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abpiccoloclarinet.formstack.com Open in urlscan Pro
52.84.174.114  Public Scan

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Submitted URL: https://clt1671079.benchurl.com/c/l?u=10E7DBE1&e=17D5D3E&c=197FA7&t=0&l=F2ACC966&email=fe6iGURGt%2Fp8f6sjBVFSy6STIcTB3CdoeeWRGMt...
Effective URL: https://abpiccoloclarinet.formstack.com/forms/employee_insurance_benefit?utm_source=BenchmarkEmail&utm_campaign=Time_off&utm_medium=email
Submission: On March 29 via manual from US — Scanned from DE

Form analysis 1 forms found in the DOM

POST https://abpiccoloclarinet.formstack.com/forms/index.php

<form autocomplete="off" id="fsForm5704637" method="post" class="StyledForm-sc-1xaj75q-0 kvUXCr fsForm" action="https://abpiccoloclarinet.formstack.com/forms/index.php" novalidate="" enctype="multipart/form-data"><input type="hidden" tabindex="-1"
    name="displayTime" value="2024-03-29T17:42:00-04:00"><input type="hidden" tabindex="-1" name="formstackFormSchemaVersion" value="4"><input type="hidden" tabindex="-1" name="formstackFormRendererVersion" value="master"><input type="hidden"
    tabindex="-1" name="form" value="5704637"><input type="hidden" tabindex="-1" name="viewkey" value="BhQpkZTLFH"><input type="hidden" tabindex="-1" name="password" value=""><input type="hidden" tabindex="-1" name="hidden_fields" value=""><input
    type="hidden" tabindex="-1" name="_submit" value="1"><input type="hidden" tabindex="-1" name="incomplete" value=""><input type="hidden" tabindex="-1" name="incomplete_email" value=""><input type="hidden" tabindex="-1" name="incomplete_password"
    value=""><input type="hidden" tabindex="-1" name="latitude" value=""><input type="hidden" tabindex="-1" name="longitude" value=""><input id="fsUserAgent" type="hidden" tabindex="-1" name="fsUserAgent"
    value="Mozilla/5.0 (Windows NT 10.0; Win64; x64) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/123.0.0.0 Safari/537.36">
  <div id="fsPage5704637-1" class="StyledPage-sc-15mrpfq-0 hCMMok fsPage">
    <div data-testid="section0-col1" id="fsSection0" class="StyledSection-sc-1jyjf4h-0 isdHqD fsSection"><span class="StyledLabel-sc-vn5hkq-0 fnVZAc fsLabelVertical fsFieldFocused fsFieldCell" id="label-field162779828" for="field162779828"
        data-testid="field-162779828"><a id="field-anchor-162779828" tabindex="-1" aria-hidden="true"></a>
        <div class="StyledLabelText-sc-1bsmirz-0 lnOUqW fsLabel fsRequiredLabel"><span>Employee Name</span><span class="StyledRequiredMarker-sc-d195mo-0 bIpoVu fsRequiredMarker">*</span></div>
        <div class="StyledSubFieldGroup-sc-ik27pq-0 gfzGQs fsSubFieldGroup">
          <div class="StyledSubField-sc-1wt4t9i-0 bdsNVQ fsSubField fsNameFirst"><input autocomplete="given-name" class="StyledInput-sc-1cxwxcf-0 dijNQr" id="field162779828-first" type="text" label="Employee Name" required="" maxlength="20"
              name="field162779828-first" data-fs-field-id="162779828" data-fs-field-name="name" data-fs-field-alias="first" value=""><label for="field162779828-first" class="StyledLabel-sc-vn5hkq-0 btranG">First Name</label></div>
          <div class="StyledSubField-sc-1wt4t9i-0 bdsNVQ fsSubField fsNameLast"><input autocomplete="family-name" class="StyledInput-sc-1cxwxcf-0 dijNQr" id="field162779828-last" type="text" label="Employee Name" required="" maxlength="20"
              name="field162779828-last" data-fs-field-id="162779828" data-fs-field-name="name" data-fs-field-alias="last" value=""><label for="field162779828-last" class="StyledLabel-sc-vn5hkq-0 btranG">Last Name</label></div>
        </div>
      </span><label class="StyledLabel-sc-vn5hkq-0 fnVZAc fsLabelVertical fsFieldCell" id="label-field162779839" for="field162779839" data-testid="field-162779839"><a id="field-anchor-162779839" tabindex="-1" aria-hidden="true"></a>
        <div class="StyledLabelText-sc-1bsmirz-0 lnOUqW fsLabel fsRequiredLabel"><span>Employee Email</span><span class="StyledRequiredMarker-sc-d195mo-0 bIpoVu fsRequiredMarker">*</span></div>
        <div class="StyledSubFieldGroup-sc-ik27pq-0 gfzGQs fsSubFieldGroup">
