{"id":2487,"date":"2020-11-08T00:23:04","date_gmt":"2020-11-07T23:23:04","guid":{"rendered":"https:\/\/aca-pl.com\/?page_id=2487"},"modified":"2020-11-08T17:04:19","modified_gmt":"2020-11-08T16:04:19","slug":"essai-formulaire","status":"publish","type":"page","link":"https:\/\/aca-pl.com\/?page_id=2487","title":{"rendered":"QUESTIONNAIRE AUTOMOBILE"},"content":{"rendered":"\n<p class=\"has-background has-small-font-size\" style=\"background-color:#f1e830\">L&rsquo;objectif de ce questionnaire est d&rsquo;obtenir les informations destin\u00e9es \u00e0 votre \u00e9tude personnalis\u00e9e. Ces informations ne seront en aucun cas transmis \u00e0 des tiers, hormis les assureurs interrog\u00e9s.  Merci de s\u00e9lectionner les propositions ou bien de remplir les informations demand\u00e9es. Si certaines r\u00e9ponses propos\u00e9es, ne correspondent pas, indiquez-le-nous dans votre message d&rsquo;envoi.<\/p>\n\n\n\n<div class=\"forminator-guttenberg\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-2444 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-2444\" data-uid=\"69e5c6049fcef\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-2444\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-2444 forminator-design--default  forminator_ajax\"\n\t\t\t\tmethod=\"post\"\n\t\t\t\tdata-forminator-render=\"0\"\n\t\t\t\tdata-form-id=\"2444\"\n\t\t\t\t\n\t\t\t\tdata-design=\"default\"\n\t\t\t\t\n\t\t\t\t\n\t\t\t\t\n\t\t\t\tdata-grid=\"open\"\n\t\t\t\tenctype=\"multipart\/form-data\"\n\t\t\t\t\n\t\t\t\tstyle=\"display: none;\"\n\t\t\t\t\n\t\t\t\tdata-uid=\"69e5c6049fcef\"\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">CONDUCTEUR PRINCIPAL <\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--name-1_69e5c6049fcef\" id=\"forminator-form-2444__field--name-1_69e5c6049fcef-label\" class=\"forminator-label\">Pr\u00e9fixe<\/label><select name=\"name-1-prefix\" id=\"forminator-form-2444__field--name-1_69e5c6049fcef\" class=\"forminator-select2\" data-multi=\"1\" aria-labelledby=\"forminator-form-2444__field--name-1_69e5c6049fcef-label\" data-default-value=\"\"><option value=\"Mr\" >M.<\/option><option value=\"Mrs\" >Mme<\/option><option value=\"Ms\" >Mme<\/option><option value=\"Mx\" >Mx<\/option><option value=\"Miss\" >Mlle<\/option><option value=\"Dr\" >Dr.<\/option><option value=\"Prof\" >Prof.<\/option><\/select><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-1_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-first-name-1_69e5c6049fcef-label\">Nom Conducteur principal  <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-first-name\" placeholder=\"Ex Dupont\" id=\"forminator-field-first-name-1_69e5c6049fcef\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-1_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-last-name-1_69e5c6049fcef-label\">Pr\u00e9nom <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-last-name\" placeholder=\"Par exemple\u00a0: \u00ab\u00a0Jean\u00a0\u00bb\" id=\"forminator-field-last-name-1_69e5c6049fcef\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"select-14\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-14_69e5c6049fcef\" id=\"forminator-form-2444__field--select-14_69e5c6049fcef-label\" class=\"forminator-label\">Sexe<\/label><select id=\"forminator-form-2444__field--select-14_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-14\" data-default-value=\"S\u00e9lectionner\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-14_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-14_69e5c6049fcef-description\"><option value=\"masculin\"  data-calculation=\"0\">Masculin<\/option><option value=\"F\u00e9minin\"  data-calculation=\"0\">F\u00e9minin<\/option><option value=\"S\u00e9lectionner\" selected=\"selected\" data-calculation=\"0\">S\u00e9lectionner<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-address-1-street_address_69e5c6049fcef-label\">Rue <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"ex: rue de Paris\" id=\"forminator-field-address-1-street_address_69e5c6049fcef\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-address_line_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-address-1-address_line_69e5c6049fcef-label\">Appartement <\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_69e5c6049fcef\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-1-city\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-city_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-address-1-city_69e5c6049fcef-label\">Ville <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"ex: Nantes\" id=\"forminator-field-address-1-city_69e5c6049fcef\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-address-1-zip_69e5c6049fcef-label\">Code postal <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"ex: 49000\" id=\"forminator-field-address-1-zip_69e5c6049fcef\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-6 \"><label for=\"forminator-field-date-1\" class=\"forminator-label\">Date de naissance<\/label><div class=\"forminator-date-input\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-1-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-day_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-date-1-day_69e5c6049fcef-label\">Jour<\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-1-day\" value=\"\" placeholder=\"ex: 01\" id=\"forminator-field-date-1-day_69e5c6049fcef\" class=\"forminator-input\" data-field=\"day\" data-format=\"dd-mm-yy\" data-parent=\"date-1\" aria-describedby=\"forminator-field-date-1_69e5c6049fcef-description\" \/><\/div><\/div><div id=\"date-1-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-month_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-date-1-month_69e5c6049fcef-label\">Mois<\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-1-month\" value=\"\" placeholder=\"ex: 01\" id=\"forminator-field-date-1-month_69e5c6049fcef\" class=\"forminator-input\" data-field=\"month\" data-format=\"dd-mm-yy\" data-parent=\"date-1\" aria-describedby=\"forminator-field-date-1_69e5c6049fcef-description\" \/><\/div><\/div><div id=\"date-1-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-year_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-date-1-year_69e5c6049fcef-label\">Ann\u00e9e<\/label><input type=\"number\" min=\"1\" name=\"date-1-year\" placeholder=\"ex: 2000\" id=\"forminator-field-date-1-year_69e5c6049fcef\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"dd-mm-yy\" data-parent=\"date-1\" aria-describedby=\"forminator-field-date-1_69e5c6049fcef-description\" \/><\/div><\/div><\/div><\/div><span id=\"forminator-field-date-1_69e5c6049fcef-description\" class=\"forminator-description\">Ex: 01\/01\/1990<\/span><\/div><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-text-7_69e5c6049fcef-label\">Lieu de naissance<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_69e5c6049fcef\" class=\"forminator-input forminator-name--field\" data-required=\"\" maxlength=\"50\" \/><span id=\"forminator-field-text-7_69e5c6049fcef-description\" class=\"forminator-description\"><span data-limit=\"50\" data-type=\"characters\">0 \/ 50<\/span><\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-phone-1_69e5c6049fcef-label\">Num\u00e9ro de t\u00e9l\u00e9phone <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_69e5c6049fcef\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" data-validation=\"1\" \/><\/div><\/div><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-email-1_69e5c6049fcef-label\">Adresse de messagerie <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"ex\u00a0: jacques@martin.com\" id=\"forminator-field-email-1_69e5c6049fcef\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_69e5c6049fcef\" id=\"forminator-field-textarea-2_69e5c6049fcef-label\" class=\"forminator-label\">Profession <span class=\"forminator-required\">*<\/span><\/label><textarea name=\"textarea-2\" placeholder=\"Ex: Carreleur\" id=\"forminator-field-textarea-2_69e5c6049fcef\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><div id=\"select-5\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-5_69e5c6049fcef\" id=\"forminator-form-2444__field--select-5_69e5c6049fcef-label\" class=\"forminator-label\">Situation matrimoniale <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-2444__field--select-5_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-5\" data-default-value=\"\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-5_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-5_69e5c6049fcef-description\"><option value=\"\">Merci de choisir une option<\/option><option value=\"Mari\u00e9\"  data-calculation=\"0\">Mari\u00e9<\/option><option value=\"C\u00e9libataire\"  data-calculation=\"0\">C\u00e9libataire<\/option><option value=\"Pacs\u00e9\"  