www.bpi-aia.com.ph
Open in
urlscan Pro
104.126.36.99
Public Scan
URL:
https://www.bpi-aia.com.ph/en/our-products/health/critical-care-100.html?cmpid=sem-ph-bplacdigital-pgoctcc100&gclid=cjwkcaj...
Submission: On October 09 via api from US — Scanned from DE
Submission: On October 09 via api from US — Scanned from DE
Form analysis 2 forms found in the DOM
<form class="search-form" id="search-form1">
<input type="hidden" name="searchExecutor" value="/en/search" id="searchExecutor">
<input type="hidden" name="type" value="123" id="search_type">
<!--*/ end, by Ocean Lan */-->
<div class="search-col-left">
<input name="keyword" data-id="search-input" class="search-input" type="search" placeholder="Type Keywords" tabindex="9801"
data-search-options="{"hideAllFilter":true,"hideProductsFilter":true,"hideArticlesFilter":true,"hideFormsFilter":true}" autocomplete="off">
</div>
<div class="search-col-right">
<button class="btn btn-primary go-btn" tabindex="9802">Go</button>
<button class="btn dismiss-search-btn" tabindex="9803">
<svg title="Dismiss" class="icon icon-xs hide-on-fallback " role="img">
<g>
<title>Dismiss</title>
<use xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="/content/dam/aia/icons/icons.svg#closewhite-glyph"></use>
<image class="icon icon-xs " src="/content/dam/aia/icons/glyph/closewhite-glyph.png" alt="undefined" xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href=""></image>
</g>
</svg>
</button>
</div>
</form><form id="aia1876436110">
<div class="container-fluid">
<div>
<div class="html-script section">
<span id="get-in-touch"></span>
</div>
<div class="sub-title section">
<h4 class="h4 text-center p4 margin-top-md-3xl margin-bottom-md-3xl margin-top-sm-3xl margin-bottom-sm-3xl margin-top-3xl margin-bottom-xxl">Get in touch</h4>
</div>
<div class="grid-control-2-col section">
<div class="row ">
<div class="col col-md-6 col-sm-6 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="text parbase section">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-bottom-md-l margin-top-sm-l margin-bottom-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<p>My first name is*<br> </p>
</div>
</div>
<div class="form-input form-base section">
<input type="text" class="primary-select parent-width" id="aia244483758" name="firstName" placeholder="First Name" required="true" re="^[a-zA-Z]([a-zA-Z]*[\s\'.-]?)+[a-zA-Z\',.-]$" validationtype="text" maxlength="100">
<div class="fieldError label-error" id="aia244483758_msg" requiredmessage="*First name is required" remessage="* Numbers and special characters are not allowed. One letter is not allowed"></div>
</div>
<div class="text parbase section">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-bottom-md-l margin-top-sm-l margin-bottom-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<p>My last name is*<br> </p>
</div>
</div>
<div class="form-input form-base section">
<input type="text" class="primary-select parent-width" id="aia1627531073" name="lastName" placeholder="Last Name" required="true" re="^[a-zA-Z]([a-zA-Z]*[\s\'.-]?)+[a-zA-Z\',.-]$" validationtype="text" maxlength="100">
<div class="fieldError label-error" id="aia1627531073_msg" requiredmessage="*Last is name is required" remessage="* Numbers and special characters are not allowed. One letter is not allowed"></div>
</div>
<div class="text parbase section">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-bottom-md-l margin-top-sm-l margin-bottom-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<p>My date of birth is*<br> </p>
</div>
</div>
<div class="form-dateselector form-base section">
<input type="text" class="parent-width" name="dateOfBirth" id="aia118156821" required="true" readonly="" validationtype="text">
<script type="text/javascript">
$(document).ready(function() {
$("input[type='text']#aia118156821").daterangepicker({
singleDatePicker: true,
showDropdowns: true,
locale: {
format: 'MM\/DD\/YYYY'
},
minDate: '01\/01\/1920',
maxDate: '10\/09\/2024',
startDate: '10\/09\/2023',
endDate: '10\/09\/2023'
});
});
</script>
<div id="aia118156821_msg" class="fieldError label-error" requiredmessage="*Date of birth is required"></div>
</div>
<div class="text parbase section">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-bottom-md-l margin-top-sm-l margin-bottom-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<p>My email address is*<br> </p>
</div>
</div>
<div class="form-input form-base section">
<input type="text" class="primary-select parent-width" id="aia160632254" name="emailAddr" placeholder="e.g. juandelacruz@test.com" required="true" re="^[A-Za-z0-9._%+-]+@[A-Za-z0-9.-]+\.[A-Za-z]{2,4}$" validationtype="text"
maxlength="100">
<div class="fieldError label-error" id="aia160632254_msg" requiredmessage="*Email is required" remessage="Please enter a valid email address."></div>
</div>
<div class="text parbase section">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-bottom-md-l margin-top-sm-l margin-bottom-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<p>Are you a BPI AIA Policyholder?*<br> </p>
</div>
</div>
<div class="grid-control-1-col section">
<div class="row ">
<div class="col col-md-9 col-sm-9 col-xs-12 col-md-offset-0 col-sm-offset-0 col-xs-offset-0 ">
<div>
<div class="form-toggle-box form-base section">
<input type="hidden" id="toggle-group-638327892" name="policyHolder" value="yes" required="true">
<div data-target="toggle-group" class="btn-toggle-group parent-width" id="638327892" name="policyHolder">
<button type="button" class="btn btn-toggle btn-selected" value="yes">yes</button>
<button type="button" class="btn btn-toggle " value="no">no</button>
</div>
<div id="toggle-group-638327892" class="fieldError label-error"></div>
<script type="text/javascript">
// Toggle buttons init
$("body").ready(function() {
$("#638327892 .btn-toggle").off("click");
$("#638327892").each(function(i, e) {
var groupID = $(e).attr("id");
$(this).find(".btn-toggle").on('click', function(e) {
$("#toggle-group-" + groupID).attr("value", $(this).attr("value"));
var toggleButtons = $("#" + groupID + " .btn-toggle");
var selectedToggleButtons = $("#" + groupID + " .btn-toggle.btn-selected");
var currentToggleIndex = toggleButtons.index(this);
selectToggleButton638327892(toggleButtons, currentToggleIndex);
});
});
});
</script>
<script type="text/javascript">
function selectToggleButton638327892(toggleButtons, currentToggleIndex) {
toggleButtons.removeClass("btn-selected");
toggleButtons.eq(currentToggleIndex).addClass("btn-selected");
}
</script>
</div>
</div>
</div>
</div>
</div>
<div class="text parbase section">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-bottom-md-l margin-top-sm-l margin-bottom-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<p>My primary need is*</p>
</div>
</div>
<div class="form-dropdown form-base section">
<select class="primary-select parent-width" name="inquiry" id="aia1483178149" required="true" style="color: #;">
<option selected=""></option>
<option value="PROTECT (To retain the quality of life of my family)" style="color: rgb(85, 67, 68);">PROTECT (To retain the quality of life of my family)</option>
<option value="GROW (To maximize potential of investments)" style="color: rgb(85, 67, 68);">GROW (To maximize potential of investments)</option>
<option value="PREPARE (To have enough funds for critical illness)" style="color: rgb(85, 67, 68);">PREPARE (To have enough funds for critical illness)</option>
<option value="SECURE (To have ready funds for the education of my children)" style="color: rgb(85, 67, 68);">SECURE (To have ready funds for the education of my children)</option>
<option value="BOOST (To live a healthier and more active lifestyle)" style="color: rgb(85, 67, 68);">BOOST (To live a healthier and more active lifestyle)</option>
<option value="None" style="color: rgb(85, 67, 68);">None</option>
</select>
<div class="fieldError label-error" id="aia1483178149_msg" requiredmessage="*Inquiry is required"></div>
<script type="text/javascript">
+ function($) {
"use strict";
$("#aia1483178149").click(function() {
var current = $(this).val();
if (current != null) {
$("#aia1483178149").css('color', '#554344');
}
});
$("#aia1483178149").change(function() {
$(this).css({
'color': '#554344'
});
});
}(jQuery);
</script>
</div>
</div>
</div>
<div class="col col-md-6 col-sm-6 col-xs-12 ">
<div>
<div class="text parbase section">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-bottom-md-l margin-bottom-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<p>My contact number is*<br> </p>
</div>
</div>
<div class="form-input form-base section">
<div class="intl-tel-input allow-dropdown">
<div class="flag-container">
<div class="selected-flag" tabindex="0" title="Philippines: +63">
<div class="iti-flag ph"></div>
<div class="iti-arrow"></div>
</div>
<ul class="country-list hide">
<li class="country preferred active" data-dial-code="63" data-country-code="ph">
<div class="flag-box">
<div class="iti-flag ph"></div>
</div><span class="country-name">Philippines</span><span class="dial-code">+63</span>
</li>
<li class="divider"></li>
<li class="country" data-dial-code="93" data-country-code="af">
<div class="flag-box">
<div class="iti-flag af"></div>
</div><span class="country-name">Afghanistan (افغانستان)</span><span class="dial-code">+93</span>
</li>
<li class="country" data-dial-code="355" data-country-code="al">
<div class="flag-box">
<div class="iti-flag al"></div>
</div><span class="country-name">Albania (Shqipëri)</span><span class="dial-code">+355</span>
</li>
<li class="country" data-dial-code="213" data-country-code="dz">
<div class="flag-box">
<div class="iti-flag dz"></div>
</div><span class="country-name">Algeria (الجزائر)</span><span class="dial-code">+213</span>
</li>
<li class="country" data-dial-code="1684" data-country-code="as">
<div class="flag-box">
<div class="iti-flag as"></div>
</div><span class="country-name">American Samoa</span><span class="dial-code">+1684</span>
</li>
<li class="country" data-dial-code="376" data-country-code="ad">
<div class="flag-box">
<div class="iti-flag ad"></div>
</div><span class="country-name">Andorra</span><span class="dial-code">+376</span>
</li>
<li class="country" data-dial-code="244" data-country-code="ao">
<div class="flag-box">
<div class="iti-flag ao"></div>
</div><span class="country-name">Angola</span><span class="dial-code">+244</span>
</li>
<li class="country" data-dial-code="1264" data-country-code="ai">
<div class="flag-box">
<div class="iti-flag ai"></div>
</div><span class="country-name">Anguilla</span><span class="dial-code">+1264</span>
</li>
<li class="country" data-dial-code="1268" data-country-code="ag">
<div class="flag-box">
<div class="iti-flag ag"></div>
</div><span class="country-name">Antigua and Barbuda</span><span class="dial-code">+1268</span>
