
</nf-section></div>
</div>
</form><form>
<div>
<div class="nf-before-form-content"><nf-section>
<div class="nf-form-fields-required"> </div>
</nf-section></div>
<div class="nf-form-content "><nf-rows-wrap>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-13_4-container" class="nf-field-container firstname-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-13_4-wrap" class="field-wrap firstname-wrap" data-field-id="13_4">
<div class="nf-field-label">
<label for="nf-field-13_4" id="nf-label-field-13_4" class=""> First Name <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-13_4" name="fname" autocomplete="given-name" placeholder="First Name*" aria-invalid="false" aria-describedby="nf-error-13_4"
aria-labelledby="nf-label-field-13_4" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-13_4" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-14_4-container" class="nf-field-container lastname-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-14_4-wrap" class="field-wrap lastname-wrap" data-field-id="14_4">
<div class="nf-field-label">
<label for="nf-field-14_4" id="nf-label-field-14_4" class=""> Last Name <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-14_4" name="lname" autocomplete="family-name" placeholder="Last Name*" aria-invalid="false" aria-describedby="nf-error-14_4"
aria-labelledby="nf-label-field-14_4" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-14_4" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-15_4-container" class="nf-field-container textbox-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-15_4-wrap" class="field-wrap textbox-wrap" data-field-id="15_4">
<div class="nf-field-label">
<label for="nf-field-15_4" id="nf-label-field-15_4" class=""> Company <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" placeholder="Company*" id="nf-field-15_4" name="company" aria-invalid="false" aria-describedby="nf-error-15_4" aria-labelledby="nf-label-field-15_4"
aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-15_4" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-16_4-container" class="nf-field-container email-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-16_4-wrap" class="field-wrap email-wrap" data-field-id="16_4">
<div class="nf-field-label">
<label for="nf-field-16_4" id="nf-label-field-16_4" class=""> Work Email <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="email" value="" class="ninja-forms-field nf-element" id="nf-field-16_4" name="email" autocomplete="email" placeholder="Work Email*" aria-invalid="false" aria-describedby="nf-error-16_4"
aria-labelledby="nf-label-field-16_4" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-16_4" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-17_4-container" class="nf-field-container phone-container label-hidden textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-17_4-wrap" class="field-wrap phone-wrap textbox-wrap" data-field-id="17_4">
<div class="nf-field-label">
<label for="nf-field-17_4" id="nf-label-field-17_4" class=""> Phone </label>
</div>
<div class="nf-field-element">
<input type="tel" value="" class="ninja-forms-field nf-element" id="nf-field-17_4" name="phone" autocomplete="tel" placeholder="Phone" aria-invalid="false" aria-describedby="nf-error-17_4"
aria-labelledby="nf-label-field-17_4">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-17_4" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-89_4-container" class="nf-field-container number-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-89_4-wrap" class="field-wrap number-wrap" data-field-id="89_4">
<div class="nf-field-label">
<label for="nf-field-89_4" id="nf-label-field-89_4" class=""> Number of Employees </label>
</div>
<div class="nf-field-element">
<input id="nf-field-89_4" name="nf-field-89_4" aria-invalid="false" aria-describedby="nf-error-89_4" class="ninja-forms-field nf-element" aria-labelledby="nf-label-field-89_4" type="number" value="" min="" max="" step="1"
placeholder="Number of Employees/Members*">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-89_4" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-18_4-container" class="nf-field-container textarea-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-18_4-wrap" class="field-wrap textarea-wrap" data-field-id="18_4">
<div class="nf-field-label">
<label for="nf-field-18_4" id="nf-label-field-18_4" class=""> Comments / Questions <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<textarea id="nf-field-18_4" name="nf-field-18_4" aria-invalid="false" aria-describedby="nf-error-18_4" class="ninja-forms-field nf-element" placeholder="Comments/Questions*" aria-labelledby="nf-label-field-18_4"
aria-required="true" required=""></textarea>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-18_4" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-19_4-container" class="nf-field-container submit-container label-above textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-19_4-wrap" class="field-wrap submit-wrap textbox-wrap" data-field-id="19_4">