data-calculation=\"0\">Pacs\u00e9<\/option><option value=\"Concubinage\"  data-calculation=\"0\">Concubinage<\/option><option value=\"Divorc\u00e9\"  data-calculation=\"0\">Divorc\u00e9<\/option><option value=\"Veuf\"  data-calculation=\"0\">Veuf<\/option><option value=\"Veuve\"  data-calculation=\"0\">Veuve<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-12 \"><label for=\"forminator-field-date-2\" class=\"forminator-label\">Date de Permis <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-date-input\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-2-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-day_69e5c6049fcef\" class=\"forminator-label\">Jour <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-2-day\" value=\"\" placeholder=\"ex: 01\" id=\"forminator-field-date-2-day_69e5c6049fcef\" class=\"forminator-input\" data-field=\"day\" data-format=\"dd-mm-yy\" data-parent=\"date-2\" aria-describedby=\"forminator-field-date-2_69e5c6049fcef-description\" \/><\/div><\/div><div id=\"date-2-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-month_69e5c6049fcef\" class=\"forminator-label\">Mois <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-2-month\" value=\"\" placeholder=\"ex: 01\" id=\"forminator-field-date-2-month_69e5c6049fcef\" class=\"forminator-input\" data-field=\"month\" data-format=\"dd-mm-yy\" data-parent=\"date-2\" aria-describedby=\"forminator-field-date-2_69e5c6049fcef-description\" \/><\/div><\/div><div id=\"date-2-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-year_69e5c6049fcef\" class=\"forminator-label\">Ann\u00e9e <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" name=\"date-2-year\" placeholder=\"ex:  2000\" id=\"forminator-field-date-2-year_69e5c6049fcef\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"dd-mm-yy\" data-parent=\"date-2\" aria-describedby=\"forminator-field-date-2_69e5c6049fcef-description\" \/><\/div><\/div><\/div><\/div><span id=\"forminator-field-date-2_69e5c6049fcef-description\" class=\"forminator-description\">Ex 01\/01\/1990<\/span><\/div><\/div><div class=\"forminator-row\"><div id=\"select-21\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-21_69e5c6049fcef\" id=\"forminator-form-2444__field--select-21_69e5c6049fcef-label\" class=\"forminator-label\">Test d&#039;alcool\u00e9mie ou aux stup\u00e9fiants positif au cours des 36 derniers mois ?<\/label><select id=\"forminator-form-2444__field--select-21_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-21\" data-default-value=\"S\u00e9lectionner une r\u00e9ponse\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-21_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-21_69e5c6049fcef-description\"><option value=\"oui\"  data-calculation=\"0\">OUI<\/option><option value=\"non\"  data-calculation=\"0\">NON<\/option><option value=\"S\u00e9lectionner une r\u00e9ponse\" selected=\"selected\" data-calculation=\"0\">S\u00e9lectionner une r\u00e9ponse<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-22\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-22_69e5c6049fcef\" id=\"forminator-form-2444__field--select-22_69e5c6049fcef-label\" class=\"forminator-label\">Annulation ou plusieurs suspensions du permis de conduire au cours des 60 derniers mois ? <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-2444__field--select-22_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-22\" data-default-value=\"S\u00e9lectionner une r\u00e9ponse\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-22_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-22_69e5c6049fcef-description\"><option value=\"\">Merci de choisir une option<\/option><option value=\"oui\"  data-calculation=\"0\">OUI<\/option><option value=\"non\"  data-calculation=\"0\">NON<\/option><option value=\"S\u00e9lectionner une r\u00e9ponse\" selected=\"selected\" data-calculation=\"0\">S\u00e9lectionner une r\u00e9ponse<\/option><\/select><\/div><\/div><div id=\"select-23\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-23_69e5c6049fcef\" id=\"forminator-form-2444__field--select-23_69e5c6049fcef-label\" class=\"forminator-label\">Si oui pour quel motif ?