</li>
<li class="country" data-dial-code="54" data-country-code="ar">
<div class="flag-box">
<div class="iti-flag ar"></div>
</div><span class="country-name">Argentina</span><span class="dial-code">+54</span>
</li>
<li class="country" data-dial-code="374" data-country-code="am">
<div class="flag-box">
<div class="iti-flag am"></div>
</div><span class="country-name">Armenia (Հայաստան)</span><span class="dial-code">+374</span>
</li>
<li class="country" data-dial-code="297" data-country-code="aw">
<div class="flag-box">
<div class="iti-flag aw"></div>
</div><span class="country-name">Aruba</span><span class="dial-code">+297</span>
</li>
<li class="country" data-dial-code="61" data-country-code="au">
<div class="flag-box">
<div class="iti-flag au"></div>
</div><span class="country-name">Australia</span><span class="dial-code">+61</span>
</li>
<li class="country" data-dial-code="43" data-country-code="at">
<div class="flag-box">
<div class="iti-flag at"></div>
</div><span class="country-name">Austria (Österreich)</span><span class="dial-code">+43</span>
</li>
<li class="country" data-dial-code="994" data-country-code="az">
<div class="flag-box">
<div class="iti-flag az"></div>
</div><span class="country-name">Azerbaijan (Azərbaycan)</span><span class="dial-code">+994</span>
</li>
<li class="country" data-dial-code="1242" data-country-code="bs">
<div class="flag-box">
<div class="iti-flag bs"></div>
</div><span class="country-name">Bahamas</span><span class="dial-code">+1242</span>
</li>
<li class="country" data-dial-code="973" data-country-code="bh">
<div class="flag-box">
<div class="iti-flag bh"></div>
</div><span class="country-name">Bahrain (البحرين)</span><span class="dial-code">+973</span>
</li>
<li class="country" data-dial-code="880" data-country-code="bd">
<div class="flag-box">
<div class="iti-flag bd"></div>
</div><span class="country-name">Bangladesh (বাংলাদেশ)</span><span class="dial-code">+880</span>
</li>
<li class="country" data-dial-code="1246" data-country-code="bb">
<div class="flag-box">
<div class="iti-flag bb"></div>
</div><span class="country-name">Barbados</span><span class="dial-code">+1246</span>
</li>
<li class="country" data-dial-code="375" data-country-code="by">
<div class="flag-box">
<div class="iti-flag by"></div>
</div><span class="country-name">Belarus (Беларусь)</span><span class="dial-code">+375</span>
</li>
<li class="country" data-dial-code="32" data-country-code="be">
<div class="flag-box">
<div class="iti-flag be"></div>
</div><span class="country-name">Belgium (België)</span><span class="dial-code">+32</span>
</li>
<li class="country" data-dial-code="501" data-country-code="bz">
<div class="flag-box">
<div class="iti-flag bz"></div>
</div><span class="country-name">Belize</span><span class="dial-code">+501</span>
</li>
<li class="country" data-dial-code="229" data-country-code="bj">
<div class="flag-box">
<div class="iti-flag bj"></div>
</div><span class="country-name">Benin (Bénin)</span><span class="dial-code">+229</span>
</li>
<li class="country" data-dial-code="1441" data-country-code="bm">
<div class="flag-box">
<div class="iti-flag bm"></div>
</div><span class="country-name">Bermuda</span><span class="dial-code">+1441</span>
</li>
<li class="country" data-dial-code="975" data-country-code="bt">
<div class="flag-box">
<div class="iti-flag bt"></div>
</div><span class="country-name">Bhutan (འབྲུག)</span><span class="dial-code">+975</span>
</li>
<li class="country" data-dial-code="591" data-country-code="bo">
<div class="flag-box">
<div class="iti-flag bo"></div>
</div><span class="country-name">Bolivia</span><span class="dial-code">+591</span>
</li>
<li class="country" data-dial-code="387" data-country-code="ba">
<div class="flag-box">
<div class="iti-flag ba"></div>
</div><span class="country-name">Bosnia and Herzegovina (Босна и Херцеговина)</span><span class="dial-code">+387</span>
</li>
<li class="country" data-dial-code="267" data-country-code="bw">
<div class="flag-box">
<div class="iti-flag bw"></div>
</div><span class="country-name">Botswana</span><span class="dial-code">+267</span>
</li>
<li class="country" data-dial-code="55" data-country-code="br">
<div class="flag-box">
<div class="iti-flag br"></div>
</div><span class="country-name">Brazil (Brasil)</span><span class="dial-code">+55</span>
</li>
<li class="country" data-dial-code="246" data-country-code="io">
<div class="flag-box">
<div class="iti-flag io"></div>
</div><span class="country-name">British Indian Ocean Territory</span><span class="dial-code">+246</span>
</li>
<li class="country" data-dial-code="1284" data-country-code="vg">
<div class="flag-box">
<div class="iti-flag vg"></div>
</div><span class="country-name">British Virgin Islands</span><span class="dial-code">+1284</span>
</li>
<li class="country" data-dial-code="673" data-country-code="bn">
<div class="flag-box">
<div class="iti-flag bn"></div>
</div><span class="country-name">Brunei</span><span class="dial-code">+673</span>
</li>
<li class="country" data-dial-code="359" data-country-code="bg">
<div class="flag-box">
<div class="iti-flag bg"></div>
</div><span class="country-name">Bulgaria (България)</span><span class="dial-code">+359</span>
</li>
<li class="country" data-dial-code="226" data-country-code="bf">
<div class="flag-box">
<div class="iti-flag bf"></div>
</div><span class="country-name">Burkina Faso</span><span class="dial-code">+226</span>
</li>
<li class="country" data-dial-code="257" data-country-code="bi">
<div class="flag-box">
<div class="iti-flag bi"></div>
</div><span class="country-name">Burundi (Uburundi)</span><span class="dial-code">+257</span>
</li>
<li class="country" data-dial-code="855" data-country-code="kh">
<div class="flag-box">
<div class="iti-flag kh"></div>
</div><span class="country-name">Cambodia (កម្ពុជា)</span><span class="dial-code">+855</span>
</li>
<li class="country" data-dial-code="237" data-country-code="cm">
<div class="flag-box">
<div class="iti-flag cm"></div>
</div><span class="country-name">Cameroon (Cameroun)</span><span class="dial-code">+237</span>
</li>
<li class="country" data-dial-code="1" data-country-code="ca">
<div class="flag-box">
<div class="iti-flag ca"></div>
</div><span class="country-name">Canada</span><span class="dial-code">+1</span>
</li>
<li class="country" data-dial-code="238" data-country-code="cv">
<div class="flag-box">
<div class="iti-flag cv"></div>
</div><span class="country-name">Cape Verde (Kabu Verdi)</span><span class="dial-code">+238</span>
</li>
<li class="country" data-dial-code="599" data-country-code="bq">
<div class="flag-box">
<div class="iti-flag bq"></div>
</div><span class="country-name">Caribbean Netherlands</span><span class="dial-code">+599</span>
</li>
<li class="country" data-dial-code="1345" data-country-code="ky">
<div class="flag-box">
<div class="iti-flag ky"></div>
</div><span class="country-name">Cayman Islands</span><span class="dial-code">+1345</span>
</li>
<li class="country" data-dial-code="236" data-country-code="cf">
<div class="flag-box">
<div class="iti-flag cf"></div>
</div><span class="country-name">Central African Republic (République centrafricaine)</span><span class="dial-code">+236</span>
</li>
<li class="country" data-dial-code="235" data-country-code="td">
<div class="flag-box">
<div class="iti-flag td"></div>
</div><span class="country-name">Chad (Tchad)</span><span class="dial-code">+235</span>
</li>
<li class="country" data-dial-code="56" data-country-code="cl">
<div class="flag-box">
<div class="iti-flag cl"></div>
</div><span class="country-name">Chile</span><span class="dial-code">+56</span>
</li>
<li class="country" data-dial-code="86" data-country-code="cn">
<div class="flag-box">
<div class="iti-flag cn"></div>
</div><span class="country-name">China (中国)</span><span class="dial-code">+86</span>
</li>
<li class="country" data-dial-code="61" data-country-code="cx">
<div class="flag-box">
<div class="iti-flag cx"></div>
</div><span class="country-name">Christmas Island</span><span class="dial-code">+61</span>
</li>
<li class="country" data-dial-code="61" data-country-code="cc">
<div class="flag-box">
<div class="iti-flag cc"></div>
</div><span class="country-name">Cocos (Keeling) Islands</span><span class="dial-code">+61</span>
</li>
<li class="country" data-dial-code="57" data-country-code="co">
<div class="flag-box">
<div class="iti-flag co"></div>
</div><span class="country-name">Colombia</span><span class="dial-code">+57</span>
</li>
<li class="country" data-dial-code="269" data-country-code="km">
<div class="flag-box">
<div class="iti-flag km"></div>
</div><span class="country-name">Comoros (جزر القمر)</span><span class="dial-code">+269</span>
</li>
<li class="country" data-dial-code="243" data-country-code="cd">
<div class="flag-box">
<div class="iti-flag cd"></div>
</div><span class="country-name">Congo (DRC) (Jamhuri ya Kidemokrasia ya Kongo)</span><span class="dial-code">+243</span>
</li>
<li class="country" data-dial-code="242" data-country-code="cg">
<div class="flag-box">
<div class="iti-flag cg"></div>
</div><span class="country-name">Congo (Republic) (Congo-Brazzaville)</span><span class="dial-code">+242</span>
</li>
<li class="country" data-dial-code="682" data-country-code="ck">
<div class="flag-box">
<div class="iti-flag ck"></div>
</div><span class="country-name">Cook Islands</span><span class="dial-code">+682</span>
</li>
<li class="country" data-dial-code="506" data-country-code="cr">
<div class="flag-box">
<div class="iti-flag cr"></div>
</div><span class="country-name">Costa Rica</span><span class="dial-code">+506</span>
</li>
<li class="country" data-dial-code="225" data-country-code="ci">
<div class="flag-box">
<div class="iti-flag ci"></div>
</div><span class="country-name">Côte d’Ivoire</span><span class="dial-code">+225</span>
</li>
<li class="country" data-dial-code="385" data-country-code="hr">
<div class="flag-box">
<div class="iti-flag hr"></div>
</div><span class="country-name">Croatia (Hrvatska)</span><span class="dial-code">+385</span>
</li>
<li class="country" data-dial-code="53" data-country-code="cu">
<div class="flag-box">
<div class="iti-flag cu"></div>
</div><span class="country-name">Cuba</span><span class="dial-code">+53</span>
</li>
<li class="country" data-dial-code="599" data-country-code="cw">
<div class="flag-box">
<div class="iti-flag cw"></div>
</div><span class="country-name">Curaçao</span><span class="dial-code">+599</span>
</li>
<li class="country" data-dial-code="357" data-country-code="cy">
<div class="flag-box">
<div class="iti-flag cy"></div>
</div><span class="country-name">Cyprus (Κύπρος)</span><span class="dial-code">+357</span>
</li>
<li class="country" data-dial-code="420" data-country-code="cz">
<div class="flag-box">
<div class="iti-flag cz"></div>
