<link rel="stylesheet" type="text/css" href="https://cdn.mwadmin.com/html/marketing/dv_quoter/v2/sidebar-v1.css"> <form action="https://www.dentalforeveryone.com/Products/Results" class="sidebar-v1"> <input name="PlanType" type="hidden" id="PlanType" value="Dental" /> <input name="EffDate" type="hidden" id="EffDate" value="1/1/2000" /> <input name="Portal" type="hidden" id="Portal" value="01407-05615" /> <img src="https://cdn.mwadmin.com/admin/File/Image/204" width="100%" alt="Dental Plans" class="mainpic" /> <div class="input-group input-group-lg"> <input type="text" class="form-control" placeholder="Zip Code" name="Zip" maxlength="5"> <span class="input-group-btn"><button type="submit" class="btn">Go!</button></span> </div> </form>