<div class="nf-field-label"></div>
<div class="nf-field-element">
<input id="nf-field-19_4" class="ninja-forms-field btn btn-default nf-element " type="submit" value="SUBMIT">
</div>
<div class="nf-error-wrap"></div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-19_4" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
</nf-rows-wrap></div>
<div class="nf-after-form-content"><nf-section>
<div id="nf-form-errors-3_4" class="nf-form-errors" role="alert"><nf-errors></nf-errors></div>
<div class="nf-form-hp"><nf-section>
<label id="nf-label-field-hp-3_4" for="nf-field-hp-3_4" aria-hidden="true"> If you are a human seeing this field, please leave it empty. <input id="nf-field-hp-3_4" name="nf-field-hp" class="nf-element nf-field-hp" type="text" value=""
aria-labelledby="nf-label-field-hp-3_4">
</label>
</nf-section></div>
</nf-section></div>
</div>
</form><form>
<div>
<div class="nf-before-form-content"><nf-section>
<div class="nf-form-fields-required"> </div>
</nf-section></div>
<div class="nf-form-content "><nf-rows-wrap>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-13_5-container" class="nf-field-container firstname-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-13_5-wrap" class="field-wrap firstname-wrap" data-field-id="13_5">
<div class="nf-field-label">
<label for="nf-field-13_5" id="nf-label-field-13_5" class=""> First Name <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-13_5" name="fname" autocomplete="given-name" placeholder="First Name*" aria-invalid="false" aria-describedby="nf-error-13_5"
aria-labelledby="nf-label-field-13_5" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-13_5" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-14_5-container" class="nf-field-container lastname-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-14_5-wrap" class="field-wrap lastname-wrap" data-field-id="14_5">
<div class="nf-field-label">
<label for="nf-field-14_5" id="nf-label-field-14_5" class=""> Last Name <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-14_5" name="lname" autocomplete="family-name" placeholder="Last Name*" aria-invalid="false" aria-describedby="nf-error-14_5"
aria-labelledby="nf-label-field-14_5" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-14_5" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-15_5-container" class="nf-field-container textbox-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-15_5-wrap" class="field-wrap textbox-wrap" data-field-id="15_5">
<div class="nf-field-label">
<label for="nf-field-15_5" id="nf-label-field-15_5" class=""> Company <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" placeholder="Company*" id="nf-field-15_5" name="company" aria-invalid="false" aria-describedby="nf-error-15_5" aria-labelledby="nf-label-field-15_5"
aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-15_5" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-16_5-container" class="nf-field-container email-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-16_5-wrap" class="field-wrap email-wrap" data-field-id="16_5">
<div class="nf-field-label">
<label for="nf-field-16_5" id="nf-label-field-16_5" class=""> Work Email <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="email" value="" class="ninja-forms-field nf-element" id="nf-field-16_5" name="email" autocomplete="email" placeholder="Work Email*" aria-invalid="false" aria-describedby="nf-error-16_5"
aria-labelledby="nf-label-field-16_5" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-16_5" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-17_5-container" class="nf-field-container phone-container label-hidden textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-17_5-wrap" class="field-wrap phone-wrap textbox-wrap" data-field-id="17_5">
<div class="nf-field-label">
<label for="nf-field-17_5" id="nf-label-field-17_5" class=""> Phone </label>
</div>
<div class="nf-field-element">
<input type="tel" value="" class="ninja-forms-field nf-element" id="nf-field-17_5" name="phone" autocomplete="tel" placeholder="Phone" aria-invalid="false" aria-describedby="nf-error-17_5"
aria-labelledby="nf-label-field-17_5">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-17_5" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-89_5-container" class="nf-field-container number-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-89_5-wrap" class="field-wrap number-wrap" data-field-id="89_5">
<div class="nf-field-label">
<label for="nf-field-89_5" id="nf-label-field-89_5" class=""> Number of Employees </label>
</div>
<div class="nf-field-element">
<input id="nf-field-89_5" name="nf-field-89_5" aria-invalid="false" aria-describedby="nf-error-89_5" class="ninja-forms-field nf-element" aria-labelledby="nf-label-field-89_5" type="number" value="" min="" max="" step="1"
