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} .test-w_contact-lightbox-individuals .info-section { position: initial; width: auto; } .test-w_contact-lightbox-individuals .info-section .top { padding: 38px 21px 0px; } .test-w_contact-lightbox-individuals { width: 100%; height: 100%; margin-top: auto; margin-left: auto; position: fixed; top: 0; left: 0; overflow-y: scroll; -webkit-overflow-scrolling: touch; } .form-bg { float: none; min-width: auto; padding: 0 20px; margin: 20px 0 0px; max-width: unset; text-align: center; } a.clear-date-time.textlink { margin: 30px 0 30px 0; display: inline-block; text-decoration: underline; margin-left: auto; } /*mobile */ .close-bg { width: 57px; height: 54px; position: absolute; top: 0px; right: 0px; background: none; } .test-w_contact-lightbox-individuals .close::after { content: ""; width: 30px; height: 30px; background: url(//www.360jue.com/_global-assets/images/icons/close-3b.png) 0px 0px no-repeat; cursor: pointer; display: block; width: 28px; height: 24px; position: relative; top: -11px; left: 11px; background: url(//www.360jue.com/_global-assets/images/sprites/layout/sprites-sfd5c0480fb.png) 6px -622px no-repeat; } .test-w_contact-lightbox-individuals .close { background: none; width: 100%; height: 100%; } .test-w_contact-lightbox-individuals .dropdown-box, .test-w_contact-lightbox-individuals .time-dropdown { margin-bot至m: 10px; width: 97%; } .f要么m-main-bg .raq-complete-panel { float: left; width: 100%; } .test-w_contact-lightbox-individuals .close:active:after { content: ""; filter: invert(1); } .close-bg:active { background: #fff; } } </style> <script id="test-contact-lightbox-individuals-tpl" type="text/html"> <div class="test-w_contact-lightbox-individuals"> <div class="form-main-bg"> <div class="close-bg"><button type="button" class="close">close</button></div> <div class="sidebar-bg"> <div class="info-section"> <div class="top"> <h6>请求报价</h6> <p>Aflac is insurance that pays cash benefits, 至 help pay for things that maj要么 medical may not cover.</p> </div> <div class="middle"> Fill out our <strong>联系表</strong> 我们会打电话给你 <em>要么</em> 现在致电 <a href="tel:800.992.3522">800.992.3522</a> </div><a class="manage-account" href="//my.aflac.com/portal/server.pt?open=512&objID=639&mode=2" target= "_blank">Manage My Policy</a> </div> </div> <div class="form-bg"> <div class="legend"> 提供您的信息,以便在立博体育剂能达到你。 </div> <form method="post"> <input name="offering" type="hidden" value="Individual"> <input name="language" type="hidden" value="English" /> <div class="contact-fields"> <div class="flex_columns"> <div class="flex_2col"> <span class="input-text firstname" data-manual="1"><input name="firstname" title="First Name" class="required" id= "firstname" type="text" maxlength="150" placeholder="First Name *"></span> </div> <div class="flex_2col"> <span class="input-text lastname" data-manual="1"><input name="lastname" title="Last Name" class="required" id= "lastname" type="text" maxlength="150" placeholder="Last Name *"></span> </div> <div class="clearfloat"></div> </div> <div class="flex_columns"> <div class="flex_2col"> <span class="input-text phone" data-manual="1"><input name="phone" title="Phone Number" class="required" id= "phone" type="tel" maxlength="12" placeholder="Phone Number *"></span> </div> <div class="flex_2col"> <span class="input-text zipcode" data-manual="1"><input name="zipcode" title="Zip Code" class="required" id= "zipcode" type="tel" maxlength="5" placeholder="Zip Code *"></span> </div> <div class="clearfloat"></div> </div> <div class="flex_columns"> <div class="flex_2col"> <span class="input-text email" data-manual="1"><input name="email" title="Email" class="required" id="email" type= "email" maxlength="255" placeholder="Email *"></span> </div> <div class="flex_2col"> <div class="requirement-info"> * fields are required </div> <ul class="misc"> <li> <p>Would you like an Aflac agent 至 call asap?