<\/label><select id=\"forminator-form-2444__field--select-23_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-23\" data-default-value=\"Choisir une r\u00e9ponse\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-23_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-23_69e5c6049fcef-description\"><option value=\"Conduite sous l&#039;emprise d&#039;un \u00e9tat alcoolique\"  data-calculation=\"0\">Conduite sous l'emprise d'un \u00e9tat alcoolique<\/option><option value=\"Conduite sous l&#039;emprise de stup\u00e9fiants\"  data-calculation=\"0\">Conduite sous l'emprise de stup\u00e9fiants<\/option><option value=\"Annulation de permis suite \u00e0 solde de points nul suite \u00e0 une ou plusieurs infractionse-ou-plusieurs-infractions\"  data-calculation=\"0\">Annulation de permis suite \u00e0 solde de points nul suite \u00e0 une ou plusieurs infractions<\/option><option value=\"Exc\u00e8s de vitesse\"  data-calculation=\"0\">Exc\u00e8s de vitesse<\/option><option value=\"D\u00e9faut d&#039;assurance\"  data-calculation=\"0\">D\u00e9faut d'assurance<\/option><option value=\"D\u00e9lit de fuite\"  data-calculation=\"0\">D\u00e9lit de fuite<\/option><option value=\"Refus d&#039;obtemp\u00e9rer\"  data-calculation=\"0\">Refus d'obtemp\u00e9rer<\/option><option value=\"Pas de suspension ou d&#039;annulation de permis\"  data-calculation=\"0\">Pas de suspension ou d'annulation de permis<\/option><option value=\"Choisir une r\u00e9ponse\" selected=\"selected\" data-calculation=\"0\">Choisir une r\u00e9ponse<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">SECOND CONDUCTEUR<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-13\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-13_69e5c6049fcef\" id=\"forminator-form-2444__field--select-13_69e5c6049fcef-label\" class=\"forminator-label\">Pr\u00e9sence d&#039;un second conducteur  d\u00e9sign\u00e9 ou secondaire ? <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-2444__field--select-13_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-13\" data-default-value=\"non\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-13_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-13_69e5c6049fcef-description\"><option value=\"\">Merci de choisir une option<\/option><option value=\"oui\"  data-calculation=\"0\">OUI<\/option><option value=\"non\" selected=\"selected\" data-calculation=\"0\">NON<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-row forminator-no-margin\" data-multiple=\"true\"><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--name-2_69e5c6049fcef\" id=\"forminator-form-2444__field--name-2_69e5c6049fcef-label\" class=\"forminator-label\">Pr\u00e9fixe<\/label><select name=\"name-2-prefix\" id=\"forminator-form-2444__field--name-2_69e5c6049fcef\" class=\"forminator-select2\" data-multi=\"1\" aria-labelledby=\"forminator-form-2444__field--name-2_69e5c6049fcef-label\" data-default-value=\"\"><option value=\"Mr\" >M.<\/option><option value=\"Mrs\" >Mme<\/option><option value=\"Ms\" >Mme<\/option><option value=\"Mx\" >Mx<\/option><option value=\"Miss\" >Mlle<\/option><option value=\"Dr\" >Dr.<\/option><option value=\"Prof\" >Prof.<\/option><\/select><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-first-name-2_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-first-name-2_69e5c6049fcef-label\">Nom Conducteur D\u00e9sign\u00e9 ou secondaire <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2-first-name\" placeholder=\"Ex: DUPONT\" id=\"forminator-field-first-name-2_69e5c6049fcef\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-2_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-last-name-2_69e5c6049fcef-label\">Pr\u00e9nom <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2-last-name\" placeholder=\"Ex: Jean\" id=\"forminator-field-last-name-2_69e5c6049fcef\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"select-17\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-17_69e5c6049fcef\" id=\"forminator-form-2444__field--select-17_69e5c6049fcef-label\" class=\"forminator-label\">Sexe<\/label><select id=\"forminator-form-2444__field--select-17_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-17\" data-default-value=\"S\u00e9lectionner\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-17_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-17_69e5c6049fcef-description\"><option value=\"masculin\"  data-calculation=\"0\">Masculin<\/option><option value=\"F\u00e9minin\"  data-calculation=\"0\">F\u00e9minin<\/option><option