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<html dir="ltr"><!--<![endif]--> <head><title>Insurance</title><meta http-equiv="Content-Type" content="text/html; charset=utf-8" /><meta name="viewport" content="width=device-width, initial-scale=1.0, maximum-scale=1.0, user-scalable=no" /><meta name="description" content="Insurance Email Forms" /><meta name="keywords" content="Insurance" /><script src="//twemoji.maxcdn.com/2/twemoji.min.js"></script><script src="//ajax.googleapis.com/ajax/libs/dojo/1.8/dojo/dojo.js"></script><script type="text/javascript"> require([ "dojo/query", "dojo/dom", "dojo/dom-geometry", "dojo/dom-class", "dojo/dom-style", "dojo/dom-construct", "dijit/focus", "dojo/parser", "dijit/form/DateTextBox", "dojo/NodeList-traverse", "dojo/domReady!" ], function(query, dom, domGeom, domClass, domStyle, domConstruct, focusUtil, parser){ // Move the focused-field class to the field-group that contains the focused input. var handle = focusUtil.watch("curNode", function(name, oldValue, newValue){ var parent = query(newValue).closest('.field-group'); if(!domClass.contains(parent, "focused-field")) { query('.focused-field').removeClass('focused-field'); parent.addClass('focused-field'); } }); // Add error class to parent wrapper and only show error borders on empty fields in addresses query('.feedback.error').closest('.field-group').addClass('error'); query('.addressfield input:text[value=""]').addClass('empty'); // Focus first input of birthdayfield or phonefield-us when parent wrapper is clicked query('div.subfields').on("click", function(e){ var firstInput = query('input', e.target)[0]; focusUtil.focus(firstInput); }); // Prevent image blowout in IE6 since it doesn't support max-width if (domClass.contains(query('html')[0], "ie-lte7")){ query('img').forEach(function(node){ var computedStyle = domStyle.getComputedStyle(node); var w = domGeom.getContentBox(node, computedStyle).w; console.log(w); if(w >= 600){ domStyle.set(node, "width", "600px"); } }); } // Use native checkboxes and radio buttons outside the app dojo.query(".radio input, .checkbox input").removeAttr("data-dojo-type"); // Render DateTextBoxes parser.parse(); query('form').on("submit",function(e){ var invalidDate = dojo.query('.dijitTextBoxError'); if(invalidDate.length){ query('.dijitDateTextBox ~ .feedback.error').forEach(domConstruct.destroy); invalidDate.forEach(function(node) { domConstruct.place('<div class="feedback error"><div class="errorText">Please enter a valid date</div></div>', node, 'after'); }); e.preventDefault(); } }); twemoji.parse(document.body, { size: 72 }); query(".emoji").forEach(function(emoji){ domStyle.set(emoji, { width: "16px", height: "16px" }); }); }); </script><script src="https://www.google.com/recaptcha/api.js" async="" defer="defer"></script><script type="text/javascript" src="https://www.google.com/jsapi"></script><style type="text/css">/* Forms */ label { display:block; width:auto; margin-top:8px; font-weight:bold; } .mergeRow { padding:0 0 6px 0 !important; clear:both; } .field-group { position:relative; margin:3px 0 12px 0; overflow:hidden; background:transparent !important; } .mergeRow-radio .field-group, .mergeRow-interests-checkboxes .field-group {margin-bottom:6px;} input, textarea, select { display:block; margin:0; padding:10px; background:#fff; width:100%; border:2px solid #d0d0d0 !important; border-radius:3px; -webkit-appearance: none; } .field-group input, select, textarea, .dijitInputField { font-size: 14px; } .field-group.error > input, .field-group.error > select, .field-group.error .addressfield input.empty, .field-group.error .birthdayfield, .field-group.error .subfields, .field-group.error .datefield .dijitInputInner, .datefield .dijitTextBoxError .dijitInputInner, .field-group.error textarea { border-color:#e85c41 !important; } textarea { font:14px/18px 'Helvetica', Arial, sans-serif; width:100%; height:150px; overflow:auto; } select { background:#fff url(/images/icons/signup-sprite.png) no-repeat right -295px; background:#fff url(/images/icons/signup-sprite.png) no-repeat right -295px, -webkit-gradient(linear, left top, left bottom, from(#fff), to(#f1f1f1)); background:#fff url(/images/icons/signup-sprite.png) no-repeat right -295px, -webkit-linear-gradient(top, #fff, #f1f1f1); background:#fff url(/images/icons/signup-sprite.png) no-repeat right -295px, -ms-linear-gradient(top, #fff, #f1f1f1); background:#fff url(/images/icons/signup-sprite.png) no-repeat right -295px, linear-gradient(to bottom, #fff, #f1f1f1); } html[dir="rtl"] select {background-position:14px -295px;} /* Firefox always displays native select arrow button, so hide the background image arrow. */ @-moz-document url-prefix() { select { padding: 8px; background-position: -99px 0 !important; -moz-appearance: none; } } input:focus, textarea:focus, select:focus, .focused-field .subfields { border-color:#5d5d5d !important; outline:none; } /* Prevent Chrome's autofill yellow box shadow */ input:-webkit-autofill { -webkit-box-shadow: 0 0 0 1000px white inset !important; } .field-help { display:block; font-weight:normal; position:static; float:none; clear:both; margin:0; padding:0; max-height:0; overflow:hidden; -webkit-transition: all .25s; -moz-transition: all .25s; -ms-transition: all .25s; transition: all .25s; } .focused-field .field-help, input:focus + .field-help { display:block; padding:10px 0; max-height:100px; } .field-help .help { min-height:16px; text-decoration: none; } /* Error container */ .feedback { padding:10px 0; line-height:16px; font-size:14px; } .feedback br {display:none;} .feedback div { font:14px/20px 'Helvetica', Arial, sans-serif !important; padding:0 !important; margin:0 !important; } .indicates-required {text-align:right;} .indicates-required span { font-size:150%; font-weight:bold; display:inline !important; } .formstatus { margin-bottom:12px; font-size:18px; } .alert { background:#e4f3d4; border:2px solid #5ca000; font-size:14px; color:#4e7e0e !important; margin:10px 0; padding:10px; } /* Groups, checkboxes, radio buttons */ ul.interestgroup_field, ul.interestgroup_field li, ul.unsub-options, ul.unsub-options li, .interestgroup_row { display:block; padding:0; margin:0; list-style:none; } label.checkbox, label.radio { font-weight:normal; position:relative; line-height:24px; } .checkbox input, .radio input { width:auto !important; display:inline-block; margin-right:5px; padding:0; border:none; background-color:transparent; } /* Address blocks */ .addressfield span {display:block; margin:3px 0 15px 0;} .addressfield label {display:none;} .cityfield {width:35%; float:left; padding-right:12px;} .statefield {width:30%; float:left; padding-right:12px;} .zipfield {width:35%; float:left;} .countryfield {clear:both;} /* Date picker */ .dijitCalendarPopup {position:absolute;} .dijitComboBox.dijitDateTextBox .dijitArrowButtonContainer { cursor:pointer; position:absolute; top:3px; right:2px; background:url(/images/icons/signup-sprite.png) no-repeat 10px -235px; height:34px; width:42px; opacity:.5; padding:0 5px; } .dijitComboBox.dijitDateTextBox .dijitArrowButtonContainer input {visibility:hidden;} .dijitComboBox.dijitDateTextBox .dijitArrowButtonContainer:hover {opacity:1;} .dijitValidationContainer {display:none;} /* Input placeholder color */ .dijitPlaceHolder {position:absolute; top:10px; left:10px; color:#ababab !important; font-weight:normal;} ::-webkit-input-placeholder {color:#ababab;} :-moz-placeholder {color:#ababab; opacity:1;} ::-moz-placeholder {color:#ababab; opacity:1;} :-ms-input-placeholder {color:#ababab;} html[dir="rtl"] .dijitComboBox.dijitDateTextBox .dijitArrowButtonContainer {left:6px; right:auto;} html[dir="rtl"] .dijitPlaceHolder {left:auto; right:10px;} /* Birthday & US phone field */ .subfields { display:block; margin:0; padding:8px 10px; background:#fff; width:100%; border:2px