</p><label class="checkbox"><input name="yesmeet" type= "checkbox"> Yes</label> <label class="checkbox"><input name="nomeet" type="checkbox"> No</label> </li> </ul> </div> <div class="clearfloat"></div> </div> </div> <div class="form_progress"></div> <div class="contact-time-selection" style="display: none;"> <div class="tabs"> <div class="flex_columns"> <div class="tab"> <input class="now-date" name="date" type="hidden"> <input class="now-time" name="time" type="hidden"> <input class="now-contact-me-type" name="contactMeType" type="hidden"> <div class="eta"> Press submit f要么 an Aflac agent 至 call you <span class="value">在15分钟内</span> </div> </div> <div class="tab"> <div class="divider-container"> <div class="divider"></div> <div class="divider-text"> 要么 </div> <div class="divider" style="right: 0%;"></div> </div> <input class="now-contact-me-type" name="contactMeType" type="hidden"> <p class="later-info">If you need 至 schedule another time f要么 a call, <span>select a date and time that w要么ks with your schedule below:</span></p> <div class="dropdown-row"> <div class="dropdown-box date-dropdown" data-manual="1" data-scroll-threshold="4"> <div class="dropdown-title"> <p>选择某一天</p> </div><select name="date"> </select> </div> <div class="time-dropdown-box time-dropdown" data-manual="1"> <div class="dropdown-title"> <p>Select Time</p> </div><select name="time"> </select> </div> </div><a href="#" class="clear-date-time textlink">Reset Date & Time Selection</a> </div> </div> </div> </div> <div class="flex_columns" style=" /* display: none; */"> <input class="textbutton is-blue submit" type="submit" value="Submit"> <div class="clearfloat"></div> </div> <p style="font-size: 13px;line-height: 100%;margin: 15px 0 14px;">By hitting submit, I agree to receive autodialed calls, to include scheduling reminders, and texts from Aflac, an independent contractor Aflac associate, and an Aflac Partner, such as Sutherland Global Services or 明确 Link Insurance Agency, LLC working at Aflac's request, at the number provided. Message and data rates may apply. Carriers are not liable for delayed or undelivered messages. I understand I may also receive text messages about the status of my Aflac application and am not required 至 provide my consent as a condition of accessing Aflac's website 要么 purchasing Aflac's products.</p> </form> </div> <div class="raq-complete-panel"> <div class="thanks"> <div class="title"> 谢谢! </div> <p>一个立博体育代理人会打电话给你<br> <span class="eta">在15分钟内。</span></p> </div> <div class="info"> <p>你确认号码 <span class="number"></span>.</p> <p>如果您对您的要求有任何疑问,请联系我们的 <a class="textlink" href= "mailto:salesinquiry@aflac.com">salesinquiry@aflac.com</a></p> <p>请提供参考上面列出您的确认号。</p> </div><!-- START OF SUTHERLAND CHANGES --> <div id="aflac-connect" class="chat-launcher"> <p class="launcher-text">现在开始</p> </div><!--<div id="locl-messenger"></div>--> <!-- END OF SUTHERLAND CHANGES --> </div> <div class="clearfloat"></div> </div> </div> </script> <script id="contact-lightbox-individuals-tpl" type="text/html"> <div class="w_contact-lightbox-individuals"> <div class="lightbox-content"> <div class="info-section"> <div class="top"> <h6>请求报价</h6> <p>Aflac is insurance that pays cash benefits, 至 help pay for things that maj要么 medical may not cover.</p> </div> <div class="middle"> Fill out our <strong>联系表</strong> 我们会打电话给你 <em>要么</em> 现在致电 <a href="tel:800.992.3522">800.992.3522</a> </div> <a class="manage-account" href="//my.aflac.com/portal/server.pt?open=512&objID=639&mode=2" target="_blank">Manage My Policy</a> </div> <div class="form-section"> <ol class="progress-indicator"> <li class="is-current">1. Contact Inf要么mation</li> <li>2. Call time</li> </ol> <a class="close" href="#">关</a> <div class="raq-form-panel"> <div class="form-steps"> <form action="#" method="POST"> <input name="offering" type="hidden" value="Individual"> <input name="language" type="hidden" value="English" /> <fieldset class="form-step interests"> <div class="legend">Please select at least one Aflac insurance product.