</div><span class="country-name">Czech Republic (Česká republika)</span><span class="dial-code">+420</span>
</li>
<li class="country" data-dial-code="45" data-country-code="dk">
<div class="flag-box">
<div class="iti-flag dk"></div>
</div><span class="country-name">Denmark (Danmark)</span><span class="dial-code">+45</span>
</li>
<li class="country" data-dial-code="253" data-country-code="dj">
<div class="flag-box">
<div class="iti-flag dj"></div>
</div><span class="country-name">Djibouti</span><span class="dial-code">+253</span>
</li>
<li class="country" data-dial-code="1767" data-country-code="dm">
<div class="flag-box">
<div class="iti-flag dm"></div>
</div><span class="country-name">Dominica</span><span class="dial-code">+1767</span>
</li>
<li class="country" data-dial-code="1" data-country-code="do">
<div class="flag-box">
<div class="iti-flag do"></div>
</div><span class="country-name">Dominican Republic (República Dominicana)</span><span class="dial-code">+1</span>
</li>
<li class="country" data-dial-code="593" data-country-code="ec">
<div class="flag-box">
<div class="iti-flag ec"></div>
</div><span class="country-name">Ecuador</span><span class="dial-code">+593</span>
</li>
<li class="country" data-dial-code="20" data-country-code="eg">
<div class="flag-box">
<div class="iti-flag eg"></div>
</div><span class="country-name">Egypt (مصر)</span><span class="dial-code">+20</span>
</li>
<li class="country" data-dial-code="503" data-country-code="sv">
<div class="flag-box">
<div class="iti-flag sv"></div>
</div><span class="country-name">El Salvador</span><span class="dial-code">+503</span>
</li>
<li class="country" data-dial-code="240" data-country-code="gq">
<div class="flag-box">
<div class="iti-flag gq"></div>
</div><span class="country-name">Equatorial Guinea (Guinea Ecuatorial)</span><span class="dial-code">+240</span>
</li>
<li class="country" data-dial-code="291" data-country-code="er">
<div class="flag-box">
<div class="iti-flag er"></div>
</div><span class="country-name">Eritrea</span><span class="dial-code">+291</span>
</li>
<li class="country" data-dial-code="372" data-country-code="ee">
<div class="flag-box">
<div class="iti-flag ee"></div>
</div><span class="country-name">Estonia (Eesti)</span><span class="dial-code">+372</span>
</li>
<li class="country" data-dial-code="251" data-country-code="et">
<div class="flag-box">
<div class="iti-flag et"></div>
</div><span class="country-name">Ethiopia</span><span class="dial-code">+251</span>
</li>
<li class="country" data-dial-code="500" data-country-code="fk">
<div class="flag-box">
<div class="iti-flag fk"></div>
</div><span class="country-name">Falkland Islands (Islas Malvinas)</span><span class="dial-code">+500</span>
</li>
<li class="country" data-dial-code="298" data-country-code="fo">
<div class="flag-box">
<div class="iti-flag fo"></div>
</div><span class="country-name">Faroe Islands (Føroyar)</span><span class="dial-code">+298</span>
</li>
<li class="country" data-dial-code="679" data-country-code="fj">
<div class="flag-box">
<div class="iti-flag fj"></div>
</div><span class="country-name">Fiji</span><span class="dial-code">+679</span>
</li>
<li class="country" data-dial-code="358" data-country-code="fi">
<div class="flag-box">
<div class="iti-flag fi"></div>
</div><span class="country-name">Finland (Suomi)</span><span class="dial-code">+358</span>
</li>
<li class="country" data-dial-code="33" data-country-code="fr">
<div class="flag-box">
<div class="iti-flag fr"></div>
</div><span class="country-name">France</span><span class="dial-code">+33</span>
</li>
<li class="country" data-dial-code="594" data-country-code="gf">
<div class="flag-box">
<div class="iti-flag gf"></div>
</div><span class="country-name">French Guiana (Guyane française)</span><span class="dial-code">+594</span>
</li>
<li class="country" data-dial-code="689" data-country-code="pf">
<div class="flag-box">
<div class="iti-flag pf"></div>
</div><span class="country-name">French Polynesia (Polynésie française)</span><span class="dial-code">+689</span>
</li>
<li class="country" data-dial-code="241" data-country-code="ga">
<div class="flag-box">
<div class="iti-flag ga"></div>
</div><span class="country-name">Gabon</span><span class="dial-code">+241</span>
</li>
<li class="country" data-dial-code="220" data-country-code="gm">
<div class="flag-box">
<div class="iti-flag gm"></div>
</div><span class="country-name">Gambia</span><span class="dial-code">+220</span>
</li>
<li class="country" data-dial-code="995" data-country-code="ge">
<div class="flag-box">
<div class="iti-flag ge"></div>
</div><span class="country-name">Georgia (საქართველო)</span><span class="dial-code">+995</span>
</li>
<li class="country" data-dial-code="49" data-country-code="de">
<div class="flag-box">
<div class="iti-flag de"></div>
</div><span class="country-name">Germany (Deutschland)</span><span class="dial-code">+49</span>
</li>
<li class="country" data-dial-code="233" data-country-code="gh">
<div class="flag-box">
<div class="iti-flag gh"></div>
</div><span class="country-name">Ghana (Gaana)</span><span class="dial-code">+233</span>
</li>
<li class="country" data-dial-code="350" data-country-code="gi">
<div class="flag-box">
<div class="iti-flag gi"></div>
</div><span class="country-name">Gibraltar</span><span class="dial-code">+350</span>
</li>
<li class="country" data-dial-code="30" data-country-code="gr">
<div class="flag-box">
<div class="iti-flag gr"></div>
</div><span class="country-name">Greece (Ελλάδα)</span><span class="dial-code">+30</span>
</li>
<li class="country" data-dial-code="299" data-country-code="gl">
<div class="flag-box">
<div class="iti-flag gl"></div>
</div><span class="country-name">Greenland (Kalaallit Nunaat)</span><span class="dial-code">+299</span>
</li>
<li class="country" data-dial-code="1473" data-country-code="gd">
<div class="flag-box">
<div class="iti-flag gd"></div>
</div><span class="country-name">Grenada</span><span class="dial-code">+1473</span>
</li>
<li class="country" data-dial-code="590" data-country-code="gp">
<div class="flag-box">
<div class="iti-flag gp"></div>
</div><span class="country-name">Guadeloupe</span><span class="dial-code">+590</span>
</li>
<li class="country" data-dial-code="1671" data-country-code="gu">
<div class="flag-box">
<div class="iti-flag gu"></div>
</div><span class="country-name">Guam</span><span class="dial-code">+1671</span>
</li>
<li class="country" data-dial-code="502" data-country-code="gt">
<div class="flag-box">
<div class="iti-flag gt"></div>
</div><span class="country-name">Guatemala</span><span class="dial-code">+502</span>
</li>
<li class="country" data-dial-code="44" data-country-code="gg">
<div class="flag-box">
<div class="iti-flag gg"></div>
</div><span class="country-name">Guernsey</span><span class="dial-code">+44</span>
</li>
<li class="country" data-dial-code="224" data-country-code="gn">
<div class="flag-box">
<div class="iti-flag gn"></div>
</div><span class="country-name">Guinea (Guinée)</span><span class="dial-code">+224</span>
</li>
<li class="country" data-dial-code="245" data-country-code="gw">
<div class="flag-box">
<div class="iti-flag gw"></div>
</div><span class="country-name">Guinea-Bissau (Guiné Bissau)</span><span class="dial-code">+245</span>
</li>
<li class="country" data-dial-code="592" data-country-code="gy">
<div class="flag-box">
<div class="iti-flag gy"></div>
</div><span class="country-name">Guyana</span><span class="dial-code">+592</span>
</li>
<li class="country" data-dial-code="509" data-country-code="ht">
<div class="flag-box">
<div class="iti-flag ht"></div>
</div><span class="country-name">Haiti</span><span class="dial-code">+509</span>
</li>
<li class="country" data-dial-code="504" data-country-code="hn">
<div class="flag-box">
<div class="iti-flag hn"></div>
</div><span class="country-name">Honduras</span><span class="dial-code">+504</span>
</li>
<li class="country" data-dial-code="852" data-country-code="hk">
<div class="flag-box">
<div class="iti-flag hk"></div>
</div><span class="country-name">Hong Kong (香港)</span><span class="dial-code">+852</span>
</li>
<li class="country" data-dial-code="36" data-country-code="hu">
<div class="flag-box">
<div class="iti-flag hu"></div>
</div><span class="country-name">Hungary (Magyarország)</span><span class="dial-code">+36</span>
</li>
<li class="country" data-dial-code="354" data-country-code="is">
<div class="flag-box">
<div class="iti-flag is"></div>
</div><span class="country-name">Iceland (Ísland)</span><span class="dial-code">+354</span>
</li>
<li class="country" data-dial-code="91" data-country-code="in">
<div class="flag-box">
<div class="iti-flag in"></div>
</div><span class="country-name">India (भारत)</span><span class="dial-code">+91</span>
</li>
<li class="country" data-dial-code="62" data-country-code="id">
<div class="flag-box">
<div class="iti-flag id"></div>
</div><span class="country-name">Indonesia</span><span class="dial-code">+62</span>
</li>
<li class="country" data-dial-code="98" data-country-code="ir">
<div class="flag-box">
<div class="iti-flag ir"></div>
</div><span class="country-name">Iran (ایران)</span><span class="dial-code">+98</span>
</li>
<li class="country" data-dial-code="964" data-country-code="iq">
<div class="flag-box">
<div class="iti-flag iq"></div>
</div><span class="country-name">Iraq (العراق)</span><span class="dial-code">+964</span>
</li>
<li class="country" data-dial-code="353" data-country-code="ie">
<div class="flag-box">
<div class="iti-flag ie"></div>
</div><span class="country-name">Ireland</span><span class="dial-code">+353</span>
</li>
<li class="country" data-dial-code="44" data-country-code="im">
<div class="flag-box">
<div class="iti-flag im"></div>
</div><span class="country-name">Isle of Man</span><span class="dial-code">+44</span>
</li>
<li class="country" data-dial-code="972" data-country-code="il">
<div class="flag-box">
<div class="iti-flag il"></div>
</div><span class="country-name">Israel (ישראל)</span><span class="dial-code">+972</span>
</li>
<li class="country" data-dial-code="39" data-country-code="it">
<div class="flag-box">
<div class="iti-flag it"></div>
</div><span class="country-name">Italy (Italia)</span><span class="dial-code">+39</span>
</li>
<li class="country" data-dial-code="1876" data-country-code="jm">
<div class="flag-box">
<div class="iti-flag jm"></div>
</div><span class="country-name">Jamaica</span><span class="dial-code">+1876</span>
</li>
<li class="country" data-dial-code="81" data-country-code="jp">
<div class="flag-box">
<div class="iti-flag jp"></div>
</div><span class="country-name">Japan (日本)</span><span class="dial-code">+81</span>
</li>
<li class="country" data-dial-code="44" data-country-code="je">
<div class="flag-box">
<div class="iti-flag je"></div>