solid #d0d0d0; border-radius:3px; color:#d0d0d0 } .subfields input { display:inline-block; margin:0; padding:0; width:2.5em; border:none !important; text-align:center; } .subfields label {display:none;} .phonedetail2 input {width:3.4em;} .birthdayfield input {width:1.7em;} /* Forward to friend */ .captcha { float:left; width:320px; margin-right:20px; min-height:150px; } .captcha input {display:inline;} /* Archive list */ #archive-list { display:block; margin:15px 0; padding:0; border-top:1px solid #eee; } #archive-list li { display:block; list-style:none; margin:0; padding:6px 10px; border-bottom:1px solid #eee; } .borderbox, .field-help, input, textarea, select { -moz-box-sizing: border-box; -webkit-box-sizing: border-box; box-sizing: border-box; } .field-shift { left: -9999px; position: absolute; } html[dir="rtl"] .field-shift { right: -9999px; left: auto; } /* Image replacement for checkbox and radio buttons. */ /* Placing in @media block forces browsers that don't support :checked to fall back to native inputs. */ @media only screen { .mergeRow-radio .field-group, .mergeRow-interests-checkboxes .field-group {margin:0 -6px 11px -6px;} .checkbox, .radio { margin:9px 0 0 0; padding:0; } /* Position and hide the real checkboxes and radio buttons */ .checkbox input, .radio input { position:absolute; width:24px; height:24px; overflow:hidden; margin:0; padding:0; outline:0; opacity:0; } .checkbox input + span, .radio input + span { display:block; border-radius:3px; padding:6px 6px 6px 38px; } .checkbox:hover span, .checkbox input:focus + span, .radio:hover span, .radio input:focus + span { background:rgba(0,0,0,.05); } /* Insert a pseudo element inside each label with a background sprite. */ .checkbox input + span:before, .radio input + span:before { display:block; position:absolute; top:6px; left:6px; width:24px; height:24px; background:url(/images/icons/signup-sprite.png) no-repeat; content:" "; vertical-align:top; } /* Position the background sprite based on state of checkbox/radio. */ .radio input:focus + span:before { background-position:0 -30px; } .radio input:checked + span:before { background-position:0 -60px; } .radio input:checked:focus + span:before { background-position:-0 -90px; } .checkbox input + span:before { background-position:0 -120px; } .checkbox input:focus + span:before { background-position:0 -150px; } .checkbox input:checked + span:before { background-position:0 -180px; } .checkbox input:checked:focus + span:before { background-position:0 -210px; } /* Right-to-left checkbox/radio modifications */ html[dir="rtl"] .checkbox input + span:before, html[dir="rtl"] .radio input + span:before {left:auto; right:0;} html[dir="rtl"] .checkbox input + span, html[dir="rtl"] .radio input + span {padding:6px 38px 6px 6px;} } /* Use high-res sprite for retina displays */ @media (-webkit-min-device-pixel-ratio: 1.5),(min-resolution: 1.5dppx) { .checkbox input + span:before, .radio input + span:before, .calendar-icon { background-image:url(/images/icons/signup-sprite-2x.png); background-size: 24px; } } /* IE6 and 7 overrides */ .ie-lte7 .field-group input, .ie-lte7 .subfields {width:535px;} .ie-lte7 .cityfield input {width:170px;} .ie-lte7 .statefield input {width:121px;} .ie-lte7 .zipfield input {width:170px;} .ie-lte7 .subfields input {width:40px;} .ie-lte7 .hidden-from-view {display:none;} .ie-lte7 select { display:inline-block; width:560px; } /* IE doesn't support input placeholders until v10, show labels on addresses */ .ie-lte7 .addressfield label, .ie-lte9 .addressfield label {display:block; font-weight:normal; font-size:14px;} /* Dijit styles for date picker */ .dijitPopup .dijitReset{margin:0;border:0;padding:0;font:inherit;line-height:normal;color:inherit;font-family:"Helvetica Neue",Helvetica,Arial,Verdana,sans-serif} .dijitPopup .dj_a11y .dijitReset{-moz-appearance:none;} .dijitPopup .dijitInline{display:inline-block;border:0;padding:0;vertical-align:middle} .dijitPopup .dijitInline{display:inline-table;box-sizing:content-box;-moz-box-sizing:content-box} .dijitPopup .dijitHidden{display:none !important} .dijitPopup .dijitVisible{display:block !important;position:relative;} .dijitPopup .dijitInputContainer{overflow:hidden;float:none !important;position:relative} .dijitPopup .dj_ie .dijitSelect input, .dijitPopup .dj_ie input.dijitTextBox, .dijitPopup .dj_ie .dijitTextBox input{font-size:100%} .dijitPopup .dijitSelect .dijitButtonText{float:left;vertical-align:top} .dijitPopup .dijitSelect{padding:0 !important;} .dijitPopup .dijitTextBox .dijitSpinnerButtonContainer, .dijitPopup .dijitTextBox .dijitArrowButtonContainer, .dijitPopup .dijitValidationTextBox .dijitValidationContainer{float:right;text-align:center} .dijitPopup .dijitSelect input.dijitInputField, .dijitPopup .dijitTextBox input.dijitInputField{padding-left:0 !important;padding-right:0 !important} .dijitPopup .dijitValidationTextBox .dijitValidationContainer{display:none} .dijitPopup .dijitTeeny{font-size:1px;line-height:1px} .dijitPopup .dijitOffScreen{position:absolute !important;left:50% !important;top:-10000px !important} .dijitPopup .dijitPositionOnly{padding:0 !important;border:0 !important;background-color:transparent !important;background-image:none !important;height:auto !important;width:auto !important} .dijitPopup .dijitNonPositionOnly{float:none !important;position:static !important;margin:0 0 0 0 !important;vertical-align:middle !important} .dijitPopup .dijitBackgroundIframe{position:absolute;left:0;top:0;width:100%;height:100%;z-index:-1;border:0;padding:0;margin:0} .dijitPopup .dijitDisplayNone{display:none !important} .dijitPopup .dijitContainer{overflow:hidden;} .dijitPopup{position:absolute;background-color:transparent;margin:0;border:0;padding:0} .dijitPopup{-webkit-box-shadow:0 6px 6px 1px rgba(0, 0, 0, 0.1);box-shadow:0 6px 6px 1px rgba(0, 0, 0, 0.1);border-radius:6px} @media screen and (max-width:40em){ .dijitPopup{width:96% !important;left:50% !important;margin:0 auto 0 -48%} } .dijitPopup .dijitMenuTable{width:100% !important} .dijitMenu{border:1px solid #000;background-color:#fff} .dijitMenuTable{border-collapse:collapse;border-width:0;background-color:#fff} .dj_webkit .dijitMenuTable td[colspan="2"]{border-right:hidden} .dijitMenuItem{text-align:left;white-space:nowrap;padding:.1em .2em;cursor:pointer} .dijitMenuItem:focus{outline:none} .dijitMenuItemIcon, .dijitMenuExpand{background-repeat:no-repeat} .dijitMenuItemDisabled *{opacity:.5;cursor:default} .dj_ie .dj_a11y .dijitMenuItemDisabled, .dj_ie .dj_a11y .dijitMenuItemDisabled *, .dj_ie .dijitMenuItemDisabled *{color:#808080;filter:alpha(opacity=35)} .dijitMenuItemLabel{position:relative;vertical-align:middle} .dj_a11y .dijitMenuItemSelected{border:1px dotted #000 !important;} .dj_ff3 .dj_a11y .dijitMenuItem td{padding:0 !important;background:none !important} .dj_a11y .dijitMenuItemSelected .dijitMenuItemLabel{border-width:1px;border-style:solid} .dj_ie8 .dj_a11y .dijitMenuItemLabel{position:static} .dijitMenuExpandA11y{display:none} .dj_a11y .dijitMenuExpandA11y{display:inline} .dijitMenuSeparator td{border:0;padding:0} .dijitMenuSeparatorTop{height:50%;margin:0;margin-top:3px;font-size:1px} .dijitMenuSeparatorBottom{height:50%;margin:0;margin-bottom:3px;font-size:1px} .dijitCheckedMenuItemIconChar{vertical-align:middle;visibility:hidden} .dijitCheckedMenuItemChecked .dijitCheckedMenuItemIconChar{visibility:visible} .dj_a11y .dijitCheckedMenuItemIconChar{display:inline !important} .dj_a11y .dijitCheckedMenuItemIcon{display:none} .dj_ie .dj_a11y .dijitMenuBar .dijitMenuItem{margin:0} .dijitCalendarContainer{width:auto;} .dijitCalendarContainer th, .dijitCalendarContainer td{padding:0;vertical-align:middle} .dijitCalendarYearLabel{white-space:nowrap;} .dijitCalendarNextYear{margin:0 0 0 .55em} .dijitCalendarPreviousYear{margin:0 .55em 0 0} .dijitCalendarIncrementControl{vertical-align:middle} .dijitCalendarIncrementControl, .dijitCalendarDateTemplate, .dijitCalendarMonthLabel, .dijitCalendarPreviousYear, .dijitCalendarNextYear{cursor:pointer} .dijitCalendarDisabledDate{color:#808080;text-decoration:line-through;cursor:default} .dijitSpacer{position:relative;height:1px;overflow:hidden;visibility:hidden} .dijitCalendarMonthMenu .dijitCalendarMonthLabel{text-align:center} .dijitCalendar{border:solid 1px #cfcfcf;background-color:#fff;text-align:center;padding:18px;border-radius:6px;border-collapse:separate} .dijitCalendar img{border:none} .dijitCalendarMonthContainer th{text-align:center;vertical-align:middle} .dijitCalendarMonthLabel{color:#595959;font-size:.9375em;font-weight:bold;padding:6px 12px} .dijitA11ySideArrow{display:none} .dijitCalendarArrow{cursor:pointer;border:1px solid transparent;position:relative;} .dijitCalendarArrow img {display:none;} .dijitCalendarArrow:hover{background-color:#f2f2f2;border-color:#d0d0d0} .dijitCalendarArrow:after{content:" "; width:0; height:0; border:6px solid transparent; border-left:6px solid #333; display:block; position:absolute; top:25%; left:45%} .dijitCalendarArrow:first-child:before{content:" "; width:0; height:0; border:6px solid transparent; border-right:6px solid #333; display:block; position:absolute; top:25%; left:45%} .dijitCalendarArrow:first-child:after{border:none;} .dijitCalendarCurrentDate {background:#eee;} .dijitCalendarDayLabelTemplate{text-align:center;font-weight:bold;padding:8px 12px} .dijitCalendarDayLabel{font-weight:bold;font-size:.9375em;text-align:center;color:#595959} .dijitCalendarDateTemplate{border-bottom:0 none;font-size:.9375em;font-weight:500;letter-spacing:.05em;text-align:center;color:#595959} .dijitCalendarPreviousMonth, .dijitCalendarNextMonth{border-bottom:0 none} .dijitCalendarDateTemplate .dijitCalendarDateLabel{text-decoration:none;display:block;padding:6px 10px;border:1px solid transparent;-webkit-transition-property:background-color,border;-ms-transition-property:background-color,border;transition-property:background-color,border;-webkit-transition-duration:.35s;-ms-transition-duration:.35s;transition-duration:.35s} .dijitCalendarPreviousMonth .dijitCalendarDateLabel, .dijitCalendarNextMonth .dijitCalendarDateLabel{color:#ababab;border-color:#fff;} .dijitCalendarYearContainer{vertical-align:middle} .dijitCalendarYearControl{padding:1px 2px 2px 2px} .dijitCalendarYearLabel{padding:8px 0 0;margin:0;font-size:.9375em} .dijitCalendarYearLabel span{vertical-align:middle} .dijitCalendarSelectedYear{padding:0 6px;font-size:.9375em;color:#52bad5} .dijitCalendarNextYear, .dijitCalendarPreviousYear{font-size:.9375em;border:1px solid transparent;padding:6px 12px} .dijitCalendarHoveredDate .dijitCalendarDateLabel, .dijitCalendarEnabledDate:hover .dijitCalendarDateLabel{background-color:#b1e0ec;border:solid 1px #52bad5;color:#595959;-webkit-transition-duration:.2s;-ms-transition-duration:.2s;transition-duration:.2s} .dijitCalendarNextYearHover, .dijitCalendarNextYear:hover, .dijitCalendarPreviousYearHover, .dijitCalendarPreviousYear:hover{color:#595959;background-color:#f2f2f2;border-color:#d0d0d0} .dijitCalendarNextYearActive, .dijitCalendarNextYear:active .dijitCalendarPreviousYearActive, .dijitCalendarPreviousYear:active{background-color:#c7c7c7} .dijitCalendarActiveDate .dijitCalendarDateLabel, .dijitCalendarEnabledDate:active .dijitCalendarDateLabel{border:solid 1px #fff;-webkit-transition-duration:.1s;-ms-transition-duration:.1s;transition-duration:.1s} .dijitCalendarSelectedDate .dijitCalendarDateLabel{color:#595959;background-color:#b1e0ec;border:solid 1px #52bad5} .dijitCalendarDisabledDate .dijitCalendarDateLabel{color:#808080;text-decoration:line-through} .dijitCalendar .dijitDropDownButton{margin:0;background-color:transparent} .dijitCalendar .dijitDropDownButtonHover .dijitButtonNode, .dijitCalendar .dijitDropDownButton:hover .dijitButtonNode{background-color:transparent;border:0 none} .dijitCalendarMonthMenu{border-color:#ababab;background-color:#fff;text-align:center;background-image:none} .dijitCalendarMonthMenu .dijitCalendarMonthLabel{border-top:solid 1px transparent;border-bottom:solid 1px transparent} .dijitCalendarMonthMenu .dijitCalendarMonthLabelHover, .dijitCalendarMonthMenu .dijitCalendarMonthLabel:hover{background-color:#b1e0ec;border-color:#52bad5;border-width:1px 0} .dijitTooltip{display:none !important;} </style><style type="text/css"> body{ font:14px/20px 'Helvetica', Arial, sans-serif; margin:0; padding:75px 0 0 0; text-align:center; -webkit-text-size-adjust:none; } p{ padding:0 0 10px 0; } h1 img{ max-width:100%; height:auto !important; vertical-align:bottom; } h2{ font-size:22px; line-height:28px; margin:0 0 12px 0; } h3{ margin:0 0 12px 0; } .headerBar{ background:none; padding:0; border:none; } .wrapper{ width:600px; margin:0 auto 10px auto; text-align:left; } input.formEmailButton{ border:none !important; } .formEmailButton{ display:inline-block; font-weight:500; font-size:16px; line-height:42px; font-family:'Helvetica', Arial, sans-serif; width:auto; white-space:nowrap; height:42px; margin:12px 5px 12px 0; padding:0 22px; text-decoration:none; text-align:center; cursor:pointer; border:0; border-radius:3px; vertical-align:top; } .formEmailButton span{ display:inline; font-family:'Helvetica', Arial, sans-serif; text-decoration:none; font-weight:500; font-style:normal; font-size:16px; line-height:42px; cursor:pointer; border:none; } .rounded6{ border-radius:6px; } .poweredWrapper{ padding:20px 0; width:560px; margin:0 auto; } .poweredBy{ display:block; } span.or{ display:inline-block; height:32px; line-height:32px; padding:0 5px; margin:5px 5px 0 0; } .clear{ clear:both; } .profile-list{ display:block; margin:15px 20px; padding:0; list-style:none; border-top:1px solid #eee; } .profile-list li{ display:block; margin:0; padding:5px 0; border-bottom:1px solid #eee; } html[dir=rtl] .wrapper,html[dir=rtl] .container,html[dir=rtl] label{ text-align:right !important; } html[dir=rtl] ul.interestgroup_field label{ padding:0; } html[dir=rtl] ul.interestgroup_field input{ margin-left:5px; } html[dir=rtl] .hidden-from-view{ right:-5000px; left:auto; } body,#bodyTable{ background-color:#eeeeee; } h1{ font-size:28px; line-height:110%; margin-bottom:30px; margin-top:0; padding:0; } #templateContainer{ background-color:none; } #templateBody{ background-color:#ffffff; } .bodyContent{ line-height:150%; font-family:Helvetica; font-size:14px; color:#333333; padding:20px; } a:link,a:active,a:visited,a{ color:#336699; } .formEmailButton:link,.formEmailButton:active,.formEmailButton:visited,.formEmailButton,.formEmailButton span{ background-color:#5d5d5d !important; color:#ffffff !important; } .formEmailButton:hover{ background-color:#444444 !important; color:#ffffff !important; } label{ line-height:150%; font-family:Helvetica; font-size:16px; color:#5d5d5d; } .field-group input,select,textarea,.dijitInputField{ font-family:Helvetica; color:#5d5d5d !important; } .asterisk{ color:#cc6600; font-size:20px; } label .asterisk{ visibility:visible; } .indicates-required{ display:none; } .field-help{ color:#de3030; } .error,.errorText{ color:#e85c41; font-weight:bold; } @media (max-width: 620px){ body{ width:100%; -webkit-font-smoothing:antialiased; padding:10px 0 0 0 !important; min-width:300px !important; } } @media (max-width: 620px){ .wrapper,.poweredWrapper{ width:auto !important; max-width:600px !important; padding:0 10px; } } @media (max-width: 620px){ #templateContainer,#templateBody,#templateContainer table{ width:100% !important; -moz-box-sizing:border-box; -webkit-box-sizing:border-box; box-sizing:border-box; } } @media (max-width: 620px){ .addressfield span{ width:auto; float:none; padding-right:0; } } @media (max-width: 