<form class=»simple_form form form-vertical» id=»new_subscriber» action=»https://diversaseguros1.ipzmarketing.com/f/Zpo0QGkAjik» accept-charset=»UTF-8″ method=»post»>
<div class=»form-group string optional subscriber_name»><label class=»control-label string optional» for=»subscriber_name»>Nombre</label><input class=»form-control string optional» type=»text» name=»subscriber[name]» id=»subscriber_name» /></div>
<div class=»form-group string optional subscriber_address»><label class=»control-label string optional» for=»subscriber_address»>Teléfono</label><input class=»form-control string optional» type=»text» name=»subscriber[address]» id=»subscriber_address» /></div>
<div class=»form-group email required subscriber_email»><label class=»control-label email required» for=»subscriber_email»><abbr title=»Requerido»> </abbr> Email</label><input class=»form-control string email required» required=»required» aria-required=»true» type=»email» name=»subscriber[email]» id=»subscriber_email» /></div>
<div class=»form-group boolean required subscriber_subscribed_with_acceptance»><div class=»checkbox»><input value=»0″ type=»hidden» name=»subscriber[subscribed_with_acceptance]» /><label class=»boolean required» for=»subscriber_subscribed_with_acceptance»><input class=»boolean required» required=»required» aria-required=»true» type=»checkbox» value=»1″ name=»subscriber[subscribed_with_acceptance]» id=»subscriber_subscribed_with_acceptance» /><abbr title=»Requerido»> </abbr> Acepto la política de privacidad de Diversa Seguros</label></div></div>
<input type=»text» name=»anotheremail» id=»anotheremail» style=»position: absolute; left: -5000px» tabindex=»-1″ autocomplete=»new-password» />
<div class=»submit-wrapper»>
<input type=»submit» name=»commit» value=»Enviar» class=»btn btn-primary» data-disable-with=»Procesando» />
</div>
</form>