</div><span class="country-name">Jersey</span><span class="dial-code">+44</span>
</li>
<li class="country" data-dial-code="962" data-country-code="jo">
<div class="flag-box">
<div class="iti-flag jo"></div>
</div><span class="country-name">Jordan (الأردن)</span><span class="dial-code">+962</span>
</li>
<li class="country" data-dial-code="7" data-country-code="kz">
<div class="flag-box">
<div class="iti-flag kz"></div>
</div><span class="country-name">Kazakhstan (Казахстан)</span><span class="dial-code">+7</span>
</li>
<li class="country" data-dial-code="254" data-country-code="ke">
<div class="flag-box">
<div class="iti-flag ke"></div>
</div><span class="country-name">Kenya</span><span class="dial-code">+254</span>
</li>
<li class="country" data-dial-code="686" data-country-code="ki">
<div class="flag-box">
<div class="iti-flag ki"></div>
</div><span class="country-name">Kiribati</span><span class="dial-code">+686</span>
</li>
<li class="country" data-dial-code="383" data-country-code="xk">
<div class="flag-box">
<div class="iti-flag xk"></div>
</div><span class="country-name">Kosovo</span><span class="dial-code">+383</span>
</li>
<li class="country" data-dial-code="965" data-country-code="kw">
<div class="flag-box">
<div class="iti-flag kw"></div>
</div><span class="country-name">Kuwait (الكويت)</span><span class="dial-code">+965</span>
</li>
<li class="country" data-dial-code="996" data-country-code="kg">
<div class="flag-box">
<div class="iti-flag kg"></div>
</div><span class="country-name">Kyrgyzstan (Кыргызстан)</span><span class="dial-code">+996</span>
</li>
<li class="country" data-dial-code="856" data-country-code="la">
<div class="flag-box">
<div class="iti-flag la"></div>
</div><span class="country-name">Laos (ລາວ)</span><span class="dial-code">+856</span>
</li>
<li class="country" data-dial-code="371" data-country-code="lv">
<div class="flag-box">
<div class="iti-flag lv"></div>
</div><span class="country-name">Latvia (Latvija)</span><span class="dial-code">+371</span>
</li>
<li class="country" data-dial-code="961" data-country-code="lb">
<div class="flag-box">
<div class="iti-flag lb"></div>
</div><span class="country-name">Lebanon (لبنان)</span><span class="dial-code">+961</span>
</li>
<li class="country" data-dial-code="266" data-country-code="ls">
<div class="flag-box">
<div class="iti-flag ls"></div>
</div><span class="country-name">Lesotho</span><span class="dial-code">+266</span>
</li>
<li class="country" data-dial-code="231" data-country-code="lr">
<div class="flag-box">
<div class="iti-flag lr"></div>
</div><span class="country-name">Liberia</span><span class="dial-code">+231</span>
</li>
<li class="country" data-dial-code="218" data-country-code="ly">
<div class="flag-box">
<div class="iti-flag ly"></div>
</div><span class="country-name">Libya (ليبيا)</span><span class="dial-code">+218</span>
</li>
<li class="country" data-dial-code="423" data-country-code="li">
<div class="flag-box">
<div class="iti-flag li"></div>
</div><span class="country-name">Liechtenstein</span><span class="dial-code">+423</span>
</li>
<li class="country" data-dial-code="370" data-country-code="lt">
<div class="flag-box">
<div class="iti-flag lt"></div>
</div><span class="country-name">Lithuania (Lietuva)</span><span class="dial-code">+370</span>
</li>
<li class="country" data-dial-code="352" data-country-code="lu">
<div class="flag-box">
<div class="iti-flag lu"></div>
</div><span class="country-name">Luxembourg</span><span class="dial-code">+352</span>
</li>
<li class="country" data-dial-code="853" data-country-code="mo">
<div class="flag-box">
<div class="iti-flag mo"></div>
</div><span class="country-name">Macau (澳門)</span><span class="dial-code">+853</span>
</li>
<li class="country" data-dial-code="389" data-country-code="mk">
<div class="flag-box">
<div class="iti-flag mk"></div>
</div><span class="country-name">Macedonia (FYROM) (Македонија)</span><span class="dial-code">+389</span>
</li>
<li class="country" data-dial-code="261" data-country-code="mg">
<div class="flag-box">
<div class="iti-flag mg"></div>
</div><span class="country-name">Madagascar (Madagasikara)</span><span class="dial-code">+261</span>
</li>
<li class="country" data-dial-code="265" data-country-code="mw">
<div class="flag-box">
<div class="iti-flag mw"></div>
</div><span class="country-name">Malawi</span><span class="dial-code">+265</span>
</li>
<li class="country" data-dial-code="60" data-country-code="my">
<div class="flag-box">
<div class="iti-flag my"></div>
</div><span class="country-name">Malaysia</span><span class="dial-code">+60</span>
</li>
<li class="country" data-dial-code="960" data-country-code="mv">
<div class="flag-box">
<div class="iti-flag mv"></div>
</div><span class="country-name">Maldives</span><span class="dial-code">+960</span>
</li>
<li class="country" data-dial-code="223" data-country-code="ml">
<div class="flag-box">
<div class="iti-flag ml"></div>
</div><span class="country-name">Mali</span><span class="dial-code">+223</span>
</li>
<li class="country" data-dial-code="356" data-country-code="mt">
<div class="flag-box">
<div class="iti-flag mt"></div>
</div><span class="country-name">Malta</span><span class="dial-code">+356</span>
</li>
<li class="country" data-dial-code="692" data-country-code="mh">
<div class="flag-box">
<div class="iti-flag mh"></div>
</div><span class="country-name">Marshall Islands</span><span class="dial-code">+692</span>
</li>
<li class="country" data-dial-code="596" data-country-code="mq">
<div class="flag-box">
<div class="iti-flag mq"></div>
</div><span class="country-name">Martinique</span><span class="dial-code">+596</span>
</li>
<li class="country" data-dial-code="222" data-country-code="mr">
<div class="flag-box">
<div class="iti-flag mr"></div>
</div><span class="country-name">Mauritania (موريتانيا)</span><span class="dial-code">+222</span>
</li>
<li class="country" data-dial-code="230" data-country-code="mu">
<div class="flag-box">
<div class="iti-flag mu"></div>
</div><span class="country-name">Mauritius (Moris)</span><span class="dial-code">+230</span>
</li>
<li class="country" data-dial-code="262" data-country-code="yt">
<div class="flag-box">
<div class="iti-flag yt"></div>
</div><span class="country-name">Mayotte</span><span class="dial-code">+262</span>
</li>
<li class="country" data-dial-code="52" data-country-code="mx">
<div class="flag-box">
<div class="iti-flag mx"></div>
</div><span class="country-name">Mexico (México)</span><span class="dial-code">+52</span>
</li>
<li class="country" data-dial-code="691" data-country-code="fm">
<div class="flag-box">
<div class="iti-flag fm"></div>
</div><span class="country-name">Micronesia</span><span class="dial-code">+691</span>
</li>
<li class="country" data-dial-code="373" data-country-code="md">
<div class="flag-box">
<div class="iti-flag md"></div>
</div><span class="country-name">Moldova (Republica Moldova)</span><span class="dial-code">+373</span>
</li>
<li class="country" data-dial-code="377" data-country-code="mc">
<div class="flag-box">
<div class="iti-flag mc"></div>
</div><span class="country-name">Monaco</span><span class="dial-code">+377</span>
</li>
<li class="country" data-dial-code="976" data-country-code="mn">
<div class="flag-box">
<div class="iti-flag mn"></div>
</div><span class="country-name">Mongolia (Монгол)</span><span class="dial-code">+976</span>
</li>
<li class="country" data-dial-code="382" data-country-code="me">
<div class="flag-box">
<div class="iti-flag me"></div>
</div><span class="country-name">Montenegro (Crna Gora)</span><span class="dial-code">+382</span>
</li>
<li class="country" data-dial-code="1664" data-country-code="ms">
<div class="flag-box">
<div class="iti-flag ms"></div>
</div><span class="country-name">Montserrat</span><span class="dial-code">+1664</span>
</li>
<li class="country" data-dial-code="212" data-country-code="ma">
<div class="flag-box">
<div class="iti-flag ma"></div>
</div><span class="country-name">Morocco (المغرب)</span><span class="dial-code">+212</span>
</li>
<li class="country" data-dial-code="258" data-country-code="mz">
<div class="flag-box">
<div class="iti-flag mz"></div>
</div><span class="country-name">Mozambique (Moçambique)</span><span class="dial-code">+258</span>
</li>
<li class="country" data-dial-code="95" data-country-code="mm">
<div class="flag-box">
<div class="iti-flag mm"></div>
</div><span class="country-name">Myanmar (Burma) (မြန်မာ)</span><span class="dial-code">+95</span>
</li>
<li class="country" data-dial-code="264" data-country-code="na">
<div class="flag-box">
<div class="iti-flag na"></div>
</div><span class="country-name">Namibia (Namibië)</span><span class="dial-code">+264</span>
</li>
<li class="country" data-dial-code="674" data-country-code="nr">
<div class="flag-box">
<div class="iti-flag nr"></div>
</div><span class="country-name">Nauru</span><span class="dial-code">+674</span>
</li>
<li class="country" data-dial-code="977" data-country-code="np">
<div class="flag-box">
<div class="iti-flag np"></div>
</div><span class="country-name">Nepal (नेपाल)</span><span class="dial-code">+977</span>
</li>
<li class="country" data-dial-code="31" data-country-code="nl">
<div class="flag-box">
<div class="iti-flag nl"></div>
</div><span class="country-name">Netherlands (Nederland)</span><span class="dial-code">+31</span>
</li>
<li class="country" data-dial-code="687" data-country-code="nc">
<div class="flag-box">
<div class="iti-flag nc"></div>
</div><span class="country-name">New Caledonia (Nouvelle-Calédonie)</span><span class="dial-code">+687</span>
</li>
<li class="country" data-dial-code="64" data-country-code="nz">
<div class="flag-box">
<div class="iti-flag nz"></div>
</div><span class="country-name">New Zealand</span><span class="dial-code">+64</span>
</li>
<li class="country" data-dial-code="505" data-country-code="ni">
<div class="flag-box">
<div class="iti-flag ni"></div>
</div><span class="country-name">Nicaragua</span><span class="dial-code">+505</span>
</li>
<li class="country" data-dial-code="227" data-country-code="ne">
<div class="flag-box">
<div class="iti-flag ne"></div>
</div><span class="country-name">Niger (Nijar)</span><span class="dial-code">+227</span>
</li>
<li class="country" data-dial-code="234" data-country-code="ng">
<div class="flag-box">
<div class="iti-flag ng"></div>
</div><span class="country-name">Nigeria</span><span class="dial-code">+234</span>
</li>
<li class="country" data-dial-code="683" data-country-code="nu">
<div class="flag-box">
<div class="iti-flag nu"></div>
</div><span class="country-name">Niue</span><span class="dial-code">+683</span>
</li>
<li class="country" data-dial-code="672" data-country-code="nf">
<div class="flag-box">
<div class="iti-flag nf"></div>