620px){ .captcha{ width:auto; float:none; } } .gdpr-mergeRow{ margin:10px 0; color:#4a4a4a; font-family:Helvetica; } .gdpr-content{ margin:0 -20px 0 -20px; padding:20px; background:rgba(255, 255, 255, 0.8); } #gdpr-label{ margin-top:0; } #gdpr-description{ margin-top:6px; margin-bottom:0; padding-bottom:11px; } .gdpr-content p{ color:#4a4a4a; font-size:13px; line-height:1.5; } .gdpr-content .checkbox-group label{ font-weight:normal; font-size:13px; } #gdpr-legal{ padding-top:20px; margin:0; } .gdpr-footer{ margin:0 -20px 0 -20px; padding:20px; background:rgba(255, 255, 255, 0.9); overflow:auto; color:#6d6d6d; } .gdpr-footer p{ font-size:10px; line-height:1.5; margin-bottom:0; } .gdpr-footer a{ color:#206578; } .gdpr-footer img{ width:65px; float:left; margin-right:15px; } </style></head><body> <div class="wrapper rounded6" id="templateContainer"> <h1 class="masthead"></h1> <div id="templateBody" class="bodyContent rounded6"> <div id="subscribeFormWelcome"></div> <div class="indicates-required"><span class="asterisk">*</span> indicates required</div> <form action="https://badassmotogear.us14.list-manage.com/subscribe/post" method="POST"><input type="hidden" name="u" value="421f39a47ff89f854a1c5808a" /> <input type="hidden" name="id" value="1865247cb9" /> <!-- people should not fill these in and expect good things --> <div class="field-shift" aria-label="Please leave the following three fields empty"><label for="b_name">Name: </label> <input type="text" name="b_name" tabindex="-1" value="" placeholder="Freddie" id="b_name" /> <label for="b_email">Email: </label> <input type="email" name="b_email" tabindex="-1" value="" placeholder="youremail@gmail.com" id="b_email" /> <label for="b_comment">Comment: </label> <textarea name="b_comment" tabindex="-1" placeholder="Please comment" id="b_comment"></textarea></div> <div id="mergeTable" class="mergeTable"> <div class="mergeRow dojoDndItem mergeRow-text" id="mergeRow-1"><label for="MERGE1">First Name</label> <div class="field-group"><input type="text" name="MERGE1" id="MERGE1" size="25" value="" /></div> </div> <div class="mergeRow dojoDndItem mergeRow-text" id="mergeRow-2"><label for="MERGE2">Last Name</label> <div class="field-group"><input type="text" name="MERGE2" id="MERGE2" size="25" value="" /></div> </div> <div class="mergeRow dojoDndItem mergeRow-email" id="mergeRow-0"><label for="MERGE0">Email: Same email you used on your amazon order <span class="req asterisk">*</span></label> <div class="field-group"><input type="email" autocapitalize="off" autocorrect="off" name="MERGE0" id="MERGE0" size="25" value="" /> <div class="field-help">Please use the same email you used on your amazon order</div> </div> </div> <div class="mergeRow dojoDndItem mergeRow-phone" id="mergeRow-4"><label for="MERGE4">Phone Number</label> <div class="field-group"><input type="text" name="MERGE4" id="MERGE4" size="25" value="" /></div> </div> <div class="mergeRow dojoDndItem mergeRow-dropdown" id="mergeRow-3"><label for="MERGE3">Motorcycle</label> <div class="field-group"> <select class="select-small" id="MERGE3" name="MERGE3"> <option value="Choose from drop down">Choose from drop down</option> <option value="Kickstand pad">Kickstand pad</option> <option value="Cover">Cover</option> <option value="Tie downs/ratchet straps">Tie downs/ratchet straps</option> <option value="Clothing/wearable gear">Clothing/wearable gear</option> <option value="Luggage / backpack">Luggage / backpack</option> <option value="Other">Other</option> </select> </div> </div> <div class="mergeRow dojoDndItem mergeRow-dropdown" id="mergeRow-5"><label for="MERGE5">ATV/UTV</label> <div class="field-group"> <select class="select-small" id="MERGE5" name="MERGE5"> <option value="Choose from drop down">Choose from drop down</option> <option value="Cover">Cover</option> <option value="Grab Handles">Grab Handles</option> <option value="Tie Downs/ratchet straps">Tie