<form id="registerSilverBillsForm" class="mobile clearfix" method="post" onsubmit="enrollment.registerSilverBills(); return false;"><!-- [et_pb_line_break_holder] --> <div class="et_pb_text_inner"><!-- [et_pb_line_break_holder] --> <h6><span style="color: #592c5f; line-height: 32px;">I would like to enroll in (select one or both):</span></h6><!-- [et_pb_line_break_holder] --> <div><!-- [et_pb_line_break_holder] --> <div style="display: inline;"><!-- [et_pb_line_break_holder] --> <input type="checkbox" name="silverBillsEnrollCheckbox" id="silverBillsEnrollCheckbox" style="margin-right: 10px;"/><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div style="display: inline;"><!-- [et_pb_line_break_holder] --> <label for="silverBillsEnrollCheckbox" style="font-weight: normal; display: inline;"><span style="color: #592c5f; line-height: 32px; font-size: 22px;"><strong> SilverBills</strong> (BILL MANAGEMENT)</span></label><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div><!-- [et_pb_line_break_holder] --> <div style="display: inline;"><!-- [et_pb_line_break_holder] --> <input type="checkbox" name="eversafeEnrollCheckbox" id="eversafeEnrollCheckbox" style="margin-right: 10px;"/><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div style="display: inline;"><!-- [et_pb_line_break_holder] --> <label for="eversafeEnrollCheckbox" style="font-weight: normal; display: inline;"><span style="color: #099bb1; line-height: 32px; font-size: 22px;"><strong> EverSafe</strong> (FRAUD & ID THEFT PROTECTION)</span><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --></div><!-- [et_pb_line_break_holder] --><div id="enrollmentChoiceMessage" class="errorMessage" style="margin-bottom: 5px;"></div><!-- [et_pb_line_break_holder] --> <h6><span style="color: #592c5f; line-height: 32px;">You are eligible for a 10% discount if you enroll in both SilverBills and EverSafe.</span></h6><!-- [et_pb_line_break_holder] --> </div><!-- [et_pb_line_break_holder] --> <p class="et_pb_contact_field et_pb_contact_field_0 et_pb_contact_field" data-id="first_name" data-type="input" style="margin-left: 0; padding-left: 0; padding-right: 10px;"><!-- [et_pb_line_break_holder] --> <label for="et_pb_contact_first_name_1" class="et_pb_contact_form_label">FIRST NAME</label> <!-- [et_pb_line_break_holder] --> <input type="text" id="et_pb_contact_first_name_1" class="input" value="" name="first" data-required_mark="required" data-field_type="input" data-original_id="first_name" placeholder="FIRST NAME" style="background-color: white !important; width: 100%;"><!-- [et_pb_line_break_holder] --> </p><!-- [et_pb_line_break_holder] --> <div id="firstMessage" class="errorMessage" style="margin-bottom: 5px;"></div><!-- [et_pb_line_break_holder] --> <p class="et_pb_contact_field et_pb_contact_field_1 et_pb_contact_field et_pb_contact_field_last" data-id="last_name" data-type="email" style="margin-left: 0; padding-left: 0; padding-right: 10px;"><!-- [et_pb_line_break_holder] --> <label for="et_pb_contact_last_name_1" class="et_pb_contact_form_label">LAST NAME</label> <!-- [et_pb_line_break_holder] --> <input type="text" id="et_pb_contact_last_name_1" class="input" value="" name="last" data-required_mark="not_required" data-field_type="input" data-original_id="last_name" placeholder="LAST NAME" style="background-color: white !important; width: 100%;"><!-- [et_pb_line_break_holder] --> </p><!-- [et_pb_line_break_holder] --> <div id="lastMessage" class="errorMessage" style="margin-bottom: 5px;"></div><!-- [et_pb_line_break_holder] --> <p class="et_pb_contact_field et_pb_contact_field_2 et_pb_contact_field" data-id="email" data-type="email" style="margin-left: 0; padding-left: 0; padding-right: 10px;"><!-- [et_pb_line_break_holder] --> <label for="et_pb_contact_email_1" class="et_pb_contact_form_label">EMAIL ADDRESS</label><!-- [et_pb_line_break_holder] --> <input type="text" id="et_pb_contact_email_1" class="input" value="" name="email" data-required_mark="required" data-field_type="email" data-original_id="email" placeholder="EMAIL ADDRESS" style="background-color: white !important; width: 100%;"> <!-- [et_pb_line_break_holder] --> </p><!-- [et_pb_line_break_holder] --> <div id="emailMessage" class="errorMessage" style="margin-bottom: 5px;"></div><!-- [et_pb_line_break_holder] --> <p class="et_pb_contact_field et_pb_contact_field_2 et_pb_contact_field" data-id="confirmEmail" data-type="email" style="margin-left: 0; padding-left: 0; padding-right: 10px;"><!-- [et_pb_line_break_holder] --> <label for="et_pb_confirm_email_1" class="et_pb_contact_form_label">VERIFY EMAIL ADDRESS</label><!-- [et_pb_line_break_holder] --> <input type="text" id="et_pb_confirm_email_1" class="input" value="" name="confirmEmail" data-required_mark="required" data-field_type="email" data-original_id="confirmEmail" placeholder="VERIFY EMAIL ADDRESS" style="background-color: white !important; width: 100%;"> <!-- [et_pb_line_break_holder] --> </p><!-- [et_pb_line_break_holder] --> <div id="confirmEmailMessage" class="errorMessage" style="margin-bottom: 5px;"></div><!-- [et_pb_line_break_holder] --> <a id="submitButton" href="#" onclick="$j('#registerSilverBillsForm').submit(); return false;" style="font-size: 18px; padding: 0px; text-decoration: none; float: left;color: #ffffff;background: #009bb1;border-width: 0px;border-radius: 26px;font-weight: bold; padding: 0.3em 1em;" class="et_pb_button et_pb_button_0 et_pb_module et_pb_bg_layout_dark"><!-- [et_pb_line_break_holder] --> <div class="signUpButton" style="height: 28px; padding-top: 0px; padding-left: 12px; padding-right: 12px;">SUBMIT</div><!-- [et_pb_line_break_holder] --> </a><!-- [et_pb_line_break_holder] --> <img id="loadingImage" src="/images/loading3c.gif" style="vertical-align: middle; display: none;" alt="Page Loading" /><!-- [et_pb_line_break_holder] --></form>