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ebconnect.singlife.com Open in urlscan Pro
23.36.163.237  Public Scan

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URL: https://ebconnect.singlife.com/eb/ehd/?caseId=732E18C475C731AF9A9861D4B5B9EAEC&requestId=2CA26854D4CBA32AF3C9EAF66A352AA3291335...
Submission: On December 12 via manual from US — Scanned from NL

Form analysis 1 forms found in the DOM

<form _ngcontent-c3="" class="ng-tns-c3-0 ng-untouched ng-pristine ng-invalid" action="" novalidate="">
  <div _ngcontent-c3="" class="flex mw-75">
    <div _ngcontent-c3="" class="m-form-row"><label _ngcontent-c3="" class="a-label" for="caseId"><b _ngcontent-c3="" class="ng-tns-c3-0">Case Number:</b></label>
      <div _ngcontent-c3="" class="m-form-row__content"><!----><input _ngcontent-c3="" class="a-textbox ng-untouched ng-pristine ng-invalid" name="caseId" placeholder="Enter your Case Number" required="" type="text"></div>
    </div>
    <div _ngcontent-c3="" class="m-form-row"><label _ngcontent-c3="" class="a-label" for="dob"><b _ngcontent-c3="" class="ng-tns-c3-0">Insured Person Date of Birth:</b></label>
      <div _ngcontent-c3="" class="m-form-row__content"><!----><input _ngcontent-c3="" class="a-date ng-untouched ng-pristine ng-invalid" name="dob" placeholder="dd/mm/yyyy" required="" type="date"></div>
    </div>
  </div>
  <div _ngcontent-c3="" class="btn-container"><button _ngcontent-c3="" class="a-button a-button--primary mb-40" type="button">Proceed</button><span _ngcontent-c3="" class="m-show-more-button ng-trigger ng-trigger-toggleHelpText"
      style="height: auto; opacity: 1;">
      <div _ngcontent-c3="" class="m-show-more-expand a-button a-button--tertiary a-button__icon" aria-controls="#helpText" aria-describedby="helpText" aria-expanded="false" href="#helpText"><span _ngcontent-c3="" class="a-button__inner">Can't find
          Case Number?</span></div>
    </span></div>
  <div _ngcontent-c3="" class="helpText ng-trigger ng-trigger-toggleHelpText" style="height: 0px; opacity: 0; overflow: hidden;">
    <div _ngcontent-c3="" class="img-container"><img _ngcontent-c3="" class="ng-tns-c3-0" alt="" src="assets/img/case-number-sample.png"></div><span _ngcontent-c3="" class="m-show-more-button">
      <div _ngcontent-c3="" class="m-show-more-contract a-button a-button--tertiary a-button__icon" aria-describedby="helpText" aria-expanded="true" href="#"><span _ngcontent-c3="" class="a-button__inner">Close</span></div>
    </span>
  </div>
  <div _ngcontent-c3="" class="m-form-row m-0"><!----></div>
</form>

Text Content

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Electronic Health Declaration


WELCOME

--------------------------------------------------------------------------------


ELECTRONIC HEALTH DECLARATION


TO CONTINUE, PLEASE ENTER YOUR CASE NUMBER AND DATE OF BIRTH FOR VERIFICATION.

Case Number:

Insured Person Date of Birth:

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 * NFPMPA0317 11/2015
 * © 2018 Singlife with Aviva

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