Downs/ratchet straps</option> <option value="Other ( enter product)">Other ( enter product)</option> </select> </div> </div> <div class="mergeRow dojoDndItem mergeRow-dropdown" id="mergeRow-6"><label for="MERGE6">Jeep</label> <div class="field-group"> <select class="select-small" id="MERGE6" name="MERGE6"> <option value="Choose from drop down">Choose from drop down</option> <option value="Grab Handles">Grab Handles</option> <option value="Sun Shade">Sun Shade</option> <option value="Accessories pack">Accessories pack</option> <option value="Storage bag">Storage bag</option> <option value="Extinguisher Holder">Extinguisher Holder</option> <option value="Other ( enter product)">Other ( enter product)</option> </select> </div> </div> <div class="mergeRow dojoDndItem mergeRow-text" id="mergeRow-7"><label for="MERGE7">Other (If it is not listed above) <span class="req asterisk">*</span></label> <div class="field-group"><input type="text" name="MERGE7" id="MERGE7" size="25" value="" /> <div class="field-help">If the product you bought isn't listed, please enter it here</div> </div> </div> <div class="mergeRow dojoDndItem mergeRow-text" id="mergeRow-9"><label for="MERGE9">Any other products you'd like to see us produce?</label> <div class="field-group"><input type="text" name="MERGE9" id="MERGE9" size="25" value="" /> <div class="field-help">we'd love your imput</div> </div> </div> <div class="mergeRow dojoDndItem mergeRow-dropdown" id="mergeRow-8"><label for="MERGE8">Do You accept Privacy policy and Terms of Service? <span class="req asterisk">*</span></label> <div class="field-group"> <select class="select-small" id="MERGE8" name="MERGE8"> <option value="YES">YES</option> <option value="" selected="selected"></option> </select> <div class="field-help">See our Privacy policy and Terms of Service from above links</div> </div> </div> <div id="mergeRow-gdpr" class="mergeRow gdpr-mergeRow"> <div class="gdpr-content"><label id="gdpr-label"> Marketing Permissions </label> <p id="gdpr-description">Please select all the ways you would like to hear from BadassMotoGear:</p> <div> <ul class="interestgroup_field checkbox-group"> <li class="!margin-bottom--lv2"><label class="checkbox" for="gdpr_20905"><input type="checkbox" data-dojo-type="dijit/form/CheckBox" id="gdpr_20905" name="gdpr[20905]" value="Y" class="av-checkbox" /><span>Email</span> </label></li> <li class="!margin-bottom--lv2"><label class="checkbox" for="gdpr_20909"><input type="checkbox" data-dojo-type="dijit/form/CheckBox" id="gdpr_20909" name="gdpr[20909]" value="Y" class="av-checkbox" /><span>Direct Mail</span> </label></li> <li class="!margin-bottom--lv2"><label class="checkbox" for="gdpr_20913"><input type="checkbox" data-dojo-type="dijit/form/CheckBox" id="gdpr_20913" name="gdpr[20913]" value="Y" class="av-checkbox" /><span>Customized Online Advertising</span> </label></li> </ul> </div> <p id="gdpr-legal">You can unsubscribe at any time by clicking the link in the footer of our emails. For information about our privacy practices, please visit our website.</p> </div> <div class="gdpr-footer"><a href="https://www.mailchimp.com/gdpr" target="_blank" rel="noopener noreferrer"><img src="https://cdn-images.mailchimp.com/icons/mailchimp-gdpr.svg" alt="GDPR" /></a> <p>We use Mailchimp as our marketing platform. By clicking below to subscribe, you acknowledge that your information will be transferred to Mailchimp for processing. <a href="https://mailchimp.com/legal/" target="_blank" rel="noopener noreferrer">Learn more about Mailchimp's privacy practices here.</a></p> </div> </div> </div> <div class="submit_container clear"><input type="submit" class="formEmailButton" name="submit" value="Submit" /></div> <input type="hidden" name="ht" value="07e81c716a910217d6339bd5efbed096c9a34d73:MTU1ODA0NTAzNy4wNjI2" /> <input type="hidden" name="mc_signupsource" value="hosted" /></form> </div> </div> </body></html>