Cigna Payer Solutions

<!doctype html> <html> <head> <meta charset="UTF-8"> <title>Cigna Payer Solutions - Register</title>  <link href="https://cdn.jsdelivr.net/npm/bootstrap@5.2.0/dist/css/bootstrap.min.css" rel="stylesheet" integrity="sha384-gH2yIJqKdNHPEq0n4Mqa/HGKIhSkIHeL5AyhkYV8i59U5AR6csBvApHHNl/vI1Bx" crossorigin="anonymous">  <script src="https://cdn.jsdelivr.net/npm/bootstrap@5.2.0/dist/js/bootstrap.bundle.min.js" integrity="sha384-A3rJD856KowSb7dwlZdYEkO39Gagi7vIsF0jrRAoQmDKKtQBHUuLZ9AsSv4jD4Xa" crossorigin="anonymous"></script> <link rel="stylesheet" href="https://cdn.jsdelivr.net/npm/bootstrap-icons@1.9.1/font/bootstrap-icons.css"> <link rel="stylesheet" href="css/custom.css"> </head> <body> <div class="container-fluid topbar">Cigna Payer Solutions - Register</div> <div class="container"> <div class="row justify-content-center"> <div class="col-12 col-sm-6"> <div class="well card p-5 mb-3"> <h2>REGISTER:</h2> <p>Please register one time (per device) to access the Cigna Payer Solutions Digital Marketing Toolkit.</p> <form class="form-horizontal" method="post" action="ppo.cfm"> <input type="hidden" name="segment" value="ppo"> <input type="hidden" name="step" value="register"> <input type="hidden" name="token" value="1EC674AF03BA294C99BAAEFDC84A3642D3F410E8"> <input type="hidden" name="return_addr" value="network-value"> <div class="row mb-3"> <label for="fname" class="col-sm-3 col-form-label">First Name</label> <div class="col-sm-9"> <input type="text" class="form-control" name="fname" id="fname" placeholder="First Name" value=""> </div> </div> <div class="row mb-3"> <label for="fname" class="col-sm-3 col-form-label">Last Name</label> <div class="col-sm-9"> <input type="text" class="form-control" name="lname" id="lname" placeholder="Last Name" value=""> </div> </div> <div class="row mb-3"> <label for="fname" class="col-sm-3 col-form-label">Company</label> <div class="col-sm-9"> <input type="text" class="form-control" name="company" id="company" placeholder="Company" value=""> </div> </div> <div class="row mb-3"> <label for="inputEmail3" class="col-sm-3 col-form-label">Business Email</label> <div class="col-sm-9"> <input type="text" class="form-control" name="email" id="email" placeholder="Email" value=""> </div> </div> <div class="row justify-content-end mb-3"> <div class="col-sm-offset-3 col-sm-9"> <div class="d-grid col text-end"> <button type="submit" class="btn btn-primary btn-block btn-lg">REGISTER <i class="glyphicon glyphicon-chevron-right"></i></button> </div> </div> </div> <div class="clearfix"></div> </form> </div> <div class="alert alert-info" role="alert"> <p><i class="bi bi-info-circle-fill"></i> Already registered? <a href="login_ppo.cfm?return_addr=network-value" style="color:#ffffff !important">Click here</a>.</p> </div> <div class="alert alert-warning" role="alert"> <p style="color:#ffffff !important">If your browser is set to block cookies, you will need to log into the Toolkit each time you access it.</p> </div> </div> </div> </div> </body> </html>

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Cigna Payer Solutions - Register