Secondary - [#192550]

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<form id="intermediariesRegisterForm" class="needs-validation custom-form"
  action="https://webto.salesforce.com/servlet/servlet.WebToCase?encoding=UTF-8" method="POST">
  
  
  <input type="hidden" name="orgid" value="00Db0000000HCeX" />
  <input type="hidden" name="recordType" id="recordType" value="012b0000000kJy2" />
  <input type="hidden" name="retURL" id="retURL" />
  <input type="hidden" name="description" id="description" />
  <input type="hidden" name="external" id="external" value="1" />
  <input type="hidden" name="subject" id="subject" value="Intermediaries Form" />
  <input type="hidden" name="type" id="type" value="Web Self Serve" />

  <p>All fields are required unless labelled optional.</p>
  <div class="form-group">
    <label for="SuppliedName">Your Name</label>
    <input type="text" id="SuppliedName" name="name" class="form-control" maxlength="50" size="20"
      placeholder="e.g John Smith" aria-required="true" required />
  </div>
  <div class="form-group">
    <label for="SuppliedCompany">Your company's name</label>
    <input type="text" id="SuppliedCompany" name="company" class="form-control" maxlength="40" size="20"
      placeholder="Company" aria-required="true" required />
  </div>
  <div class="form-group">
    <label for="simplyIntermediary">Your company's Simplyhealth intermediary reference</label>
    <input type="text" id="simplyIntermediary" name="simplyIntermediary" class="form-control" maxlength="40" size="20"
      placeholder="simplyIntermediary" aria-required="true" required />
  </div>
  <div class="form-group">
    <label for="companies">Which companies do you need to have access to view?</label>
    <textarea id="companies" name="companies"
      placeholder="List names and group references, separate each company and group number with a comma"
      class="form-control" aria-required="true" required></textarea>
  </div>
  <div class="form-group">
    <label for="SuppliedEmail">Email address</label>
    <em>Please ensure you provide a work email address and not a generic shared
      email address.</em>
    <input type="text" id="SuppliedEmail" name="email" class="form-control" maxlength="80" size="20"
      placeholder="Email address" aria-required="true" required />
  </div>
  <div class="form-group">
    <label for="SuppliedPhone">Contact number</label>
    <input type="tel" id="SuppliedPhone" name="phone" class="form-control" maxlength="80" size="20"
      placeholder="07400 123456" aria-required="true" required />
  </div>
  <div class="form-group">
    <label for="jobTitle">Job title</label>
    <input type="text" id="jobTitle" name="job" class="form-control" maxlength="80" size="20" placeholder="Job title"
      aria-required="true" required />
  </div>
  <section class="mb-2">
    <p class="m-t-2 mb-1">
      <strong>What should you have access to view on the portal?</strong>
    </p>
    <div class="custom-control custom-radio">
      <input type="radio" class="custom-control-input" id="access-invoice" name="access" value="invoice only"
        aria-required="true" required />
      <label class="custom-control-label" for="access-invoice">Invoice only</label>
    </div>
    <div class="custom-control custom-radio">
      <input type="radio" class="custom-control-input" id="access-admin" name="access" value="admin only"
        aria-required="true" required />
      <label class="custom-control-label" for="access-admin">Admin only</label>
    </div>
    <div class="custom-control custom-radio">
      <input type="radio" class="custom-control-input" id="access-full" name="access" value="full access"
        aria-required="true" required />
      <label class="custom-control-label" for="access-full">Full access (invoice and admin)</label>
    </div>
  </section>
  <div class="form-group">
    <label for="comments">Comments (optional)</label>
    <textarea id="comments" name="comments" class="form-control"></textarea>
  </div>
  <div class="buttons">
    <button type="submit" id="formsubmit" name="submit" class="btn btn-tertiary">
      Submit
    </button>
  </div>
</form>

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