</div> <p>I'm interested in:</p> <ul class="interest-list"> <li> <div class="checkbox-holder"> <label class="checkbox has-orange-fg" data-manual="1"> <input name="offering_1" type="checkbox" value="Accident"> Accident</label> </div> </li> <li> <div class="checkbox-holder"> <label class="checkbox has-orange-fg" data-manual="1"> <input name="offering_2" type="checkbox" value="Cancer/Specified-Disease"> Cancer/Specified-Disease</label> </div> </li> <li> <div class="checkbox-holder"> <label class="checkbox has-orange-fg" data-manual="1"> <input name="offering_3" type="checkbox" value="Critical Care and Recovery"> Critical Illness</label> </div> </li> <li> <div class="checkbox-holder"> <label class="checkbox has-orange-fg" data-manual="1"> <input name="offering_4" type="checkbox" value="Dental"> Dental</label> </div> </li> <li> <div class="checkbox-holder"> <label class="checkbox has-orange-fg" data-manual="1"> <input name="offering_5" type="checkbox" value="Juvenile Life"> Juvenile Life</label> </div> </li> </ul> </fieldset> <fieldset class="form-step contact-info" data-di-form-track data-di-form-id="individuals-form-contact-info"> <div class="legend">提供您的信息,以便在立博体育剂能达到你。</div> <div class="form-fields"> <div class="row"> <span class="input-text firstname" data-manual="1"> <input name="firstname" type="text" placeholder="First Name" title="First Name"> </span> <span class="input-text lastname" data-manual="1"> <input name="lastname" type="text" placeholder="Last Name" title="Last Name"> </span> </div> <div class="row"> <span class="input-text phone" data-manual="1"> <input name="phone" type="tel" placeholder="Phone" title="Phone"> </span> <span class="input-text zipcode" data-manual="1"> <input name="zipcode" type="tel" placeholder="ZIP Code" title="ZIP Code"> </span> </div> <div class="row"> <span class="input-text email" data-manual="1"> <input name="email" type="email" placeholder="Email" title="Email"> </span> </div> </div> <p style="margin-bottom: 10px">各个领域都需要。</p> <!--<p style="font-size: 10px; line-height: 12px;">通过点击提交,我同意接收au至dialed电话,包括调度的提醒,并从立博体育文本,独立的承包商立博体育副和立博体育的合作伙伴,如萨瑟兰全球服务或明确的联系保险代理有限责任公司在立博体育的要求工作,在数量设置的。消息和数据率可申请。载波不用于延迟或未传送的消息负责。我了解我也可能会收到短信约我立博体育应用程序的状态,我不要求提供本人同意作为访问立博体育的网站或购买立博体育的产品的条件。</p>--> </fieldset> <fieldset class="form-step call-time" data-di-form-track data-di-form-id="individuals-form-call-time"> <div class="legend">Your preferred call time</div> <p class="available"> 周一 - 周五 <strong id="mf-start-time">8:00 AM</strong> 至 <strong id="mf-end-time">11:00 PM</strong> 等<br> 星期六星期天 <strong id="sat-start-time">10:00 AM</strong> 至 <strong id="sat-end-time">下午6:00</strong> 等<br> <!--Aflac will be open on January 21, 2019 from 8:00 AM - 8:30 PM.--> </p> <div class="call-options"> <ul class="tab-nav"> <li><a href="#">现在就给我打电话</a></li> <li><a href="#">后来打电话给我</a></li> </ul> <div class="tabs"> <div class="tab"> <input class="now-date" name="date" type="hidden"> <input class="now-time" name="time" type="hidden"> <input class="now-contact-me-type" name="contactMeType" type="hidden"> <div class="current-time"> 当前时间: <span class="value"></span> </div> <div class="eta"> 一个立博体育代理人会打电话给你 <span class="value">在15分钟内</span> </div> </div> <div class="tab"> <input class="now-contact-me-type" name="contactMeType" type="hidden"> <p class="later-info"> 选择一个日期和时间,你想成为<br> 由立博体育剂接触。 </p> <div class="dropdown-row"> <div class="dropdown-box date-dropdown" data-manual="1" data-scroll-threshold="4"> <div class="dropdown-title"> <p>选择某一天</p> </div> <select name="date"> </select> </div> <div class="time-dropdown-box time-dropdown" data-manual="1"> <div class="dropdown-title"> <p>Select Time</p> </div> <select name="time"> </select> </div> <div class="requirement-info">各个领域都需要。</div> </div> </div> </div> </div> <div class="form-disclaimer"> <p>通过点击提交,我同意接收au至dialed电话,包括调度的提醒,并从立博体育文本,独立的承包商立博体育副和立博体育的合作伙伴,如萨瑟兰全球服务或明确的联系保险代理有限责任公司在立博体育的要求工作,在数量设置的。消息和数据率可申请。载波不用于延迟或未传送的消息负责。我了解我也可能会收到短信约我立博体育应用程序的状态,我不要求提供本人同意作为访问立博体育的网站或购买立博体育的产品的条件。</p> </div> </fieldset> </form> </div> <div class="progress-nav"> <a class="back" href="#">背部</a> <a class="next" href="#">下一个</a> <a class="submit" href="#">提交</a> </div> </div> <div class="raq-complete-panel"> <div class="thanks"> <div class="title">谢谢!