Individual & Family Health

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<div class="wrap"><!-- [et_pb_line_break_holder] --> <p class="required hidemeToo">[*] Required Fields</p><!-- [et_pb_line_break_holder] --> <form name="form1" method="post" action="https://www.quotit.net/quotit/apps/epro/ifp/posttoquote" target="results" id="form1"><!-- [et_pb_line_break_holder] --> <input type="hidden" name="license_no" value="XKGBBS" /><!-- [et_pb_line_break_holder] --> <input type="hidden" name="brokerID" value="170678" /><!-- [et_pb_line_break_holder] --> <input type="hidden" name="accessID" value="5CF34A51-BAB1-4316-A675-6085B87D5C87" /><!-- [et_pb_line_break_holder] --> <input type="hidden" name="planTypeID" value="%" /><!-- [et_pb_line_break_holder] --> <div class="input-group"><strong>First Name</strong></br><input type="text" name="applicantFirstName" class="lgInput" value="John"></div><!-- [et_pb_line_break_holder] --> <div class="input-group inputGroupTwo"><strong>Last Name</strong></br><input type="text" name="applicantLastName" class="lgInput" value="Conner"></div><!-- [et_pb_line_break_holder] --> <div class="input-group"><strong>Phone</strong></br><input type="text" name="applicantPhone" class="lgInput" value="866-478-6848"></div><!-- [et_pb_line_break_holder] --> <div class="input-group inputGroupTwo"><strong>Email</strong><br /><input type="text" name="applicantEmail" class="lgInput" value="test@gmail.com"></div><!-- [et_pb_line_break_holder] --> <div class="input-group"><strong>Zipcode<span class="reqAst">*</span></strong><br /><input type="text" name="zipCode" size="5" value="92606" class="smInput" /></div><!-- [et_pb_line_break_holder] --> <div class="input-group inputGroupTwo"><strong>Effective Date<span class="reqAst">*</span></strong><br /><input type="text" name="effectiveDate" size="10" class="smInput" value="3/1/2018" /></div><!-- [et_pb_line_break_holder] --> <div class="input-group"><strong>Household Size</strong><br /><input type="text" name="householdSize" size="2" value="1" class="smInput" /></div><!-- [et_pb_line_break_holder] --> <div class="input-group inputGroupTwo"><strong>Household Income</strong><br /><input type="text" name="Income" value="35000" class="smInput" /></div><!-- [et_pb_line_break_holder] --> <div class="input-group"><strong>Show plans with subsidy?<span class="reqAst">*</span></strong><br /><label><input type="radio" name="InsuranceTypeID" value="5" checked>Yes</label> <label><input type="radio" name="InsuranceTypeID" value="6">No</label></div><!-- Health On-Exchange Parameter is "5" , Health Off-Exchange Parameter is "6"--><!-- [et_pb_line_break_holder] --> <table width="700" border="0" cellspacing="2" cellpadding="2"><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <th> </th><!-- [et_pb_line_break_holder] --> <th>Gender</th><!-- [et_pb_line_break_holder] --> <th>DOB<span class="reqAst">*</span></th><!-- [et_pb_line_break_holder] --> <th>Smoke</th><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td>Applicant:</td><!-- [et_pb_line_break_holder] --> <td><label><input type="radio" name="sSex" value="M" checked>Male</label> <label><input type="radio" name="sSex" value="F">Female</label></td><!-- [et_pb_line_break_holder] --> <td><input size="10" name="sDateOfBirth" value="04/01/1976" placeholder="MM/DD/YYYY" class="smInput" /></td><!-- [et_pb_line_break_holder] --> <td><label><input type="radio" name="sIsSmoker" value="0" checked>No</label> <label><input type="radio" name="sIsSmoker" value="1">Yes</label></td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td>Spouse:</td><!-- [et_pb_line_break_holder] --> <td><label><input type="radio" name="spSex" value="F" checked>Female</label> <label><input type="radio" name="spSex" value="M">Male</label></td><!-- [et_pb_line_break_holder] --> <td><input size="10" name="spDateOfBirth" value="" placeholder="MM/DD/YYYY" class="smInput" /></td><!-- [et_pb_line_break_holder] --> <td><label><input type="radio" name="spIsSmoker" value="0" checked>No</label> <label><input type="radio" name="spIsSmoker" value="1">Yes</label></td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td>Child 1:</td><!