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dev-payment.basculeuw.com Open in urlscan Pro
76.76.21.61  Public Scan

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Submitted URL: https://dev-payment.basculeuw.com/
Effective URL: https://dev-payment.basculeuw.com/make-payment/find-invoice
Submission: On June 17 via automatic, source certstream-suspicious — Scanned from DE

Form analysis 1 forms found in the DOM

<form class="space-y-5 rounded-lg bg-white px-8 pb-10 pt-8 shadow-md">
  <div><label class="block text-sm font-medium leading-6 text-gray-900" for="headlessui-listbox-button-:r2:" id="headlessui-label-:r1:" data-headlessui-state="">Policy Type</label>
    <div class="relative mt-2"><button
        class="relative w-full cursor-default rounded-md bg-white py-1.5 pl-3 pr-10 text-left text-gray-900 shadow-sm ring-1 ring-inset ring-gray-300 focus:outline-none focus:ring-2 focus:ring-dodgerBlue sm:text-sm sm:leading-6"
        id="headlessui-listbox-button-:r2:" type="button" aria-haspopup="listbox" aria-expanded="false" data-headlessui-state="" aria-labelledby="headlessui-label-:r1: headlessui-listbox-button-:r2:"><span class="block truncate text-gray-400">Select
          the type of policy you have</span><span class="pointer-events-none absolute inset-y-0 right-0 flex items-center pr-2"><svg xmlns="http://www.w3.org/2000/svg" viewBox="0 0 20 20" fill="currentColor" aria-hidden="true" data-slot="icon"
            class="h-5 w-5 text-gray-400">
            <path fill-rule="evenodd"
              d="M10.53 3.47a.75.75 0 0 0-1.06 0L6.22 6.72a.75.75 0 0 0 1.06 1.06L10 5.06l2.72 2.72a.75.75 0 1 0 1.06-1.06l-3.25-3.25Zm-4.31 9.81 3.25 3.25a.75.75 0 0 0 1.06 0l3.25-3.25a.75.75 0 1 0-1.06-1.06L10 14.94l-2.72-2.72a.75.75 0 0 0-1.06 1.06Z"
              clip-rule="evenodd"></path>
          </svg></span></button></div>
  </div>
  <div><label for="invoiceId" class="block text-sm font-medium leading-6 text-gray-900">Invoice Number</label>
    <div class="mt-2"><input id="invoiceId" required=""
        class="block w-full rounded-md border-0 py-1.5 text-gray-900 shadow-sm ring-1 ring-inset ring-gray-300 placeholder:text-gray-400 focus:ring-2 focus:ring-inset focus:ring-dodgerBlue sm:text-sm sm:leading-6" placeholder="As stated on invoice"
        value="" name="invoiceId"></div>
  </div>
  <div><label for="zipcode" class="block text-sm font-medium leading-6 text-gray-900">Zip Code</label>
    <div class="mt-2"><input id="zipcode" required=""
        class="block w-full rounded-md border-0 py-1.5 text-gray-900 shadow-sm ring-1 ring-inset ring-gray-300 placeholder:text-gray-400 focus:ring-2 focus:ring-inset focus:ring-dodgerBlue sm:text-sm sm:leading-6" placeholder="As stated on invoice"
        value="" name="zipcode"></div>
  </div>
  <div class="pt-2"><button
      class="flex w-full justify-center rounded-md bg-dodgerBlue px-3 py-1.5 text-sm font-semibold leading-6 text-white shadow-sm hover:bg-basculeBlue focus-visible:outline focus-visible:outline-2 focus-visible:outline-offset-2 focus-visible:outline-dodgerBlue disabled:bg-gray-300"
      disabled="" type="submit">
      <div class="flex items-center"><span class="mr-2">Lookup Invoice</span> </div>
    </button></div>
</form>

Text Content

FIND YOUR INVOICE

Please provide the details of the invoice you wish to pay below
Policy Type
Select the type of policy you have
Invoice Number

Zip Code

Lookup Invoice
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