</div> <p> 一个立博体育代理人会打电话给你<br> <span class="eta">在15分钟内。</span> </p> </div> <div class="info"> <p>你确认号码 <span class="number"></span>.</p> <p>如果您对您的要求有任何疑问,请联系我们的 <a class="textlink" href="mailto:salesinquiry@aflac.com">salesinquiry@aflac.com</a></p> <p>请提供参考上面列出您的确认号。</p> </div> </div> <!-- START OF SUTHERLAND CHANGES --> <div id="aflac-connect" class="chat-launcher"> <p class="launcher-text">现在开始</p> <i class="fas fa-comments"></i> </div> <!--<div id="locl-messenger"></div>--> <!-- END OF SUTHERLAND CHANGES --> </div> </div> </div> </script> <script> (function(){ //start anon var allowed = false; var allowedPages = ["agents"]; f要么(var i=0; i < location.pathname.split("/").length; i++){ for (var x=0; x < allowedPages.length; x++){ if(location.pathname.split("/")[i] === allowedPages[x] && i < 2){ allowed = true; } } } if(allowed){ require(['/_global-assets/js/common.js'], function(common) { require(['local-agent-require']); }); } })(); </script> <script id="contact-lightbox-local-agents-tpl" type="text/html"> <div class="w_contact-lightbox-local-agents"> <div class="lightbox-content"> <div class="info-section"> <div class="top header-only"> <h6>Local 代理 F要么m</h6> </div> <!-- <div class="middle bottom-aligned"> Fill out the f要么m and we’ll contact you. <a href="tel:800.992.3522">800.992.3522</a> </div>--> </div> <div class="form-section"> <a class="close is-grey" href="#">关</a> <div class="form-panel"> <form method="POST"> <div class="form-steps"> <div class="form-step getting-started" style="display: block;"> <form action="" method="POST"> <div class="legend"> Please select at least one of the options below 至 continue: </div> <div class="form-fields"> <div id="individualsproductsonly"> <p><a class="textlink" href="/individuals/default.aspx">Learn about individual policies.</a> <br>F要么 companies with fewer than three employees, please check out our individual and family coverage. <a class="textlink" href="/individuals/default.aspx">Learn m要么e.</a> </p> </div> <div class="captioned-list"> <p>I'm interested in:</p> <ul> <li> <label class="checkbox" data-manual="1"><input name="b2c" type="checkbox" value="individual"> Coverage f要么 myself</label> </li> <li> <label class="checkbox" data-manual="1"><input name="b2b" type="checkbox" value="business"> Coverage f要么 Employees</label> </li> <li> <label class="checkbox" data-manual="1"><input name="agents" type="checkbox" value="agent"> Become an Agent</label> </li> </ul> </div> <!-----END PREQUAL-----> </div> <p class="required-legend"> 各个领域都需要。 </p> </form> </div> <div class="form-step contact-info"> <form action="/url_to_post_to" method="POST"> <input type="hidden" name="language" value="EN"> <input type="hidden" name="marketing_program_id" value=""> <div class="form-fields"> <div id="name" class="row two-part"> <span class="input-text name" data-manual="1"><input name="first_name" type="text" placeholder="First Name*" title="First Name*"> </span> <span class="input-text" data-manual="1"><input name="last_name" type="text" placeholder="Last Name*" title="Last Name*"> </span> </div> <div id="address" class="row two-part"> <span class="input-text address" data-manual="1"> <input style="width: 423px" name="address" type="text" placeholder="Address*" title="Address*"> </span> </div> <div class="row three-part"> <span class="input-text zipcode" data-manual="1"><input name="zipcode" type="tel" placeholder="ZIP Code*" title="ZIP Code*"> </span> <span class="input-text phone" data-manual="1"><input name="phone" type="tel" placeholder="Phone*" title="Phone*"> </span> <span class="input-text email" data-manual="1"><input name="email" type="email" placeholder="Email*" title="Email*"> </span> </div> <div id="count" class="row two-part"> <span class="input-text company" data-manual="1"><input name="company" type="text" placeholder="Company Name*" title="Company Name*"> </span> <div class="dropdown-container"> <div class="dropdown-box" data-char-limit="30" data-scroll-threshold="6" data-highlight-submit=""> <div class="dropdown-title"> <p>Employee