          <div class="StyledSubField-sc-1wt4t9i-0 cfEVbD"><input id="field162779839" type="email" maxlength="" label="Employee Email" required="" autocomplete="email" class="StyledInput-sc-1cxwxcf-0 dijNQr fsFieldEmail" name="field162779839"
              size="50" placeholder="" data-fs-field-id="162779839" data-fs-field-name="email" data-fs-field-alias="value" value=""></div>
        </div>
      </label><label class="StyledLabel-sc-vn5hkq-0 fnVZAc fsLabelVertical fsFieldCell" id="label-field162779902" for="field162779902" data-testid="field-162779902"><a id="field-anchor-162779902" tabindex="-1" aria-hidden="true"></a>
        <div class="StyledLabelText-sc-1bsmirz-0 lnOUqW fsLabel fsRequiredLabel"><span>Department</span><span class="StyledRequiredMarker-sc-d195mo-0 bIpoVu fsRequiredMarker">*</span></div>
        <div class="StyledSubFieldGroup-sc-ik27pq-0 gfzGQs fsSubFieldGroup">
          <div class="StyledSubField-sc-1wt4t9i-0 gnOLlR"><input autocomplete="on" class="StyledInput-sc-1cxwxcf-0 dijNQr fsFieldShortAnswer" id="field162779902" type="text" label="Department" required="" name="field162779902" placeholder=""
              data-fs-field-id="162779902" data-fs-field-name="text" data-fs-field-alias="value" value=""></div>
        </div>
      </label><label class="StyledLabel-sc-vn5hkq-0 fnVZAc fsLabelVertical fsFieldCell" id="label-field162780127" for="field162780127" data-testid="field-162780127"><a id="field-anchor-162780127" tabindex="-1" aria-hidden="true"></a>
        <div class="StyledLabelText-sc-1bsmirz-0 lnOUqW fsLabel fsRequiredLabel"><span>Authorize Submission</span><span class="StyledRequiredMarker-sc-d195mo-0 bIpoVu fsRequiredMarker">*</span></div>
        <div class="StyledSubFieldGroup-sc-ik27pq-0 gfzGQs fsSubFieldGroup">
          <div class="StyledSubField-sc-1wt4t9i-0 gnOLlR"><input autocomplete="on" class="StyledInput-sc-1cxwxcf-0 dijNQr fsFieldShortAnswer" id="field162780127" type="text" label="Authorize Submission" required="" name="field162780127"
              placeholder="" data-fs-field-id="162780127" data-fs-field-name="text" data-fs-field-alias="value" value=""></div>
        </div><span class="StyledSupportingText-sc-1pgm78z-0 khZCkW fsSupporting"><span>Ensure you enter your password correctly</span></span>
      </label><span class="StyledLabel-sc-vn5hkq-0 fnVZAc fsLabelVertical fsFieldCell" id="label-field162780719" for="field162780719" data-testid="field-162780719-vertical"><a id="field-anchor-162780719" tabindex="-1" aria-hidden="true"></a>
        <div class="StyledLabelText-sc-1bsmirz-0 lnOUqW fsLabel fsRequiredLabel"><span>I acknowledge that all information entered above is correct</span><span class="StyledRequiredMarker-sc-d195mo-0 bIpoVu fsRequiredMarker">*</span></div>
        <fieldset aria-labelledby="162780719-legend" role="group" class="StyledFieldset-sc-1r8yz9c-0 StyledOptionWrapper-sc-1ah0fdf-0 cdlqHK PSYyM"><span style="position: absolute; left: -999em; width: 0.1em; height: 0.1em; overflow: hidden;">
            <legend id="162780719-legend">I acknowledge that all information entered above is correct Required field</legend>
          </span>
          <div><label for="field162780719_1" class="StyledOptionLabel-sc-1bymt4x-0 gZbrPz fsOptionLabel"><input label="I acknowledge that all information entered above is correct" required="" name="field162780719[]"
                class="StyledOptionButton-sc-wqe0tc-0 FSkuJ" type="checkbox" id="field162780719_1" data-fs-field-id="162780719" data-fs-field-name="checkbox" data-fs-field-alias="0" value="YES">YES</label></div>
        </fieldset>
      </span></div>
  </div>
  <div id="fsSubmit5704637" class="StyledFormFooter-sc-9cjpwp-0 gqkVov fsSubmit fsPagination">
    <div class="StyledFormNavigations-sc-t0vu6u-0 jnnwJH"><button id="fsSubmitButton5704637" class="StyledSubmitButton-sc-1ylq3c5-0 jfHuqe fsSubmitButton" type="submit">Proceed</button></div>
  </div>
</form>

Text Content

Employee Name*
First Name
Last Name
Employee Email*

Department*

Authorize Submission*

Ensure you enter your password correctly
I acknowledge that all information entered above is correct*
I acknowledge that all information entered above is correct Required field
YES
Proceed
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