value=\"S\u00e9lectionner\" selected=\"selected\" data-calculation=\"0\">S\u00e9lectionner<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-2\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-2-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-street_address_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-address-2-street_address_69e5c6049fcef-label\">Rue <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-2-street_address\" placeholder=\"Par exemple: rue de Paris\" id=\"forminator-field-address-2-street_address_69e5c6049fcef\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-2-address_line\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-address_line_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-address-2-address_line_69e5c6049fcef-label\">Appartement, suite, etc.<\/label><input type=\"text\" name=\"address-2-address_line\" placeholder=\"\" id=\"forminator-field-address-2-address_line_69e5c6049fcef\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-2-city\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-city_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-address-2-city_69e5c6049fcef-label\">Ville <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-2-city\" placeholder=\"Par exemple\u00a0: Nantes\" id=\"forminator-field-address-2-city_69e5c6049fcef\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-2-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-zip_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-address-2-zip_69e5c6049fcef-label\">Code postal <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-2-zip\" placeholder=\"Par exemple\u00a0: 49000\" id=\"forminator-field-address-2-zip_69e5c6049fcef\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-6 \"><label for=\"forminator-field-date-3\" class=\"forminator-label\">Date de naissance<\/label><div class=\"forminator-date-input\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-3-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-day_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-date-3-day_69e5c6049fcef-label\">Jour<\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-3-day\" value=\"\" placeholder=\"01\" id=\"forminator-field-date-3-day_69e5c6049fcef\" class=\"forminator-input\" data-field=\"day\" data-format=\"dd-mm-yy\" data-parent=\"date-3\" aria-describedby=\"forminator-field-date-3_69e5c6049fcef-description\" \/><\/div><\/div><div id=\"date-3-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-month_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-date-3-month_69e5c6049fcef-label\">Mois<\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-3-month\" value=\"\" placeholder=\"01\" id=\"forminator-field-date-3-month_69e5c6049fcef\" class=\"forminator-input\" data-field=\"month\" data-format=\"dd-mm-yy\" data-parent=\"date-3\" aria-describedby=\"forminator-field-date-3_69e5c6049fcef-description\" \/><\/div><\/div><div id=\"date-3-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-year_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-date-3-year_69e5c6049fcef-label\">Ann\u00e9e<\/label><input type=\"number\" min=\"1\" name=\"date-3-year\" placeholder=\"1960\" id=\"forminator-field-date-3-year_69e5c6049fcef\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"dd-mm-yy\" data-parent=\"date-3\" aria-describedby=\"forminator-field-date-3_69e5c6049fcef-description\" \/><\/div><\/div><\/div><\/div><span id=\"forminator-field-date-3_69e5c6049fcef-description\" class=\"forminator-description\">Ex: 01\/01\/1990<\/span><\/div><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-text-6_69e5c6049fcef-label\">Lieu de naissance <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_69e5c6049fcef\" class=\"forminator-input forminator-name--field\" data-required=\"1\" maxlength=\"50\" \/><span id=\"forminator-field-text-6_69e5c6049fcef-description\" class=\"forminator-description\"><span data-limit=\"50\" data-type=\"characters\">0 \/ 50<\/span><\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-phone-2_69e5c6049fcef-label\">Num\u00e9ro de t\u00e9l\u00e9phone <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"Par exemple\u00a0: +1 3004005000\" id=\"forminator-field-phone-2_69e5c6049fcef\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" data-validation=\"1\" \/><\/div><\/div><div id=\"email-2\" class=\"forminator-field-email forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-2_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-email-2_69e5c6049fcef-label\">Adresse de