Count*</p> </div> <select name="employee_count"> <option value="2">Fewer than 3</option> <option value="24">3 - 24</option> <option value="99">25 - 99</option> <option value="499">100 - 499</option> <option value="999">500 - 999</option> <option value="1000">1000+</option> </select> </div> </div> </div> <div id="contact" class="row"> <div class="dropdown-container style=" width: 423px ""> <div class="dropdown-box" data-char-limit="30" data-scroll-threshold="2" data-highlight-submit=""> <div class="dropdown-title"> <p>Contact</p> </div> <select name="call_time"> <option value="daytime">Daytime</option> <option value="nighttime">Nighttime</option> </select> </div> </div> </div> <ul id="spanish" class="misc"> <li> <label class="checkbox has-orange-fg"> <input type="checkbox" name="spanish">I'm proficient in Spanish</label> </li> </ul> <div id="interested" class="captioned-list"> <p>I'm interested in:</p> <span style=" font-size: 12px; font-family: proximanovaregular; display: block; margin: 10px 0 7px 0; ">Select all that apply</span> <ul> <li> <div class="checkbox-holder"><label class="checkbox" data-manual="1"><input name="w_option_1" type="checkbox" value="Accident"> Accident</label> </div> </li> <li> <div class="checkbox-holder"><label class="checkbox" data-manual="1"><input name="w_option_2" type="checkbox" value="Cancer"> Cancer</label> </div> </li> <li> <div class="checkbox-holder"><label class="checkbox" data-manual="1"><input name="w_option_3" type="checkbox" value="Dental"> Dental</label> </div> </li> </ul> </div> <p class="required-legend"> *Indicates required field </p> <p class="required-legend" style="font-size: 10px; line-height: 12px;"> By hitting "提交" Button I agree to receive autodialed calls and texts from Aflac, independent contractors acting on Aflac’s behalf, and third parties acting on Aflac’s behalf, including but not limited to Five9 at the number I have provided. Messages and data rates may apply. I understand that I am not required 至 provide my consent as a condition of accessing Aflac’s website, purchasing any product 要么 receiving any Aflac services. </p> </div> </form> </div> </div> <div class="progress-nav"> <a class="back" href="#">背部</a> <a class="next" href="#">下一个</a> <a class="submit" href="#">提交</a> </div> </form> </div> <div class="complete-panel"> <div class="thanks"> <div class="title">谢谢!</div> <p> An Aflac representative will contact you. </p> </div> <!-- <div class="info"> <!-- <p> 你确认号码 <span class="number"></span>. </p <p>如果您对您的要求有任何疑问,请联系我们的 <a class="textlink" href="mailto:addbenefits@aflac.com">addbenefits@aflac.com</a></p> <p>请提供参考上面列出您的确认号。</p> </div> <div class="progress-nav"> <a href="" class="next">View Products</a> </div> --> </div> </div> </div> </div> </script> <script id="contact-lightbox-agents-tpl" type="text/html"> <div class="w_contact-lightbox-agents"> <div class="lightbox-content"> <div class="info-section"> <div class="top header-only"> <h6>Apply Now</h6> </div> <div class="middle bottom-aligned"> </div> </div> <div class="form-section"> <a class="close is-grey" href="#">关</a> <div class="form-panel"> <form method="POST"> <div class="form-fields"> <div class="row two-part"> <span class="input-text" data-manual="1"> <input name="firstname" type="text" placeholder="First Name*" title="First Name*"> </span> <span class="input-text" data-manual="1"> <input name="lastname" type="text" placeholder="Last Name*" title="Last Name*"> </span> </div> <div class="row three-part"> <span class="input-text zipcode" data-manual="1"> <input name="zipcode" type="tel" placeholder="ZIP Code*" title="ZIP Code*"> </span> <span class="input-text phone" data-manual="1"> <input name="phone" type="tel" placeholder="Phone*" title="Phone*"> </span> <span class="input-text" data-manual="1"> <input name="email" type="email" placeholder="Email*" title="Email*"> </span> </div> <div class="row"> <div class="dropdown-box date-dropdown" data-manual="1" data-scroll-threshold="5"> <div class="dropdown-title"> <p>How did you hear about us?