</div><span class="country-name">Norfolk Island</span><span class="dial-code">+672</span>
</li>
<li class="country" data-dial-code="850" data-country-code="kp">
<div class="flag-box">
<div class="iti-flag kp"></div>
</div><span class="country-name">North Korea (조선 민주주의 인민 공화국)</span><span class="dial-code">+850</span>
</li>
<li class="country" data-dial-code="1670" data-country-code="mp">
<div class="flag-box">
<div class="iti-flag mp"></div>
</div><span class="country-name">Northern Mariana Islands</span><span class="dial-code">+1670</span>
</li>
<li class="country" data-dial-code="47" data-country-code="no">
<div class="flag-box">
<div class="iti-flag no"></div>
</div><span class="country-name">Norway (Norge)</span><span class="dial-code">+47</span>
</li>
<li class="country" data-dial-code="968" data-country-code="om">
<div class="flag-box">
<div class="iti-flag om"></div>
</div><span class="country-name">Oman (عُمان)</span><span class="dial-code">+968</span>
</li>
<li class="country" data-dial-code="92" data-country-code="pk">
<div class="flag-box">
<div class="iti-flag pk"></div>
</div><span class="country-name">Pakistan (پاکستان)</span><span class="dial-code">+92</span>
</li>
<li class="country" data-dial-code="680" data-country-code="pw">
<div class="flag-box">
<div class="iti-flag pw"></div>
</div><span class="country-name">Palau</span><span class="dial-code">+680</span>
</li>
<li class="country" data-dial-code="970" data-country-code="ps">
<div class="flag-box">
<div class="iti-flag ps"></div>
</div><span class="country-name">Palestine (فلسطين)</span><span class="dial-code">+970</span>
</li>
<li class="country" data-dial-code="507" data-country-code="pa">
<div class="flag-box">
<div class="iti-flag pa"></div>
</div><span class="country-name">Panama (Panamá)</span><span class="dial-code">+507</span>
</li>
<li class="country" data-dial-code="675" data-country-code="pg">
<div class="flag-box">
<div class="iti-flag pg"></div>
</div><span class="country-name">Papua New Guinea</span><span class="dial-code">+675</span>
</li>
<li class="country" data-dial-code="595" data-country-code="py">
<div class="flag-box">
<div class="iti-flag py"></div>
</div><span class="country-name">Paraguay</span><span class="dial-code">+595</span>
</li>
<li class="country" data-dial-code="51" data-country-code="pe">
<div class="flag-box">
<div class="iti-flag pe"></div>
</div><span class="country-name">Peru (Perú)</span><span class="dial-code">+51</span>
</li>
<li class="country" data-dial-code="63" data-country-code="ph">
<div class="flag-box">
<div class="iti-flag ph"></div>
</div><span class="country-name">Philippines</span><span class="dial-code">+63</span>
</li>
<li class="country" data-dial-code="48" data-country-code="pl">
<div class="flag-box">
<div class="iti-flag pl"></div>
</div><span class="country-name">Poland (Polska)</span><span class="dial-code">+48</span>
</li>
<li class="country" data-dial-code="351" data-country-code="pt">
<div class="flag-box">
<div class="iti-flag pt"></div>
</div><span class="country-name">Portugal</span><span class="dial-code">+351</span>
</li>
<li class="country" data-dial-code="1" data-country-code="pr">
<div class="flag-box">
<div class="iti-flag pr"></div>
</div><span class="country-name">Puerto Rico</span><span class="dial-code">+1</span>
</li>
<li class="country" data-dial-code="974" data-country-code="qa">
<div class="flag-box">
<div class="iti-flag qa"></div>
</div><span class="country-name">Qatar (قطر)</span><span class="dial-code">+974</span>
</li>
<li class="country" data-dial-code="262" data-country-code="re">
<div class="flag-box">
<div class="iti-flag re"></div>
</div><span class="country-name">Réunion (La Réunion)</span><span class="dial-code">+262</span>
</li>
<li class="country" data-dial-code="40" data-country-code="ro">
<div class="flag-box">
<div class="iti-flag ro"></div>
</div><span class="country-name">Romania (România)</span><span class="dial-code">+40</span>
</li>
<li class="country" data-dial-code="7" data-country-code="ru">
<div class="flag-box">
<div class="iti-flag ru"></div>
</div><span class="country-name">Russia (Россия)</span><span class="dial-code">+7</span>
</li>
<li class="country" data-dial-code="250" data-country-code="rw">
<div class="flag-box">
<div class="iti-flag rw"></div>
</div><span class="country-name">Rwanda</span><span class="dial-code">+250</span>
</li>
<li class="country" data-dial-code="590" data-country-code="bl">
<div class="flag-box">
<div class="iti-flag bl"></div>
</div><span class="country-name">Saint Barthélemy</span><span class="dial-code">+590</span>
</li>
<li class="country" data-dial-code="290" data-country-code="sh">
<div class="flag-box">
<div class="iti-flag sh"></div>
</div><span class="country-name">Saint Helena</span><span class="dial-code">+290</span>
</li>
<li class="country" data-dial-code="1869" data-country-code="kn">
<div class="flag-box">
<div class="iti-flag kn"></div>
</div><span class="country-name">Saint Kitts and Nevis</span><span class="dial-code">+1869</span>
</li>
<li class="country" data-dial-code="1758" data-country-code="lc">
<div class="flag-box">
<div class="iti-flag lc"></div>
</div><span class="country-name">Saint Lucia</span><span class="dial-code">+1758</span>
</li>
<li class="country" data-dial-code="590" data-country-code="mf">
<div class="flag-box">
<div class="iti-flag mf"></div>
</div><span class="country-name">Saint Martin (Saint-Martin (partie française))</span><span class="dial-code">+590</span>
</li>
<li class="country" data-dial-code="508" data-country-code="pm">
<div class="flag-box">
<div class="iti-flag pm"></div>
</div><span class="country-name">Saint Pierre and Miquelon (Saint-Pierre-et-Miquelon)</span><span class="dial-code">+508</span>
</li>
<li class="country" data-dial-code="1784" data-country-code="vc">
<div class="flag-box">
<div class="iti-flag vc"></div>
</div><span class="country-name">Saint Vincent and the Grenadines</span><span class="dial-code">+1784</span>
</li>
<li class="country" data-dial-code="685" data-country-code="ws">
<div class="flag-box">
<div class="iti-flag ws"></div>
</div><span class="country-name">Samoa</span><span class="dial-code">+685</span>
</li>
<li class="country" data-dial-code="378" data-country-code="sm">
<div class="flag-box">
<div class="iti-flag sm"></div>
</div><span class="country-name">San Marino</span><span class="dial-code">+378</span>
</li>
<li class="country" data-dial-code="239" data-country-code="st">
<div class="flag-box">
<div class="iti-flag st"></div>
</div><span class="country-name">São Tomé and Príncipe (São Tomé e Príncipe)</span><span class="dial-code">+239</span>
</li>
<li class="country" data-dial-code="966" data-country-code="sa">
<div class="flag-box">
<div class="iti-flag sa"></div>
</div><span class="country-name">Saudi Arabia (المملكة العربية السعودية)</span><span class="dial-code">+966</span>
</li>
<li class="country" data-dial-code="221" data-country-code="sn">
<div class="flag-box">
<div class="iti-flag sn"></div>
</div><span class="country-name">Senegal (Sénégal)</span><span class="dial-code">+221</span>
</li>
<li class="country" data-dial-code="381" data-country-code="rs">
<div class="flag-box">
<div class="iti-flag rs"></div>
</div><span class="country-name">Serbia (Србија)</span><span class="dial-code">+381</span>
</li>
<li class="country" data-dial-code="248" data-country-code="sc">
<div class="flag-box">
<div class="iti-flag sc"></div>
</div><span class="country-name">Seychelles</span><span class="dial-code">+248</span>
</li>
<li class="country" data-dial-code="232" data-country-code="sl">
<div class="flag-box">
<div class="iti-flag sl"></div>
</div><span class="country-name">Sierra Leone</span><span class="dial-code">+232</span>
</li>
<li class="country" data-dial-code="65" data-country-code="sg">
<div class="flag-box">
<div class="iti-flag sg"></div>
</div><span class="country-name">Singapore</span><span class="dial-code">+65</span>
</li>
<li class="country" data-dial-code="1721" data-country-code="sx">
<div class="flag-box">
<div class="iti-flag sx"></div>
</div><span class="country-name">Sint Maarten</span><span class="dial-code">+1721</span>
</li>
<li class="country" data-dial-code="421" data-country-code="sk">
<div class="flag-box">
<div class="iti-flag sk"></div>
</div><span class="country-name">Slovakia (Slovensko)</span><span class="dial-code">+421</span>
</li>
<li class="country" data-dial-code="386" data-country-code="si">
<div class="flag-box">
<div class="iti-flag si"></div>
</div><span class="country-name">Slovenia (Slovenija)</span><span class="dial-code">+386</span>
</li>
<li class="country" data-dial-code="677" data-country-code="sb">
<div class="flag-box">
<div class="iti-flag sb"></div>
</div><span class="country-name">Solomon Islands</span><span class="dial-code">+677</span>
</li>
<li class="country" data-dial-code="252" data-country-code="so">
<div class="flag-box">
<div class="iti-flag so"></div>
</div><span class="country-name">Somalia (Soomaaliya)</span><span class="dial-code">+252</span>
</li>
<li class="country" data-dial-code="27" data-country-code="za">
<div class="flag-box">
<div class="iti-flag za"></div>
</div><span class="country-name">South Africa</span><span class="dial-code">+27</span>
</li>
<li class="country" data-dial-code="82" data-country-code="kr">
<div class="flag-box">
<div class="iti-flag kr"></div>
</div><span class="country-name">South Korea (대한민국)</span><span class="dial-code">+82</span>
</li>
<li class="country" data-dial-code="211" data-country-code="ss">
<div class="flag-box">
<div class="iti-flag ss"></div>
</div><span class="country-name">South Sudan (جنوب السودان)</span><span class="dial-code">+211</span>
</li>
<li class="country" data-dial-code="34" data-country-code="es">
<div class="flag-box">
<div class="iti-flag es"></div>
</div><span class="country-name">Spain (España)</span><span class="dial-code">+34</span>
</li>
<li class="country" data-dial-code="94" data-country-code="lk">
<div class="flag-box">
<div class="iti-flag lk"></div>
</div><span class="country-name">Sri Lanka (ශ්රී ලංකාව)</span><span class="dial-code">+94</span>
</li>
<li class="country" data-dial-code="249" data-country-code="sd">
<div class="flag-box">
<div class="iti-flag sd"></div>
</div><span class="country-name">Sudan (السودان)</span><span class="dial-code">+249</span>
</li>
<li class="country" data-dial-code="597" data-country-code="sr">
<div class="flag-box">
<div class="iti-flag sr"></div>
</div><span class="country-name">Suriname</span><span class="dial-code">+597</span>
</li>
<li class="country" data-dial-code="47" data-country-code="sj">
<div class="flag-box">
<div class="iti-flag sj"></div>
</div><span class="country-name">Svalbard and Jan Mayen</span><span class="dial-code">+47</span>
</li>