messagerie<\/label><input type=\"email\" name=\"email-2\" value=\"\" placeholder=\"Ex: jacques@martin.com\" id=\"forminator-field-email-2_69e5c6049fcef\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-24\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-24_69e5c6049fcef\" id=\"forminator-form-2444__field--select-24_69e5c6049fcef-label\" class=\"forminator-label\">Test d&#039;alcool\u00e9mie ou aux stup\u00e9fiants positif au cours des 36 derniers mois ? <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-2444__field--select-24_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-24\" data-default-value=\"S\u00e9lectionner une r\u00e9ponse\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-24_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-24_69e5c6049fcef-description\"><option value=\"\">Merci de choisir une option<\/option><option value=\"oui\"  data-calculation=\"0\">OUI<\/option><option value=\"non\"  data-calculation=\"0\">NON<\/option><option value=\"S\u00e9lectionner une r\u00e9ponse\" selected=\"selected\" data-calculation=\"0\">S\u00e9lectionner une r\u00e9ponse<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-25\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-25_69e5c6049fcef\" id=\"forminator-form-2444__field--select-25_69e5c6049fcef-label\" class=\"forminator-label\">Annulation ou plusieurs suspensions du permis de conduire au cours des 60 derniers mois <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-2444__field--select-25_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-25\" data-default-value=\"S\u00e9lectionner une r\u00e9ponse\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-25_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-25_69e5c6049fcef-description\"><option value=\"\">Merci de choisir une option<\/option><option value=\"oui\"  data-calculation=\"0\">OUI<\/option><option value=\"non\"  data-calculation=\"0\">NON<\/option><option value=\"S\u00e9lectionner une r\u00e9ponse\" selected=\"selected\" data-calculation=\"0\">S\u00e9lectionner une r\u00e9ponse<\/option><\/select><\/div><\/div><div id=\"select-26\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-26_69e5c6049fcef\" id=\"forminator-form-2444__field--select-26_69e5c6049fcef-label\" class=\"forminator-label\">Si oui pour quel motif ?<\/label><select id=\"forminator-form-2444__field--select-26_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-26\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-26_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-26_69e5c6049fcef-description\"><option value=\"Conduite sous l&#039;emprise d&#039;un \u00e9tat alcoolique\"  data-calculation=\"0\">Conduite sous l'emprise d'un \u00e9tat alcoolique<\/option><option value=\"Conduite sous l&#039;emprise de stup\u00e9fiants\"  data-calculation=\"0\">Conduite sous l'emprise de stup\u00e9fiants<\/option><option value=\"Annulation de permis suite \u00e0 solde de points nul suite \u00e0 une ou plusieurs infractionse-ou-plusieurs-infractions\"  data-calculation=\"0\">Annulation de permis suite \u00e0 solde de points nul suite \u00e0 une ou plusieurs infractions<\/option><option value=\"Exc\u00e8s de vitesse\"  data-calculation=\"0\">Exc\u00e8s de vitesse<\/option><option value=\"D\u00e9faut d&#039;assurance\"  data-calculation=\"0\">D\u00e9faut d'assurance<\/option><option value=\"D\u00e9lit de fuite\"  data-calculation=\"0\">D\u00e9lit de fuite<\/option><option value=\"Refus d&#039;obtemp\u00e9rer\"  data-calculation=\"0\">Refus d'obtemp\u00e9rer<\/option><option value=\"Pas de suspension ou d&#039;annulation de permis\"  data-calculation=\"0\">Pas de suspension ou d'annulation de permis<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-6\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-6_69e5c6049fcef\" id=\"forminator-form-2444__field--select-6_69e5c6049fcef-label\" class=\"forminator-label\">Situation matrimoniale <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-2444__field--select-6_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-6\" data-default-value=\"\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-6_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-6_69e5c6049fcef-description\"><option value=\"\">Merci de choisir une option<\/option><option value=\"Mari\u00e9\"  data-calculation=\"0\">Mari\u00e9<\/option><option value=\"C\u00e9libataire\"  