betteroralhealthil.com
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64.227.19.225
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URL:
https://betteroralhealthil.com/
Submission: On January 13 via api from US — Scanned from US
Submission: On January 13 via api from US — Scanned from US
Form analysis 1 forms found in the DOM
<form id="newentry">
<div class="fields">
<input type="text" id="first_name" name="first_name" class="required" value="" placeholder="First Name*" required="true">
<input type="text" id="last_name" name="last_name" class="required" value="" placeholder="Last Name*" required="true">
</div>
<div class="fields">
<input type="text" id="school_district" name="school_district" class="required" value="" placeholder="School District*" required="true">
<input type="text" id="title" name="title" class="required" value="" placeholder="Title*" required="true">
</div>
<!-- <div class="fields">
<input type="text" id="address_1" name="address_1" class="required" value="" placeholder="Street Address*" required="true">
</div> -->
<div class="fields three">
<input type="text" id="city" name="city" class="required" value="" placeholder="City*" required="true">
<input type="text" id="state" name="state" class="required" value="" placeholder="State*" maxlength="2" required="true">
<input type="text" id="zip" name="zip" class="required" value="" placeholder="ZIP*" maxlength="5" required="true" data-rule-zipcodeus="true">
</div>
<div class="fields">
<input type="text" id="phone_number" name="phone_number" value="" placeholder="Phone*" required="true" maxlength="14">
</div>
<div class="fields">
<input type="email" id="email" name="email" class="required email" value="" placeholder="Email Address*" required="true">
</div>
<div class="form-items form-items-email">
<div class="form-items--left">
<label>May we contact you by email?</label>
</div>
<div class="form-items--right has-pretty-child">
<div class="clearfix prettyradio labelright blue"><input type="radio" name="optin" id="optin-yes" value="yes" data-label="yes" checked="checked" style="display: none;"><a href="#" class="checked "></a>
<label for="optin-yes">yes</label>
</div>
<div class="clearfix prettyradio labelright blue"><input type="radio" name="optin" id="optin-no" value="no" data-label="no" style="display: none;"><a href="#" class=" "></a>
<label for="optin-no">no</label>
</div>
</div>
</div>
<div class="form-items">
<div class="form-items--left">
<label>Do you currently offer your employees dental benefits?</label>
</div>
<div class="form-items--right has-pretty-child">
<div class="clearfix prettyradio labelright blue"><input type="radio" name="dental_benefits" class="js-pretty-check-click" id="dental-benefits-yes" data-input="#plan_renewal_date" value="yes" data-label="yes"
data-showhide=".js-offer-benefits-show" style="display: none;"><a href="#" class=" "></a>
<label for="dental-benefits-yes">yes</label>
</div>
<div class="clearfix prettyradio labelright blue"><input type="radio" name="dental_benefits" class="js-pretty-check-click" id="dental-benefits-no" data-input="#plan_renewal_date" value="no" data-label="no"
data-showhide=".js-offer-benefits-show" style="display: none;"><a href="#" class=" "></a>
<label for="dental-benefits-no">no</label>
</div>
</div>
</div>
<div class="form-items js-offer-benefits-show hidden">
<div class="form-items--left width-75p">
<label>Is your current dental plan voluntary (100 percent employee paid) or non-voluntary (employer contribution)?</label>
</div>
</div>
<div class="clearfix"></div>
<div class="form-items js-offer-benefits-show hidden">
<div class="form-items--left">
</div>
<div class="form-items--right width-45p has-pretty-child">
<div class="clearfix prettyradio labelright blue"><input type="radio" name="voluntary_dental_plan" class="js-pretty-check-click" id="voluntary_dental_plan-yes" data-input="#voluntary_dental_plan" value="voluntary" data-label="voluntary"
data-hideshow="" style="display: none;"><a href="#" class=" "></a>
<label for="voluntary_dental_plan-yes">voluntary</label>
</div>