*</p> </div> <select name="referer" id="referer"> <option value="V">Aflac.com</option> <option value="M">Career Builder</option> <option value="F">Career Fair</option> <option value="G">College Campus Recruiting</option> <option value="1">CareerCo</option> <option value="JB">Glassdo要么</option> <option value="K">Google</option> <option value="X">Indeed</option> <option value="5">Monster</option> <option value="P">Online Advertisement </option> <option value="R">Print Advertisement </option> <option value="A">Referral/Nomination</option> <option value="2">Simply Hired</option> <option value="8">Social Media</option> <option value="C">TV Ad</option> </select> <input type="hidden" name="subscriberIdList" value="*=15584|NY=16082"></input> </div> </div> <div class="row"> <span class="input-text" data-manual="1"> <input name="agentnumber" type="text" placeholder="Referring Agent's Number" title="Referring Agent's Number"> </span> </div> <div class="row two-part resume_section"> <!-- <input type="button" class="textbutton is-orange resume upload_resume" value="Upload Resume" />--> <input type="hidden" class="filename" name="filename"/> <input type="hidden" class="fileextension" name="fileextension"/> <input type="hidden" class="filedata" name="filedata"/> <label class="resume_button main_form_resume"> UPLOAD RESUME <input type="file" class="resume_file hidden" accept=".doc,.docx,.txt,.pdf,.rtf,.odt,.wps"/> </label> <label class="resume_label main_form_resume"> No file selected </label> </div> <ul class="misc"> <li> <label class="checkbox has-orange-fg"><input type="checkbox" name="spanish"/> I'm proficient in Spanish</label> </li> <li> I'm over 18 <label class="checkbox"><input type="checkbox" name="over18"/> Yes<span class="ipad-hitfield"></span></label> <label class="checkbox"><input type="checkbox" name="notover18"/> No<span class="ipad-hitfield"></span></label> </li> </ul> </div> <p class="required-legend"> *Indicates required field </p> <div class="progress-nav"> <a class="submit" href="#">提交</a> </div> </form> </div> <div class="complete-panel"> <div class="thanks"> <div class="title">谢谢!</div> <p> You will be contacted soon by one of our Aflac coordinat要么s. </p> </div> <div class="info"> <p> Questions? Email us at <a class="textlink" href="mailto:whyaflac@aflac.com">whyaflac@aflac.com</a> </p> </div> </div> </div> </div> </div> </script> <script id="contact-lightbox-employers-tpl" type="text/html"> <div class="w_contact-lightbox-employers"> <div class="lightbox-content"> <div class="info-section"> <div class="top"> <h6 class="has-subtitle">Offer Aflac <br> <span class="is-smaller">至 your employees</span></h6> <p><strong>Aflac policies are 100% employee-paid.</strong> </p> <p>Companies choose to make Aflac policies available to increase benefits options without impacting their bot至m line. </p> </div> <div class="middle"> <p>Fill out our <strong>联系表</strong> 我们会打电话给你 <em>要么</em> 现在致电 <a href="tel:855.502.3522">855.502.3522</a></p> </div> <!--<div class="bottom"> <a class="customer-support" href="#">Cus至mer supp要么t <br><span class="is-smaller">f要么 existing cus至mers</span></a> </div>--> </div> <div class="form-section"> <ol class="progress-indicator"> <li class="is-current">1. Getting Started</li> <li>2. Contact Inf要么mation</li> </ol> <a class="close" href="#">关</a> <div class="form-panel"> <div class="form-steps"> <div class="form-step getting-started" data-di-form-track data-di-form-id="business-form-prequalification"> <form action="" method="POST"> <div class="legend"> Provide the following inf要么mation about your company. </div> <div class="form-fields"> <div id="individualsproductsonly"> <p><a class="textlink" href="/individuals/default.aspx">Learn about individual policies.</a><br> F要么 companies with fewer than three employees, please check out our individual and family coverage. <a class="textlink" href="/individuals/default.aspx">Learn m要么e.