<li class="country" data-dial-code="268" data-country-code="sz">
<div class="flag-box">
<div class="iti-flag sz"></div>
</div><span class="country-name">Swaziland</span><span class="dial-code">+268</span>
</li>
<li class="country" data-dial-code="46" data-country-code="se">
<div class="flag-box">
<div class="iti-flag se"></div>
</div><span class="country-name">Sweden (Sverige)</span><span class="dial-code">+46</span>
</li>
<li class="country" data-dial-code="41" data-country-code="ch">
<div class="flag-box">
<div class="iti-flag ch"></div>
</div><span class="country-name">Switzerland (Schweiz)</span><span class="dial-code">+41</span>
</li>
<li class="country" data-dial-code="963" data-country-code="sy">
<div class="flag-box">
<div class="iti-flag sy"></div>
</div><span class="country-name">Syria (سوريا)</span><span class="dial-code">+963</span>
</li>
<li class="country" data-dial-code="886" data-country-code="tw">
<div class="flag-box">
<div class="iti-flag tw"></div>
</div><span class="country-name">Taiwan (台灣)</span><span class="dial-code">+886</span>
</li>
<li class="country" data-dial-code="992" data-country-code="tj">
<div class="flag-box">
<div class="iti-flag tj"></div>
</div><span class="country-name">Tajikistan</span><span class="dial-code">+992</span>
</li>
<li class="country" data-dial-code="255" data-country-code="tz">
<div class="flag-box">
<div class="iti-flag tz"></div>
</div><span class="country-name">Tanzania</span><span class="dial-code">+255</span>
</li>
<li class="country" data-dial-code="66" data-country-code="th">
<div class="flag-box">
<div class="iti-flag th"></div>
</div><span class="country-name">Thailand (ไทย)</span><span class="dial-code">+66</span>
</li>
<li class="country" data-dial-code="670" data-country-code="tl">
<div class="flag-box">
<div class="iti-flag tl"></div>
</div><span class="country-name">Timor-Leste</span><span class="dial-code">+670</span>
</li>
<li class="country" data-dial-code="228" data-country-code="tg">
<div class="flag-box">
<div class="iti-flag tg"></div>
</div><span class="country-name">Togo</span><span class="dial-code">+228</span>
</li>
<li class="country" data-dial-code="690" data-country-code="tk">
<div class="flag-box">
<div class="iti-flag tk"></div>
</div><span class="country-name">Tokelau</span><span class="dial-code">+690</span>
</li>
<li class="country" data-dial-code="676" data-country-code="to">
<div class="flag-box">
<div class="iti-flag to"></div>
</div><span class="country-name">Tonga</span><span class="dial-code">+676</span>
</li>
<li class="country" data-dial-code="1868" data-country-code="tt">
<div class="flag-box">
<div class="iti-flag tt"></div>
</div><span class="country-name">Trinidad and Tobago</span><span class="dial-code">+1868</span>
</li>
<li class="country" data-dial-code="216" data-country-code="tn">
<div class="flag-box">
<div class="iti-flag tn"></div>
</div><span class="country-name">Tunisia (تونس)</span><span class="dial-code">+216</span>
</li>
<li class="country" data-dial-code="90" data-country-code="tr">
<div class="flag-box">
<div class="iti-flag tr"></div>
</div><span class="country-name">Turkey (Türkiye)</span><span class="dial-code">+90</span>
</li>
<li class="country" data-dial-code="993" data-country-code="tm">
<div class="flag-box">
<div class="iti-flag tm"></div>
</div><span class="country-name">Turkmenistan</span><span class="dial-code">+993</span>
</li>
<li class="country" data-dial-code="1649" data-country-code="tc">
<div class="flag-box">
<div class="iti-flag tc"></div>
</div><span class="country-name">Turks and Caicos Islands</span><span class="dial-code">+1649</span>
</li>
<li class="country" data-dial-code="688" data-country-code="tv">
<div class="flag-box">
<div class="iti-flag tv"></div>
</div><span class="country-name">Tuvalu</span><span class="dial-code">+688</span>
</li>
<li class="country" data-dial-code="1340" data-country-code="vi">
<div class="flag-box">
<div class="iti-flag vi"></div>
</div><span class="country-name">U.S. Virgin Islands</span><span class="dial-code">+1340</span>
</li>
<li class="country" data-dial-code="256" data-country-code="ug">
<div class="flag-box">
<div class="iti-flag ug"></div>
</div><span class="country-name">Uganda</span><span class="dial-code">+256</span>
</li>
<li class="country" data-dial-code="380" data-country-code="ua">
<div class="flag-box">
<div class="iti-flag ua"></div>
</div><span class="country-name">Ukraine (Україна)</span><span class="dial-code">+380</span>
</li>
<li class="country" data-dial-code="971" data-country-code="ae">
<div class="flag-box">
<div class="iti-flag ae"></div>
</div><span class="country-name">United Arab Emirates (الإمارات العربية المتحدة)</span><span class="dial-code">+971</span>
</li>
<li class="country" data-dial-code="44" data-country-code="gb">
<div class="flag-box">
<div class="iti-flag gb"></div>
</div><span class="country-name">United Kingdom</span><span class="dial-code">+44</span>
</li>
<li class="country" data-dial-code="1" data-country-code="us">
<div class="flag-box">
<div class="iti-flag us"></div>
</div><span class="country-name">United States</span><span class="dial-code">+1</span>
</li>
<li class="country" data-dial-code="598" data-country-code="uy">
<div class="flag-box">
<div class="iti-flag uy"></div>
</div><span class="country-name">Uruguay</span><span class="dial-code">+598</span>
</li>
<li class="country" data-dial-code="998" data-country-code="uz">
<div class="flag-box">
<div class="iti-flag uz"></div>
</div><span class="country-name">Uzbekistan (Oʻzbekiston)</span><span class="dial-code">+998</span>
</li>
<li class="country" data-dial-code="678" data-country-code="vu">
<div class="flag-box">
<div class="iti-flag vu"></div>
</div><span class="country-name">Vanuatu</span><span class="dial-code">+678</span>
</li>
<li class="country" data-dial-code="39" data-country-code="va">
<div class="flag-box">
<div class="iti-flag va"></div>
</div><span class="country-name">Vatican City (Città del Vaticano)</span><span class="dial-code">+39</span>
</li>
<li class="country" data-dial-code="58" data-country-code="ve">
<div class="flag-box">
<div class="iti-flag ve"></div>
</div><span class="country-name">Venezuela</span><span class="dial-code">+58</span>
</li>
<li class="country" data-dial-code="84" data-country-code="vn">
<div class="flag-box">
<div class="iti-flag vn"></div>
</div><span class="country-name">Vietnam (Việt Nam)</span><span class="dial-code">+84</span>
</li>
<li class="country" data-dial-code="681" data-country-code="wf">
<div class="flag-box">
<div class="iti-flag wf"></div>
</div><span class="country-name">Wallis and Futuna (Wallis-et-Futuna)</span><span class="dial-code">+681</span>
</li>
<li class="country" data-dial-code="212" data-country-code="eh">
<div class="flag-box">
<div class="iti-flag eh"></div>
</div><span class="country-name">Western Sahara (الصحراء الغربية)</span><span class="dial-code">+212</span>
</li>
<li class="country" data-dial-code="967" data-country-code="ye">
<div class="flag-box">
<div class="iti-flag ye"></div>
</div><span class="country-name">Yemen (اليمن)</span><span class="dial-code">+967</span>
</li>
<li class="country" data-dial-code="260" data-country-code="zm">
<div class="flag-box">
<div class="iti-flag zm"></div>
</div><span class="country-name">Zambia</span><span class="dial-code">+260</span>
</li>
<li class="country" data-dial-code="263" data-country-code="zw">
<div class="flag-box">
<div class="iti-flag zw"></div>
</div><span class="country-name">Zimbabwe</span><span class="dial-code">+263</span>
</li>
<li class="country" data-dial-code="358" data-country-code="ax">
<div class="flag-box">
<div class="iti-flag ax"></div>
</div><span class="country-name">Åland Islands</span><span class="dial-code">+358</span>
</li>
</ul>
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re="^(?:(?:\(?(?:00|\+)([1-4]\d\d|[1-9]\d?)\)?)?[\-\.\ \\\/]?)?((?:\(?\d{1,}\)?[\-\.\ \\\/]?){7,})(?:[\-\.\ \\\/]?(?:#|ext\.?|extension|x)[\-\.\ \\\/]?(\d+))?$" validationtype="text" autocomplete="off" maxlength="100">
</div>
<div class="fieldError label-error" id="aia1108825939_msg" requiredmessage="*Contact number is required" remessage="*Invalid phone number format."></div>
</div>
<div class="text parbase section">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-bottom-md-l margin-top-sm-l margin-bottom-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<p>My bank is*<br> </p>
</div>
</div>
<div class="form-dropdown form-base section">
<select class="primary-select parent-width" name="bank" id="aia2101546372" required="true" style="color: #B3B1A8;">
<option value="" selected="selected" default="" disabled="" style="color:#B3B1A8">Please select a bank</option>
<option value="BPI">BPI</option>
<option value="BFB">BFB</option>
</select>
<div class="fieldError label-error" id="aia2101546372_msg" requiredmessage="*Bank is required"></div>
<script type="text/javascript">
+ function($) {
"use strict";
$("#aia2101546372").click(function() {
var current = $(this).val();
if (current != null) {
$("#aia2101546372").css('color', '#554344');
}
});
$("#aia2101546372").change(function() {
$(this).css({
'color': '#554344'
});
});
}(jQuery);
</script>
</div>
<div class="text parbase section">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-bottom-md-l margin-top-sm-l margin-bottom-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<p>My province is*<br> </p>
</div>
</div>
<div class="form-dropdown form-base section">
<select class="primary-select parent-width" name="province" id="aia1409993103" required="true" style="color: #B3B1A8;">
</select>
<div class="fieldError label-error" id="aia1409993103_msg" requiredmessage="*Province is required"></div>
<script type="text/javascript">
+ function($) {
"use strict";
$("#aia1409993103").click(function() {
var current = $(this).val();
if (current != null) {
$("#aia1409993103").css('color', '#554344');
}
});
$("#aia1409993103").change(function() {
$(this).css({
'color': '#554344'
});
});
}(jQuery);
</script>
</div>
<div class="text parbase section">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-bottom-md-l margin-top-sm-l margin-bottom-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<p>My city/municipality is*<br> </p>
</div>
</div>
<div class="form-dropdown form-base section">
<select class="primary-select parent-width" name="cityMunicipality" id="aia1345301892" required="true" style="color: #B3B1A8;">
</select>
<div class="fieldError label-error" id="aia1345301892_msg" requiredmessage="*City/Municipality is required"></div>
<script type="text/javascript">
+ function($) {
"use strict";
$("#aia1345301892").click(function() {
var current = $(this).val();
if (current != null) {
$("#aia1345301892").css('color', '#554344');
}
});
$("#aia1345301892").change(function() {
