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Health Insurance Marketplace, Affordable Care Act | HealthCare.gov
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<input type="hidden" name="t" value="USCMSHIM_19"/> <input type="hidden" name="a" value="1"/> <div class="modal-header"> <a href="#" class="icon icon-large close" data-dismiss="modal">close</a> <h2 title="Get Email Updates modal window" id="modal-nams" class="header2">Get Email Updates</h2> </div> <div class="modal-body"> <div class="forms screen" id="screen1"> <div class="subscribe-type group"> <p>Learn more about new health insurance options and benefits.</p> <hr class="dark"> <label for="address">Email Address</label> <script src="/web/20140404174037js_/https://www.healthcare.gov/js/civem.js" type="text/javascript"></script> <input placeholder="Email Address" id="address" name="e" type="email" value=""/><span class="help-inline">Required</span> <label for="modal-state-dropdown">Select a State</label> <select id="modal-state-dropdown" name="q_23536" class="state"> <option disabled selected value="state">Select a State</option> <option value="58659">Alabama</option> <option 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value="58709">Wyoming</option> <option value="58710">American Samoa</option> <option value="58711">Guam</option> <option value="58712">Northern Mariana Islands</option> <option value="58713">Puerto Rico</option> <option value="58714">Virgin Islands</option> </select><span class="help-inline">Required</span> <label for="number">For Text Messages</label> <input title="Phone Number" placeholder="For Text Messages" id="number" name="w" type="tel"/><span class="help-inline number-help">Optional</span> <p class="header5"><a class="privacy" href="/web/20140404174037/https://www.healthcare.gov/privacy">Privacy Policy</a></p> </div> </div> <!--complete--> <div class="complete screen nodisplay" id="screen2"> <div class="emphasize"> <h3 class="header2"><span class="icon icon-large icon-inline checkmark">checkmark</span>Subscription Complete!</h3> <p>Now that you've signed up for email or text message updates about the Health Insurance Marketplace, you're one step closer to getting the health 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We'll send you tips and alerts that will help you stay on track to get health insurance that fits your budget and meets your needs.</p> </div> <p class="header5"><a class="privacy" href="/web/20140404174037/https://www.healthcare.gov/privacy">Privacy Policy</a></p> </div> </div> <div class="modal-footer row-fluid"> <input title="Submit" class="btn btn-large btn-green next span3 pull-right valid" type="submit" value="Submit"> <a href="/web/20140404174037/https://www.healthcare.gov/marketplace/individual" class="btn btn-large btn-green next span3 pull-right valid">Learn More</a> </div> </form> <!--googleon: all--> <script> $('a.valid').hide(); $('#number').keyup(function(){ var number = $('#number').val(); var regexObj = /^\(?([0-9]{3})\)?[-. ]?([0-9]{3})[-. ]?([0-9]{4})$/; if (regexObj.test(number)||number=='') { number.replace(regexObj, '($1) $2-$3'); $('.number-help').html('Number is Valid'); } else { $('.number-help').html('Number is invalid'); } }); $('select.state').change(function() { var stateStr = $('option:selected', this).text(); //Set state cookie app.quickAnswers = app.quickAnswers || {}; app.quickAnswers.state = stateStr; $.cookie('quickAnswers', app.quickAnswers, { expires: 30, path: '/', secure: true }); selectState(stateStr); }); var submitForm = function(e) { var email = $('#address', this).val(); var state = $('select.state', this).val(); var number = $('#number', this).val(); var regexObj = /^\(?([0-9]{3})\)?[-. ]?([0-9]{3})[-. ]?([0-9]{4})$/; var languageNum = 'USCMSHIM_19'; if (regexObj.test(number) || number == '') { number.replace(regexObj, '($1) $2-$3'); if (state !== 'state') { if (IsEmail(email)) { var url = 'https://web.archive.org/web/20140404174037/https://api-dc2.govdelivery.com/api/add_script_subscription'; var values = {}; $.each($(this).serializeArray(), function(i, field) { if (field.value.length > 0) { values[field.name] = field.value; }; }); switch(values["a"]) { case "1": values["k"] = key1; break; case "2": values["k"] = key2; break; } $('input[type=submit]', this).attr('disabled', 'disabled'); $.ajax({ url: url, data: values, complete: function(d) { $('#screen1').addClass('nodisplay'); $('#screen2').removeClass('nodisplay'); $('[id*=subscribe-form] a.valid').show(); $('[id*=subscribe-form] input.valid').hide(); }, dataType: 'jsonp' }); } else { alert('E-Mail is invalid'); } } else { alert('Select a State'); } } else { alert('Number is invalid'); } $('#subscribe-modal .modal-header').focus(); return false; }; $('[id*=subscribe-form]').submit(submitForm); $('input[data-email]').keyup(function() { var value = $(this).val(); $('#address').val(value); }); $(function() { $('#subscribe-modal').on('shown', function(e) { $('.modal-header', this).focus(); }); //Set state based on cookie if it exists if (app.quickAnswers && app.quickAnswers.state) { var cookieState = app.quickAnswers.state; selectState(cookieState); } }); function selectState(state) { $('select.state option').filter(function () { return $(this).text() === state; }).attr('selected', true); } </script> </div> </div> </div><!-- wrapper --> <script type="text/javascript"> $(function() { var langCode; 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