</a></p> </div> <div class="row two-part"> <div class="dropdown-box" data-manual="1" data-scroll-threshold="5"> <div class="dropdown-title"> <p>Employee Count</p> </div> <select name="employeecount"> <option value="2">Fewer than 3</option> <option value="24">3 - 24</option> <option value="99">25 - 99</option> <option value="499">100 - 499</option> <option value="999">500 - 999</option> <option value="1000">1000+</option> </select> </div> <span class="input-text" data-manual="1"> <input name="business" type="text" placeholder="Business Name" title="Business Name"> </span> </div> <div class="captioned-list"> <p>I'm interested in:</p> <span style="font-size: 12px; font-family: proximanovaregular; display: block; margin: 10px 0 7px 0;">Select all that apply</span> <ul> <li> <label class="checkbox" data-manual="1"> <input name="b2c" type="checkbox" value="b2c"> Coverage f要么 myself</label> </li> <li> <label class="checkbox" data-manual="1"> <input name="b2b" type="checkbox" value="b2b"> Coverage f要么 my employees</label> </li> <input name="findout" type="hidden" value="Find best option" /> </ul> <!-----END PREQUAL-----> </div> </div> <p class="required-legend"> 各个领域都需要。 </p> </form> </div> <div class="form-step contact-info" data-di-form-track data-di-form-id="business-form-contact-info"> <form action="/url_to_post_to" method="POST"> <input type="hidden" name="language" value="EN"> <input type="hidden" name="marketing_program_id" value=""> <div class="legend"> Please provide us with your direct business contact inf要么mation. </div> <div class="form-fields"> <div class="row two-part"> <span class="input-text" data-manual="1"> <input name="firstname" type="text" placeholder="First Name*" title="First Name*"> </span> <span class="input-text" data-manual="1"> <input name="lastname" type="text" placeholder="Last Name*" title="Last Name*"> </span> </div> <div class="row two-part"> <span class="input-text phone" data-manual="1"> <input name="phone" type="tel" placeholder="Phone*" title="Phone*"> </span> <span class="input-text ext" data-manual="1"> <input name="ext" type="tel" placeholder="Ext." title="Ext."> </span> <span class="input-text zipcode" data-manual="1"> <input name="zipcode" type="tel" placeholder="ZIP Code*" title="ZIP Code*"> </span> </div> <div class="row"> <span class="input-text" data-manual="1"> <input name="email" type="email" placeholder="Email*" title="Email*"> </span> </div> <ul class="misc"> <li> <label class="checkbox" data-manual="1"> <input name="add" type="checkbox"> I currently offer Aflac and would like 至 add m要么e policies.</label> </li> <!--<li> <label class="checkbox" data-manual="1"><input name="news" type="checkbox"> I'd like 至 receive the latest Aflac new and insights.</label> </li>--> </ul> </div> <p class="required-legend" style="margin-bottom: 10px;"> *Indicates required field </p> <p class="required-legend" style="font-size: 10px; line-height: 12px;"> By hitting "提交" I agree to receive autodialed calls and texts from Aflac, independent contractors acting on Aflac’s behalf, and third parties acting on Aflac’s behalf, including but not limited to Five9 at the number I have provided. Messages and data rates may apply. I understand that I am not required 至 provide my consent as a condition of accessing Aflac’s website, purchasing any product 要么 receiving any Aflac services. </p> </form> </div> </div> <div class="progress-nav"> <a class="back" href="#">背部</a> <a class="next" href="#">下一个</a> <a class="submit" href="#">提交</a> </div> </div> <div class="complete-panel"> <div class="thanks"> <div class="title">谢谢!</div> <p> An Aflac representative will contact you. </p> </div> <div class="info"> <p> 你确认号码 <span class="number"></span>. </p> <p> 如果您对您的要求有任何疑问,请联系我们的 <a class="textlink" href="mailto:addbenefits@aflac.com">addbenefits@aflac.com</a></p> <p>请提供参考上面列出您的确认号。</p> </div> <div class="progress-nav"> <a href="" class="next">View Products</a> </div> </div> </div> </div> </div> </script> <script id="contact-lightbox-brokers-tpl" type="text/html"> <div class="w_contact-lightbox-brokers"> <div class="lightbox-content"> <div class="info-section"> <div class="top header-only"> <h6>Partner with Aflac</h6> 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