$(this).css({
'color': '#554344'
});
});
}(jQuery);
</script>
</div>
<div class="text parbase section">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-bottom-md-l margin-top-sm-l margin-bottom-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<p>My preferred BPI branch is*<br> </p>
</div>
</div>
<div class="form-dropdown form-base section">
<select class="primary-select parent-width" name="branch" id="aia457034458" required="true" style="color: #B3B1A8;">
</select>
<div class="fieldError label-error" id="aia457034458_msg" requiredmessage="*BPI branch is required"></div>
<script type="text/javascript">
+ function($) {
"use strict";
$("#aia457034458").click(function() {
var current = $(this).val();
if (current != null) {
$("#aia457034458").css('color', '#554344');
}
});
$("#aia457034458").change(function() {
$(this).css({
'color': '#554344'
});
});
}(jQuery);
</script>
</div>
<div class="html-script section">
<style>
//select {color:#B3B1A8 !important}
select option:not(first-child) {
color: black !important
}
</style>
<script>
var $branchUrl = "/content/dam/bplac/en/js/json/bplac-branch-data.json";
var bank = {};
$.ajax({
url: $branchUrl,
type: "GET"
}).done(function(data) {
$.each(data, function(i, item) {
if (bank[item["BANK"]] === undefined) {
bank[item["BANK"]] = true;
}
});
$('select[name="bank"]').prepend("<option value='' selected='selected' default disabled style='color:#B3B1A8'>Please select a bank</option>");
var banks = Object.keys(bank);
$.each(banks, function(i, item) {
$('select[name="bank"]').append($('<option>', {
value: item,
text: item
}));
});
var provinces = [],
cities = [],
branches = [];
$('select[name="bank"]').change(function() {
var selectedBank = $(this).val();
$('select[name="province"]').empty();
provinces = $.grep(data, function(v) {
return v["BANK"] === selectedBank;
});
if (provinces.length > 0) {
provinces.sort(function(a, b) {
return a["PROVINCE"] == b["PROVINCE"] ? 0 : a["PROVINCE"] < b["PROVINCE"] ? -1 : 1
});
$('select[name="province"]').prepend("<option value='' selected='selected' default disabled style='color:#B3B1A8'>Please select a province</option>");
$.each(provinces, function(i, item) {
if (!$('select[name="province"] option[value="' + item["PROVINCE"] + '"]').length > 0) {
$('select[name="province"]').append($('<option>', {
value: item["PROVINCE"],
text: item["PROVINCE"]
}));
}
});
}
$('select[name="province"]').trigger("change");
});
$('select[name="province"]').change(function() {
var selectedProvince = $(this).val();
if (selectedProvince) {
$(this).css("color", "black");
} else {
$(this).css("color", "#B3B1A8");
}
$('select[name="cityMunicipality"]').empty();
cities = $.grep(provinces, function(v) {
return v["PROVINCE"] === selectedProvince;
});
if (cities.length > 0) {
cities.sort(function(a, b) {
return a["CITY/MUNICIPALITY"] == b["CITY/MUNICIPALITY"] ? 0 : a["CITY/MUNICIPALITY"] < b["CITY/MUNICIPALITY"] ? -1 : 1
});
$('select[name="cityMunicipality"]').prepend("<option value='' selected='selected' default disabled style='color:#B3B1A8'>Please select a city/municipality</option>");
$.each(cities, function(i, item) {
if (!$('select[name="cityMunicipality"] option[value="' + item["CITY/MUNICIPALITY"] + '"]').length > 0) {
$('select[name="cityMunicipality"]').append($('<option>', {
value: item["CITY/MUNICIPALITY"],
text: item["CITY/MUNICIPALITY"]
}));
}
});
}
$('select[name="cityMunicipality"]').trigger("change");
});
$('select[name="cityMunicipality"]').change(function() {
var selectedCity = $(this).val();
if (selectedCity) {
$(this).css("color", "black");
} else {
$(this).css("color", "#B3B1A8");
}
$('select[name="branch"]').empty();
branches = $.grep(cities, function(v) {
return v["CITY/MUNICIPALITY"] === selectedCity;
});
if (branches.length > 0) {
branches.sort(function(a, b) {
return a["BRANCH NAME"] == b["BRANCH NAME"] ? 0 : a["BRANCH NAME"] < b["BRANCH NAME"] ? -1 : 1
});
$('select[name="branch"]').prepend("<option value='' selected='selected' default disabled style='color:#B3B1A8'>Please select a branch</option>");
$.each(branches, function(i, item) {
if (!$('select[name="branch"] option[value="' + item["BRANCH NAME"] + '"]').length > 0) {
$('select[name="branch"]').append($('<option>', {
value: item["BRANCH NAME"],
text: item["BRANCH NAME"]
}));
}
});
}
$('select[name="branch"]').trigger("change");
});
$('select[name="branch"]').change(function() {
var selectedBranch = $(this).val();
if (selectedBranch) {
$(this).css("color", "black");
} else {
$(this).css("color", "#B3B1A8");
}
})
});
</script>
</div>
<div class="text parbase section">
<div class="aia-text text-left p4 bt3 margin-top-md-l margin-bottom-md-l margin-top-sm-l margin-bottom-sm-l margin-top-l margin-bottom-l" data-emptytext="Text">
<p>My question/message is:<br> </p>
</div>
</div>
<div class="form-textarea form-input form-base section">
<textarea class="primary-select parent-width" id="aia114147837" rows="3" name="message" maxlength="1500"></textarea>
<div id="aia114147837_msg" class="fieldError label-error" requiredmessage="*Please fill in your message." remessage="This answer is in error."></div>
</div>
<div class="html-script section">
<br>
<div class="g-recaptcha" data-sitekey="6LdOX0AdAAAAAJ9U-fkWEP7cXayMQvkjwiqr97fJ">
<div style="width: 304px; height: 78px;">
<div><iframe title="reCAPTCHA" width="304" height="78" role="presentation" name="a-hdqwfhgnmfxb" frameborder="0" scrolling="no"
sandbox="allow-forms allow-popups allow-same-origin allow-scripts allow-top-navigation allow-modals allow-popups-to-escape-sandbox"
src="https://www.google.com/recaptcha/api2/anchor?ar=1&k=6LdOX0AdAAAAAJ9U-fkWEP7cXayMQvkjwiqr97fJ&co=aHR0cHM6Ly93d3cuYnBpLWFpYS5jb20ucGg6NDQz&hl=de&v=lLirU0na9roYU3wDDisGJEVT&size=normal&cb=8183kqv44feb"></iframe>
</div><textarea id="g-recaptcha-response" name="g-recaptcha-response" class="g-recaptcha-response"
style="width: 250px; height: 40px; border: 1px solid rgb(193, 193, 193); margin: 10px 25px; padding: 0px; resize: none; display: none;"></textarea>
</div><iframe style="display: none;"></iframe>
</div>
<br>
<style>
@media (max-width:480px) {
.g-recaptcha>div>div {
transform: scale(0.75);
transform-origin: 0 0;
}
}
</style>
</div>
<div class="form-input form-base section">
<input type="text" class="primary-select parent-width" id="aia2096278753" name="g-recaptcha-check" placeholder="g-recaptcha-check" required="true" validationtype="text" style="display: none;">
<div class="fieldError label-error" id="aia2096278753_msg" requiredmessage="*Please verify the reCAPTCHA and tick the check box before submission"></div>
</div>
<div class="html-script section">
<script>
$('input[name="g-recaptcha-check"]').parent().children(':not(div)').hide();
$('input[name="g-recaptcha-check"]').parent().show();
$(function() {
setTimeout(function() {
$('.leads-form-page').find('button').bind("click mouseenter mouseleave", function() {
$('input[name="g-recaptcha-check"]').val($('[name="g-recaptcha-response"]').val());
});
}, 3000)
});
</script>
</div>
<div class="form-checkbox form-base section">
<label class="checkbox margin-bottom-s terms-ctr" for="14088744611">
<input type="checkbox" id="14088744611" name="agreement" value="1" groupid="1868979572" index="0" required="true">
<span class="indicator"><span class="tick"></span></span>
<span class="p3 bt8 terms-desc">I agree with BPI AIA’s statements indicated in the marketing consent and privacy consent.</span>
</label>
<div id="1868979572_msg" class="fieldError label-error" requiredmessage="*Please read the terms and conditions and check the box before submitting."></div>
</div>
<div class="html-script section">
<script>
$(function() {
$(".terms-desc").parent().addClass("terms-ctr")
});
</script>
<style>
@media (min-width: 768px) and (max-width: 991px) {
.terms-ctr {
width: 250px;
}
}
@media (min-width: 1200px) and (max-width: 1620px) {
.terms-ctr {
width: 248px;
}
}
</style>
</div>
<div class="form-hidden-field form-base section">
<div class="margin-bottom-l" style="display: none;">
<label class="form-label margin-bottom-xxs p3 bt4">email_address_id</label>
<input type="text" id="aia647023506" name="email_address_id">
<div class="fieldError label-error" id="aia647023506_msg"></div>
</div>
</div>
<div class="form-hidden-field form-base section">
<div class="margin-bottom-l" style="display: none;">
<label class="form-label margin-bottom-xxs p3 bt4">email_subject</label>
<input type="text" id="aia336050073" name="email_subject" value="Website enquiry">
<div class="fieldError label-error" id="aia336050073_msg"></div>
</div>
</div>
<div class="html-script section">
<script>
// HANDLES THE SOURGE PAGE NAME (TAKEN FROM THE TITLE)
$(function() {
var parentSrcVal = $('title').html();
$('input[name="source"]').val(parentSrcVal);
});
</script>
</div>
<div class="form-hidden-field form-base section">
<div class="margin-bottom-l" style="display: none;">
<label class="form-label margin-bottom-xxs p3 bt4">productName</label>
<input type="text" id="aia336050188" name="source">
<div class="fieldError label-error" id="aia336050188_msg"></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="html-script section">
<script>
// LIMITS THE NUMBER OF CHARACTER INSERTED IN INPUTS
$((function() {
$('input[name="fullName"], input[name="contactNum"], input[name="branch"], input[name="address"], input[name="emailAddr"]').attr("maxlength", "100"), $('textarea[name="message"]').attr("maxlength", "1500"), $(
'input[name="firstName"], input[name="lastName"]').attr("maxlength", "100")
}));
</script>
</div>
<div class="html-script section">
<script>
// VALIDATES THE DATE OF BIRTH, DON'T ACCEPT BELOW 18 yrs old and ABOVE 75 yeas old
$((function() {
$('input[name="dateOfBirth"]').val(""), $('input[name="dateOfBirth"]').prop("readonly", !0);
var e = (new Date).getFullYear(),
t = (new Date).getMonth();
$(".form-dateselector input").attr("validationtype", "text"), $(".form-dateselector input").on("click focus", (function() {
$(".yearselect option").removeAttr("selected"), $(".monthselect option").removeAttr("selected"), $(".yearselect option[value=" + e + "]").attr("selected", "selected").trigger("change"), $(".monthselect option[value=" + t +
"]").attr("selected", "selected").trigger("change")
})), $(".form-dateselector input").on("change", (function() {
if ($(this).addClass("field-error"), "Invalid date" === $(this).val()) return $(this).val(""), !1;
var e, t, a, r;
if (new Date($(this).val()).getTime() > (new Date).getTime()) $(this).addClass("field-error"), $(this).parent().children(".label-error").text("*Future dates are not allowed"), $(this).val("");
else {
var l = (e = $(this).val(), t = new Date(e), a = Date.now() - t.getTime(), r = new Date(a), Math.abs(r.getUTCFullYear() - 1970));
