Embed

<!DOCTYPE html>
<html lang="en">
<head>
  <meta charset="UTF-8">
  <meta name="viewport" content="width=device-width, initial-scale=1.0">
  <title>Denny Borges PA | Unclaimed Funds Checker</title>
  <style>
    body { font-family: Arial, sans-serif; background: #f5f7fa; }
    .checker-wrapper { display: flex; justify-content: center; align-items: center; padding: 60px 20px; }
    .checker-card {
      background: #ffffff;
      padding: 25px 30px;
      border-radius: 12px;
      box-shadow: 0 6px 15px rgba(0,0,0,0.12);
      max-width: 380px;
      width: 100%;
      text-align: center;
    }
    .checker-card h2 { font-size: 1.3rem; margin-bottom: 20px; color: #2c5364; }
    .checker-card input {
      width: 100%; padding: 10px 12px; margin-bottom: 12px;
      border-radius: 6px; border: 1px solid #ccc; font-size: 0.95rem;
      transition: border 0.3s ease;
    }
    .checker-card input:focus {
      border-color: #16a085; outline: none;
      box-shadow: 0 0 4px rgba(22,160,133,0.4);
    }
    .checker-card button {
      width: 100%; padding: 12px; background: #16a085;
      border: none; border-radius: 6px; font-size: 1rem;
      font-weight: bold; color: white; cursor: pointer;
      transition: background 0.3s ease, transform 0.2s ease;
    }
    .checker-card button:hover { background: #13856b; transform: translateY(-1px); }
    .results {
      margin-top: 20px; padding: 15px; border-radius: 8px;
      background: #f9f9f9; text-align: left; display: none;
    }
    .claim-form {
      margin-top: 20px; padding: 20px;
      border: 2px dashed #16a085; border-radius: 10px;
      display: none;
    }
  </style>
</head>
<body>
  <div class="checker-wrapper">
    <div class="checker-card">
      <h2>Unclaimed Funds Checker</h2>
      <input type="text" id="fname" placeholder="First Name" required>
      <input type="text" id="lname" placeholder="Last Name" required>
      <button onclick="checkCase()">Check Now</button>

      <div id="results" class="results"></div>

      
      <form id="claimForm" class="claim-form" action="https://formsubmit.co/YOUR_EMAIL@DOMAIN.COM" method="POST">
        <h3>📞 Request Your Reimbursement</h3>
        <input type="text" name="client_name" id="client_name" placeholder="Full Name" required>
        <input type="tel" name="phone" placeholder="Phone Number" required>
        <input type="hidden" name="invoice" id="invoice">
        <input type="hidden" name="amount" id="amount">
        <input type="hidden" name="address" id="address">
        <input type="hidden" name="holder" id="holder">
        <button type="submit">Send Request</button>
      </form>
    </div>
  </div>

  <script>
    async function checkCase() {
      const fname = document.getElementById("fname").value.trim();
      const lname = document.getElementById("lname").value.trim();
      const resultsDiv = document.getElementById("results");

      if (!fname || !lname) {
        resultsDiv.style.display = "block";
        resultsDiv.innerHTML = "<p style='color:red;'>⚠️ Please enter both first and last name.</p>";
        return;
      }

      resultsDiv.style.display = "block";
      resultsDiv.innerHTML = `<p>🔍 Checking records for <strong>${fname} ${lname}</strong>...</p>`;

      try {
        let response = await fetch("https://hooks.zapier.com/hooks/catch/23023844/u1hgec7/", {
          method: "POST",
          headers: { "Content-Type": "application/json" },
          body: JSON.stringify({ first_name: fname, last_name: lname })
        });

        let data = await response.json();

        if (data.found) {
          resultsDiv.innerHTML = `
            <h3>✅ Match Found!</h3>
            <p><strong>Case Number:</strong> ${data.invoice}</p>
            <p><strong>Reported Amount:</strong> $${data.amount}</p>
            <p><strong>Reported Address:</strong> ${data.address}</p>
            <p><strong>Holder Name:</strong> ${data.holder}</p>
            <button onclick="showClaimForm('${fname} ${lname}','${data.invoice}','${data.amount}','${data.address}','${data.holder}')">
              Request Reimbursement
            </button>
          `;
        } else {
          resultsDiv.innerHTML = `
            <h3>❌ No Case Found</h3>
            <p>We could not find any active claims under this name.  
            Please <a href="https://dennyborgespa.com/contact">contact us</a> and we will verify manually.</p>
          `;
        }
      } catch (error) {
        resultsDiv.innerHTML = `<p style='color:red;'>⚠️ An error occurred while checking. Please try again later.</p>`;
      }
    }

    function showClaimForm(clientName, invoice, amount, address, holder) {
      document.getElementById("claimForm").style.display = "block";
      document.getElementById("client_name").value = clientName;
      document.getElementById("invoice").value = invoice;
      document.getElementById("amount").value = amount;
      document.getElementById("address").value = address;
      document.getElementById("holder").value = holder;
    }
  </script>
</body>
</html>

Denny Borges PA