-- [et_pb_line_break_holder] --> <td><label><input type="radio" name="c1Sex" value="M">Male</label><label><input type="radio" name="c1Sex" value="F">Female</label></td><!-- [et_pb_line_break_holder] --> <td><input name="c1DateOfBirth" value="" size="10" placeholder="MM/DD/YYYY" class="smInput" /></td><!-- [et_pb_line_break_holder] --> <td><label><input type="radio" name="c1IsSmoker" value="0" checked>No</label> <label><input type="radio" name="c1IsSmoker" value="1">Yes</label></td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td>Child 2:</td><!-- [et_pb_line_break_holder] --> <td><label><input type="radio" name="c2Sex" value="M">Male</label><label><input type="radio" name="c2Sex" value="F">Female</label></td><!-- [et_pb_line_break_holder] --> <td><input name="c2DateOfBirth" value="" size="10" placeholder="MM/DD/YYYY" class="smInput" /></td><!-- [et_pb_line_break_holder] --> <td><label><input type="radio" name="c2IsSmoker" value="0" checked>No</label> <label><input type="radio" name="c2IsSmoker" value="1">Yes</label></td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td>Child 3:</td><!-- [et_pb_line_break_holder] --> <td><label><input type="radio" name="c3Sex" value="M">Male</label><label><input type="radio" name="c3Sex" value="F">Female</label></td><!-- [et_pb_line_break_holder] --> <td><input name="c3DateOfBirth" value="" size="10" placeholder="MM/DD/YYYY" class="smInput" /></td><!-- [et_pb_line_break_holder] --> <td><label><input type="radio" name="c3IsSmoker" value="0" checked>No</label> <label><input type="radio" name="c3IsSmoker" value="1">Yes</label></td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td>Child 4:</td><!-- [et_pb_line_break_holder] --> <td><label><input type="radio" name="c4Sex" value="M">Male</label><label><input type="radio" name="c4Sex" value="F">Female</label></td><!-- [et_pb_line_break_holder] --> <td><input name="c3DateOfBirth" value="" size="10" placeholder="MM/DD/YYYY" class="smInput" /></td><!-- [et_pb_line_break_holder] --> <td><label><input type="radio" name="c4IsSmoker" value="0" checked>No</label> <label><input type="radio" name="c4IsSmoker" value="1">Yes</label></td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> <tr><!-- [et_pb_line_break_holder] --> <td>Child 5:</td><!-- [et_pb_line_break_holder] --> <td><label><input type="radio" name="c5Sex" value="M">Male</label><label><input type="radio" name="c5Sex" value="F">Female</label></td><!-- [et_pb_line_break_holder] --> <td><input name="c3DateOfBirth" value="" size="10" placeholder="MM/DD/YYYY" class="smInput" /></td><!-- [et_pb_line_break_holder] --> <td><label><input type="radio" name="c5IsSmoker" value="0" checked>No</label> <label><input type="radio" name="c5IsSmoker" value="1">Yes</label></td><!-- [et_pb_line_break_holder] --> </tr><!-- [et_pb_line_break_holder] --> </table><!-- [et_pb_line_break_holder] --> <input type="submit" name="Submit" value="Submit" class="btnSubmit" id="HideMe" /><!-- [et_pb_line_break_holder] --> </form><!-- [et_pb_line_break_holder] --> <script type="text/javascript" src="https://ajax.microsoft.com/ajax/jQuery/jquery-1.4.2.min.js"></script><!-- [et_pb_line_break_holder] --> <script type="text/javascript"><!-- [et_pb_line_break_holder] --> $(document).ready(function(){<!-- [et_pb_line_break_holder] --> $("#frame").hide();<!-- [et_pb_line_break_holder] --> $("#HideMe").click(function() {<!-- [et_pb_line_break_holder] --> $("#form1").hide();<!-- [et_pb_line_break_holder] --> $(".hidemeToo").hide();<!-- [et_pb_line_break_holder] --> $("#frame").show();<!-- [et_pb_line_break_holder] --> });<!-- [et_pb_line_break_holder] --> });<!-- [et_pb_line_break_holder] --> </script><!-- [et_pb_line_break_holder] --> <script><!-- [et_pb_line_break_holder] --> try {<!-- [et_pb_line_break_holder] --> // but form result will load in this iframe<!-- [et_pb_line_break_holder] --> document.write('<iframe id="frame" scrolling="no" name="results" style="width: 1024px; height: 5450px; float: left; border: none; overflow: none;" onload="resizeIframe(this)"></iframe>');<!-- [et_pb_line_break_holder] --> } catch (e) {<!-- [et_pb_line_break_holder] --> alert(e);<!-- [et_pb_line_break_holder] --> }<!-- [et_pb_line_break_holder] --> </script><!-- [et_pb_line_break_holder] --></div><!--end:wrap-->