placeholder="Number of Employees/Members*">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-89_5" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-18_5-container" class="nf-field-container textarea-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-18_5-wrap" class="field-wrap textarea-wrap" data-field-id="18_5">
<div class="nf-field-label">
<label for="nf-field-18_5" id="nf-label-field-18_5" class=""> Comments / Questions <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<textarea id="nf-field-18_5" name="nf-field-18_5" aria-invalid="false" aria-describedby="nf-error-18_5" class="ninja-forms-field nf-element" placeholder="Comments/Questions*" aria-labelledby="nf-label-field-18_5"
aria-required="true" required=""></textarea>
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-18_5" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-19_5-container" class="nf-field-container submit-container label-above textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-19_5-wrap" class="field-wrap submit-wrap textbox-wrap" data-field-id="19_5">
<div class="nf-field-label"></div>
<div class="nf-field-element">
<input id="nf-field-19_5" class="ninja-forms-field btn btn-default nf-element " type="submit" value="SUBMIT">
</div>
<div class="nf-error-wrap"></div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-19_5" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
</nf-rows-wrap></div>
<div class="nf-after-form-content"><nf-section>
<div id="nf-form-errors-3_5" class="nf-form-errors" role="alert"><nf-errors></nf-errors></div>
<div class="nf-form-hp"><nf-section>
<label id="nf-label-field-hp-3_5" for="nf-field-hp-3_5" aria-hidden="true"> If you are a human seeing this field, please leave it empty. <input id="nf-field-hp-3_5" name="nf-field-hp" class="nf-element nf-field-hp" type="text" value=""
aria-labelledby="nf-label-field-hp-3_5">
</label>
</nf-section></div>
</nf-section></div>
</div>
</form><form>
<div>
<div class="nf-before-form-content"><nf-section>
<div class="nf-form-fields-required"> </div>
</nf-section></div>
<div class="nf-form-content "><nf-rows-wrap>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-13_6-container" class="nf-field-container firstname-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-13_6-wrap" class="field-wrap firstname-wrap" data-field-id="13_6">
<div class="nf-field-label">
<label for="nf-field-13_6" id="nf-label-field-13_6" class=""> First Name <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-13_6" name="fname" autocomplete="given-name" placeholder="First Name*" aria-invalid="false" aria-describedby="nf-error-13_6"
aria-labelledby="nf-label-field-13_6" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-13_6" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-14_6-container" class="nf-field-container lastname-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-14_6-wrap" class="field-wrap lastname-wrap" data-field-id="14_6">
<div class="nf-field-label">
<label for="nf-field-14_6" id="nf-label-field-14_6" class=""> Last Name <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" id="nf-field-14_6" name="lname" autocomplete="family-name" placeholder="Last Name*" aria-invalid="false" aria-describedby="nf-error-14_6"
aria-labelledby="nf-label-field-14_6" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-14_6" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-15_6-container" class="nf-field-container textbox-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-15_6-wrap" class="field-wrap textbox-wrap" data-field-id="15_6">
<div class="nf-field-label">
<label for="nf-field-15_6" id="nf-label-field-15_6" class=""> Company <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="text" value="" class="ninja-forms-field nf-element" placeholder="Company*" id="nf-field-15_6" name="company" aria-invalid="false" aria-describedby="nf-error-15_6" aria-labelledby="nf-label-field-15_6"
aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-15_6" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-16_6-container" class="nf-field-container email-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-16_6-wrap" class="field-wrap email-wrap" data-field-id="16_6">
<div class="nf-field-label">
<label for="nf-field-16_6" id="nf-label-field-16_6" class=""> Work Email <span class="ninja-forms-req-symbol">*</span>
</label>
</div>
<div class="nf-field-element">
<input type="email" value="" class="ninja-forms-field nf-element" id="nf-field-16_6" name="email" autocomplete="email" placeholder="Work Email*" aria-invalid="false" aria-describedby="nf-error-16_6"
aria-labelledby="nf-label-field-16_6" aria-required="true" required="">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-16_6" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
<div class="nf-cell" style="width: 50%;">
<nf-fields><nf-field>
<div id="nf-field-17_6-container" class="nf-field-container phone-container label-hidden textbox-container">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-17_6-wrap" class="field-wrap phone-wrap textbox-wrap" data-field-id="17_6">
<div class="nf-field-label">
