<form method=”post” id=”claimReportForm” style=”text-align: center; width: 348px; margin: auto; background: rgb(13, 49, 193); border-color: rgb(221, 221, 221); border-width: 1px; border-style: solid; padding-top: 10px; padding-bottom: 10px; border-radius: 4px 4px 0px 0px;” action=”http://leadfeedlocalv2.herokuapp.com/external/generateReportThroughWidget”>
<div>
<h4 id=”captureDialogTitle”>Let Me Run My Own Website Report</h4>
</div>
<div id=”formGroup”>

<div id=”urlGroup” style=”padding: 10px”>
<input type=”url” id=”url” placeholder=”URL” minlength=”6″ name=”url” required=”true” style=” height: 40px;
padding: 6px 12px;
margin-top: 5px;
margin-bottom: 5px;
font-size: 14px;
line-height: 1.42857143;
color: #555;
box-sizing: border-box;
width: 100%;
background-color: #fff;” aria-required=”true”>
</div>
<div id=”idGroup”>
<input type=”hidden” id=”leadfeedUsername” required=”true” name=”leadfeedUsername” value=”4192″>
</div>

<div id=”nameGroup” class=”js-configurable” style=”padding: 10px”>
<input type=”text” style=” height: 40px;
padding: 6px 12px;
font-size: 14px;
line-height: 1.42857143;
color: #555;
margin-top: 5px;
margin-bottom: 5px;
box-sizing: border-box;
width: 100%;
background-color: #fff;” id=”name” placeholder=”Name” name=”name” minlength=”3″ required=”” aria-required=”true”>
</div><div id=”emailGroup” class=”js-configurable” style=”padding: 10px”>
<input type=”email” id=”email” placeholder=”Email” name=”email” required=”” style=” height: 40px;
padding: 6px 12px;
margin-top: 5px;
margin-bottom: 5px;
font-size: 14px;
line-height: 1.42857143;
color: #555;
box-sizing: border-box;
width: 100%;
background-color: #fff;” aria-required=”true”>
</div><div id=”phoneGroup” class=”js-configurable” style=”padding: 10px”>
<input type=”text” id=”phoneNumber” name=”phoneNumber” placeholder=”Phone Number” minlength=”6″ required=”” style=” height: 40px;
padding: 6px 12px;
margin-top: 5px;
margin-bottom: 5px;
font-size: 14px;
line-height: 1.42857143;
color: #555;
box-sizing: border-box;
width: 100%;
background-color: #fff;” aria-required=”true”>
</div></div>
<div>
<button id=”submitClaimReportForm” type=”submit” onsubmit=”this.disabled = false” style=”margin-top: 10px; color: rgb(51, 51, 51); background: rgb(255, 255, 255); display: inline-block; padding: 6px 12px; margin-bottom: 0px; font-size: 14px; font-weight: 400; line-height: 1.42857; text-align: center; white-space: nowrap; vertical-align: middle; border: 1px solid rgb(204, 204, 204); border-radius: 4px;”>Show Me My Own Website Report
</button>
</div>
</form>