l < 18 ? ($(this).addClass("field-error"), $(this).parent().children(".label-error").text("*Can't be below 18 years of age"), $(this).val("")) : l > 75 ? ($(this).addClass("field-error"), $(this).parent().children(
".label-error").text("*Can't be above 75 years of age"), $(this).val("")) : ($(this).removeClass("field-error"), $(this).parent().children(".label-error").text(""))
}
}))
}));
</script>
</div>
<div class="html-script section">
<script src="https://www.google.com/recaptcha/api.js" async="" defer=""></script>
<style>
.submit button {
min-width: 200px !important
}
.modal.fade.show {
opacity: 1 !important
}
</style>
</div>
<div class="html-script section">
<script>
//HANDLES POLICY HOLDER BASED EMAIL RECIPIENTS
//leads-form-contact.html
var bplac = bplac || {};
$(function() {
var root;
bplac.emailRecipients = {
init: function() {
root = bplac.emailRecipients;
root.config = {
'defaultSelected': $("div[name='policyHolder'] .btn.btn-selected").val().trim(),
'emailAddressId': $("input[name='email_address_id']"),
'recipients': {
'distributionSalesReport': 'BPI-Philam_Customerservice@aia.com',
'digitalMarketing': 'BPI-Philam_MyPage@AIA.COM,AnaJanine-J.Balois@aia.com,CandiceAnne.Venturanza@aia.com,bpi-aia_digitalmarketing@aia.com',
'crm': 'KristopherRey-F.Quirapas@aia.com',
'customerExperience': 'BPI-Philam_CustomerExperience@aia.com',
'corporateSolutions': 'Felisa-B.Ronan@aia.com',
'of': 'BPI-Philam.OFSegment@aia.com',
'bam': 'Viven-R.Jimenea@aia.com',
'directSales': 'MarkOwell-MO.Moreno@aia.com',
},
'isPolicyHolder': true,
}
// check the default value of policy toggle btn
root.config.isPolicyHolder = (root.config.defaultSelected === "yes") ? true : false;
root.addEmailAddToInput();
//init policy toggle event handler
root.policyToggleHandler();
},
addEmailAddToInput: function() {
// change the recipients based on the form category
if (root.config.isPolicyHolder) {
root.config.emailAddressId.val(root.config.recipients.distributionSalesReport + ',' + root.config.recipients.digitalMarketing + ',' + root.config.recipients.customerExperience);
} else {
root.config.emailAddressId.val(root.config.recipients.digitalMarketing + ',' + root.config.recipients.directSales);
}
},
policyToggleHandler: function() {
root.config.policyToggleBtn = $("div[name='policyHolder'] .btn");
root.config.policyToggleBtn.click(function() {
root.config.isPolicyHolder = ($(this).val().trim() === "yes") ? true : false;
root.addEmailAddToInput();
})
}
}
// SELF-INIT
bplac.emailRecipients.init();
});
</script>
</div>
<div class="html-script section">
<!-- add intl-tel-input plugin to phone numbers
https://github.com/jackocnr/intl-tel-input -->
<link rel="stylesheet" href="/etc.clientlibs/aia-bplac/clientlibs/intl-tel-input.intlTelInput.css" type="text/css">
<script src="/etc.clientlibs/aia-bplac/clientlibs/intl-tel-input.intlTelInput.min.js"></script>
<style>
body {
margin: 0
}
.intl-tel-input {
width: 100%
}
</style>
<script>
$('input[name="contactNum"]').intlTelInput({
utilsScript: "/etc.clientlibs/aia-bplac/clientlibs/intl-tel-input.utils.js",
separateDialCode: !1,
nationalMode: !1,
preferredCountries: ["ph"],
autoPlaceholder: "aggressive"
}), $("input[name=contactNum]").on("change", (function() {
if (13 == $(this).val().length) {
var t = $(this).val().substring(1);
$(this).val(t)
}
}));
</script>
</div>
</div>
<p class="bt4 u2 text-center lead-form-validation" data-validation="tss-return-error-message"></p>
<div class="submit btn parent-width margin-bottom-xl">
<div class="margin-top-md-l margin-top-sm-l margin-top-l">
<div>
<button id="btn1467965625" class="btn btn-default btn-primary center-block " type="button" onclick="" data-target="_blank">Submit</button>
</div>
</div>
</div>
</div>
</form>Text Content
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Philam Life Vitality
CRITICAL CARE 100
Life and Health Insurance
Period
WHOLE LIFE
Issue Age
0-65 YEARS OLD
You can buy this via
BPI AIA BANCASSURANCE SALES EXECUTIVE
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WHAT IS THE PRODUCT ABOUT?
You are at your happiest when you are with your loved ones. You want to be
healthy so you can live longer and spend more time with them.
With Critical Care 100, a comprehensive health and life insurance plan, you’ll
enjoy a lifetime health protection from up to 100 critical illnesses until age
100 so you can always live a happy and worry-free life with your family!
Talk to US
* Download Brochure Download Brochure
* share with a friend share with a friend
I SEE YOU PROUD AND ASSURED
Watch Video
I SEE YOU BRAVING IT OUT
Watch Video
I SEE YOU CHASING YOUR DREAMS
Watch Video
I SEE YOU HAPPY
Watch Video
I SEE YOU PROUD AND ASSURED
Watch Video
I SEE YOU BRAVING IT OUT
Watch Video
* HOW TO SECURE YOUR FAMILY’S FUTURE
* HOW TO MAKE YOUR DREAM FUTURE HAPPEN
* HOW TO LIVE A LIFE FREE FROM WORRIES
* HOW TO SECURE YOUR LEGACY
FEATURES & BENEFITS
* CRITICAL ILLNESS COVERAGE UNTIL AGE 100
CRITICAL ILLNESS COVERAGE UNTIL AGE 100
Receive a cash benefit to help you recover from any of the covered illnesses.
Critical Care 100 gives you and your family protection from up to 100
illnesses, from age 0 to 100.
* LIFE INSURANCE COVERAGE
LIFE INSURANCE COVERAGE
Protect your family with a life insurance benefit should anything happen to
you.
* PROTECTION BOOST
PROTECTION BOOST
Add more benefits to your plan for a more comprehensive coverage.
CANCER BOOSTER
Receive an additional cash benefit should you get diagnosed with any of the
covered gender specific cancers (e.g. breast cancer, prostate cancer) .
RECOVERY BENEFIT
Get a recovery income that’s payable for 5 years after a diagnosis of a
critical illness.
PAYOR’S BENEFIT FOR DEATH AND DISABILITY
If you get a plan for your child, you don’t have to pay for the remaining
premiums should anything happen to you or if you get totally and permanently
disabled before 60 or before the child turns 25.
* AIA VITALITY
AIA VITALITY
Enjoy rewards as you live a healthier life with AIA Vitality. You get an
additional 20-50% life insurance coverage as you live healthier. You can also
enjoy discounts from a range of partners as a reward for living healthy.
PROVIDE YOUR BEST INTERESTS WITH THE FINANCIAL PROTECTION THEY DESERVE AS YOU
LIVE A HEALTHIER LIFE TODAY!
Find out more
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GET IN TOUCH
My first name is*
My last name is*
My date of birth is*
My email address is*
Are you a BPI AIA Policyholder?*
yes no
My primary need is*
PROTECT (To retain the quality of life of my family) GROW (To maximize potential
of investments) PREPARE (To have enough funds for critical illness) SECURE (To
have ready funds for the education of my children) BOOST (To live a healthier
and more active lifestyle) None
My contact number is*
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PRIVACY CONSENT
I/we agree for the Company to use my information and all related documents in
the design and communication of the Company’s marketing campaigns and offers in
order to improve the quality of service the Company provides, and to receive
such marketing campaigns. Said information will be stored by BPI AIA for 5
years.
I/we agree to share my information with BPI AIA’s accredited third parties for
marketing campaigns.
I/we agree for the Company to use such information for profiling to develop,
enhance and offer me/us financial services and products that the Company
considers as suitable for my/our insurance and other financial needs. Said
information will be stored by BPI AIA for 5 years.
I/we authorize BPI AIA and its representatives to get in touch with me about
their products and services.
I/we may at any time withdraw our consent by visiting BPI AIA branches, calling
the Company’s contact center, or by emailing the request to bpiaia.dpo@aia.com.
Upon receipt of such withdrawal of consent, the Company will no longer approach
me/us for promotions or products that may be suited to my/our insurance needs.
I/We am/are assured that this will not affect the Company’s ability to provide
quality service in relation to my/our existing policies.
Please visit our website, www.bpi-aia.com.ph for our Privacy Statement, which
provides further details on why your personal data is collected, how it is
intended to be used, to whom your personal data may be transferred to, how to
access, review and amend your personal data, and our policies on direct
marketing.
I agree with BPI AIA statements indicated in the marketing consent and privacy
consent.
AGREE
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THE FINE PRINT
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DETAILED TERMS AND CONDITIONS
--------------------------------------------------------------------------------
DETAILED TERMS AND CONDITIONS
- COLLAPSE + EXPAND
IMPORTANT NOTES
Critical Care 100 is a peso-denominated and non-participating whole-life health
insurance plan that provides customers financial protection from health and life
emergencies. Critical Care 100 is available in 10-pay and 20-pay variants.
Issue Ages
* 10-pay: 0-65
* 20-pay: 0-55
This plan provides the following benefits:
* Bundled with AIA Vitality
* The Death Benefit or Life Insurance Coverage is equal to the Face Amount less
Minor Critical Illness (CI) paid and any debt to the Company. Upon payment of
the life insurance coverage, the plan will terminate.
* The Major Critical Illness is equal to the Face Amount less Minor Critical
Illness paid and any debt to the Company. Upon payment of the Major CI, the
plan will terminate.
* The Minor Critical Illness benefit is equal to the Face Amount or P1 million,
whichever is lower, will be advanced upon diagnosis of a listed Minor CI.
This can only be claimed once.
* Optional additional coverage for diagnosis of any of the covered gender
specific cancers. Additional coverage is up to 50% of the Face Amount
* Optional Recover Benefit. With the Recovery Benefit, Recovery Benefit, the
Insured will receive 5 annual cash payouts equal to 10% of the Face Amount
each year as long as he or she is alive. The first payout happens 1 year
after the Major CI claim.
* Optional Payor's Benefit for Death and Disability
The Policy will terminate in the event of any of the following:
* Upon death of the Insured
* Upon claim of a covered Major Critical Illness
* Upon reaching age 100 of the Insured
* Upon non-payment of premiums
* Upon written notice to terminate the Policy
Actual terms and conditions of Critical Care 100 are found in the Policy. In
case of conflict, the Policy terms shall prevail.
CONTACT BPI AIA
(02) 8 528 5501
FACEBOOK MESSENGER
15th Floor BPI-Philam Life Makati (formerly Ayala-FGU Bldg) 6811 Ayala Avenue
Makati City 1226
CONTACT BPI AIA
(02) 8 528 5501
FACEBOOK MESSENGER
15th Floor BPI-Philam Life Makati (formerly Ayala-FGU Bldg) 6811 Ayala Avenue
Makati City 1226
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