<label for="nf-field-17_6" id="nf-label-field-17_6" class=""> Phone </label>
</div>
<div class="nf-field-element">
<input type="tel" value="" class="ninja-forms-field nf-element" id="nf-field-17_6" name="phone" autocomplete="tel" placeholder="Phone" aria-invalid="false" aria-describedby="nf-error-17_6"
aria-labelledby="nf-label-field-17_6">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
<div id="nf-error-17_6" class="nf-error-wrap nf-error" role="alert"></div>
</nf-section></div>
</div>
</nf-field></nf-fields>
</div>
</nf-cells>
</div>
<div class="nf-row">
<nf-cells>
<div class="nf-cell" style="width: 100%;">
<nf-fields><nf-field>
<div id="nf-field-89_6-container" class="nf-field-container number-container label-hidden ">
<div class="nf-before-field"><nf-section>
</nf-section></div>
<div class="nf-field">
<div id="nf-field-89_6-wrap" class="field-wrap number-wrap" data-field-id="89_6">
<div class="nf-field-label">
<label for="nf-field-89_6" id="nf-label-field-89_6" class=""> Number of Employees </label>
</div>
<div class="nf-field-element">
<input id="nf-field-89_6" name="nf-field-89_6" aria-invalid="false" aria-describedby="nf-error-89_6" class="ninja-forms-field nf-element" aria-labelledby="nf-label-field-89_6" type="number" value="" min="" max="" step="1"
placeholder="Number of Employees/Members*">
</div>
</div>
</div>
<div class="nf-after-field"><nf-section>
<div class="nf-input-limit"></div>
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Learn more about our comprehensive health plan management > EXPAND YOUR FOOTPRINT Extend your presence in New York, New Jersey, and Connecticut with our large, high-quality, affordable network, trusted by local, regional, national, and international TPAs and carriers for more than 30 years. Learn more about leasing our PPO network > IMPROVE YOUR CASUALTY OUTCOMES Dramatically improve Workers’ Compensation outcomes at lower cost in New York and New Jersey, and lease the broadest network with the steepest discounts for auto injuries. Learn more about our casualty solutions > GET THE RIGHT CARE AT THE BEST COST Get your members the most appropriate and highest quality medical care at the lowest cost. We have consistently demonstrated cost savings for our clients while maximizing health and wellness for their members. Learn more about our Medical Management services > * Company * Contact * Careers * Information Security * DEI * Legal & Privacy * Terms Glossary * Sitemap MagnaCare is powered by Brighton Health Plan Solutions, LLC, the company accredited by URAC for Health Utilization Management Electronic Claims Submissions ©2023 Brighton Health Plan Solutions. All Rights Reserved. Feedback CONTACT US TO LEARN MORE WE OFFER GROUP HEALTH PLAN SOLUTIONS ONLY. (NOT FOR INDIVIDUALS) Call 888.799.6465 or fill out the form below. -------------------------------------------------------------------------------- First Name * Last Name * Company * Work Email * Phone Number of Employees Comments / Questions * If you are a human seeing this field, please leave it empty. × LEARN ABOUT OUR MEDICAL MANAGEMENT PROGRAMS WE OFFER GROUP HEALTH PLAN SOLUTIONS ONLY. 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(NOT FOR INDIVIDUALS) FILL IN THE FORM BELOW -------------------------------------------------------------------------------- First Name * Last Name * Company * Work Email * Phone Number of Employees Comments / Questions * If you are a human seeing this field, please leave it empty. × CUSTOMIZE YOUR HEALTH PLAN WITH MAGNACARE WE OFFER GROUP HEALTH PLAN SOLUTIONS ONLY. (NOT FOR INDIVIDUALS) Call 1-866-250-8679 or fill out the form below. -------------------------------------------------------------------------------- First Name * Last Name * Company * Work Email * Phone Number of Employees Comments / Questions * If you are a human seeing this field, please leave it empty. × LEARN MORE ABOUT OUR ADVANCED TECHNOLOGY PLATFORM. WE OFFER GROUP HEALTH PLAN SOLUTIONS ONLY. (NOT FOR INDIVIDUALS) CALL 1-866-250-8679 OR FILL IN THE FORM BELOW -------------------------------------------------------------------------------- First Name * Last Name * Company * Work Email * Phone Number of Employees Comments / Questions * If you are a human seeing this field, please leave it empty. × Important Notice for Local 810 Members Your new, enhanced service portal is now live! Log onto MyCreateHealth.com to view all your claims for services received in 2017 and later. You’ll enjoy the experience on MyCreateHealth.com where you can: * Find a provider * View your ID card * Track your deductibles and out-of-pocket costs * Check your eligibility * Review your plan details, including medical, dental, vision, etc. * Change your account settings * And much more To view older claims (from 2016 and earlier), log onto the service portal at magnacare.com. X ORIGINALTEXT Bessere Übersetzung vorschlagen --------------------------------------------------------------------------------