<div class="clearfix prettyradio labelright blue"><input type="radio" name="voluntary_dental_plan" class="js-pretty-check-click" id="voluntary_dental_plan-no" data-input="#voluntary_dental_plan" value="non-voluntary" data-label="non-voluntary"
data-hideshow="" style="display: none;"><a href="#" class=" "></a>
<label for="voluntary_dental_plan-no">non-voluntary</label>
</div>
</div>
</div>
<div class="clearfix margin-bottom-7"></div>
<div class="fields js-offer-benefits-show hidden">
<label>Who is your current dental carrier and what is your dental plan’s renewal date?</label>
<input type="text" id="plan_renewal_date" name="plan_renewal_date" class="margin-top-7" value="" required="true">
</div>
<div class="clearfix margin-bottom-7"></div>
<div class="form-items">
<div class="form-items--left">
<label>Do you currently work with a broker/insurance agent?</label>
<br>
<br class="hidden js-brokerage-show">
<label class="hidden js-brokerage-show">What is the name of the brokerage/agency?</label>
</div>
<div class="form-items--right has-pretty-child">
<div class="clearfix prettyradio labelright blue"><input type="radio" name="work_with_agent" class="js-pretty-check-click" id="agent-yes" data-input="#brokerage_name" value="yes" data-label="yes" data-showhide=".js-brokerage-show"
style="display: none;"><a href="#" class=" "></a>
<label for="agent-yes">yes</label>
</div>
<div class="clearfix prettyradio labelright blue"><input type="radio" name="work_with_agent" class="js-pretty-check-click" id="agent-no" data-input="#brokerage_name" value="no" data-label="no" data-showhide=".js-brokerage-show"
style="display: none;"><a href="#" class=" "></a>
<label for="agent-no">no</label>
</div>
</div>
<div class="fields">
<input type="text" id="brokerage_name" name="brokerage_name" class="margin-top-7 hidden js-brokerage-show" value="" required="true">
</div>
<div class="fields hidden js-brokerage-show">
<label>Broker's name and email:</label>
<input type="text" id="brokers_name_email" name="brokers_name_email" class="margin-top-7" value="">
</div>
</div>
<div class="clearfix margin-bottom-7"></div>
<div class="fields">
<label>How many people that are eligible for benefits does your district employ?</label>
<input type="text" id="people_eligible_benefits" name="people_eligible_benefits" class="margin-top-7" value="">
</div>
<p>Where should we send 100 free oral health kits?</p>
<div class="fields">
<input type="text" id="school_name" name="school_name" class="required" value="" placeholder="Organization Name*" required="true">
</div>
<div class="fields">
<input type="text" id="school_address" name="school_address" class="required" value="" placeholder="Address*" required="true">
</div>
<div class="fields three">
<input type="text" id="school_city" name="school_city" class="required" value="" placeholder="City*" required="true">
<input type="text" id="school_state" name="school_state" class="required" value="" placeholder="State*" maxlength="2" required="true">
<input type="text" id="school_zip" name="school_zip" class="required" value="" placeholder="ZIP*" maxlength="5" required="true" data-rule-zipcodeus="true">
</div>
<div class="fields">
<input type="text" id="donor_name" name="donor_name" class="required" value="" placeholder="Name to include as donor*" required="true">
</div>
<input type="submit" name="submit" id="submit" value="Submit" data-form="#newentry">
</form>Text Content
GIVE A LITTLE INFO. GIVE A LITTLE BACK. Please tell us about your school district's current dental benefits plan — and we'll send 100 oral health kits to the organization of your choice. May we contact you by email? yes no Do you currently offer your employees dental benefits? yes no Is your current dental plan voluntary (100 percent employee paid) or non-voluntary (employer contribution)? voluntary non-voluntary Who is your current dental carrier and what is your dental plan’s renewal date? Do you currently work with a broker/insurance agent? What is the name of the brokerage/agency? yes no Broker's name and email: How many people that are eligible for benefits does your district employ? Where should we send 100 free oral health kits?