data-calculation=\"0\">C\u00e9libataire<\/option><option value=\"Pacs\u00e9\"  data-calculation=\"0\">Pacs\u00e9<\/option><option value=\"Concubinage\"  data-calculation=\"0\">Concubinage<\/option><option value=\"Divorc\u00e9\"  data-calculation=\"0\">Divorc\u00e9<\/option><option value=\"Veuf\"  data-calculation=\"0\">Veuf<\/option><option value=\"Veuve\"  data-calculation=\"0\">Veuve<\/option><\/select><\/div><\/div><div id=\"textarea-3\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-3_69e5c6049fcef\" id=\"forminator-field-textarea-3_69e5c6049fcef-label\" class=\"forminator-label\">Profession<\/label><textarea name=\"textarea-3\" placeholder=\"Profession exerc\u00e9e\nEx: Carreleur\" id=\"forminator-field-textarea-3_69e5c6049fcef\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">VEHICULE A GARANTIR<\/h2><hr class=\"forminator-border\" style=\"border: 1px solid 1;\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-text-1_69e5c6049fcef-label\">Marque de votre v\u00e9hicule <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"par exemple: Citro\u00ebn\" id=\"forminator-field-text-1_69e5c6049fcef\" class=\"forminator-input forminator-name--field\" data-required=\"1\" aria-describedby=\"forminator-field-text-1_69e5c6049fcef-description\" \/><span id=\"forminator-field-text-1_69e5c6049fcef-description\" class=\"forminator-description\">Votre v\u00e9hicule:<\/span><\/div><\/div><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-text-2_69e5c6049fcef-label\">Mod\u00e8le commercial pr\u00e9cis <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_69e5c6049fcef\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-text-4_69e5c6049fcef-label\">Type carte grise<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_69e5c6049fcef\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-2_69e5c6049fcef\" id=\"forminator-form-2444__field--select-2_69e5c6049fcef-label\" class=\"forminator-label\">Puissance du v\u00e9hicule <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-2444__field--select-2_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-2\" data-default-value=\"4-cv\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-2_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-2_69e5c6049fcef-description\"><option value=\"\">Merci de choisir une option<\/option><option value=\"1-cv\"  data-calculation=\"0\">1 CV<\/option><option value=\"2-cv\"  data-calculation=\"0\">2 CV<\/option><option value=\"3-cv\"  data-calculation=\"0\">3 CV<\/option><option value=\"4-cv\" selected=\"selected\" data-calculation=\"0\">4 CV<\/option><option value=\"5-cv\"  data-calculation=\"0\">5 CV<\/option><option value=\"6-cv\"  data-calculation=\"0\">6 CV<\/option><option value=\"7-cv\"  data-calculation=\"0\">7 CV<\/option><option value=\"8-cv\"  data-calculation=\"0\">8 CV<\/option><option value=\"9-cv\"  data-calculation=\"0\">9 CV<\/option><option value=\"10-cv\"  data-calculation=\"0\">10 CV<\/option><option value=\"11-cv\"  data-calculation=\"0\">11 CV<\/option><option value=\"12-cv\"  data-calculation=\"0\">12 CV<\/option><option value=\"13-cv\"  data-calculation=\"0\">13 CV<\/option><option value=\"14-cv\"  data-calculation=\"0\">14 CV<\/option><option value=\"15-cv\"  data-calculation=\"0\">15 CV<\/option><option value=\"16-cv\"  data-calculation=\"0\">16 CV<\/option><option value=\"17-cv\"  data-calculation=\"0\">17 CV<\/option><option value=\"18-cv\"  data-calculation=\"0\">18 CV<\/option><option value=\"au-dela-de-18-cv-contacter-le-cabinet\"  data-calculation=\"0\">Au dela de 18 cv contacter le cabinet<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-text-3_69e5c6049fcef-label\">Immatriculation <\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"Par exemple\u00a0: AZ-751-MD\" id=\"forminator-field-text-3_69e5c6049fcef\" class=\"forminator-input forminator-name--field\" data-required=\"\" aria-describedby=\"forminator-field-text-3_69e5c6049fcef-description\" \/><span id=\"forminator-field-text-3_69e5c6049fcef-description\" class=\"forminator-description\">Renseigner votre immatriculation<\/span><\/div><\/div><div id=\"number-1\" class=\"forminator-field-number forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-1_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-number-1_69e5c6049fcef-label\">Valeur du v\u00e9hicule <\/label><input name=\"number-1\" value=\"\" placeholder=\"Par exemple\u00a0: 15000\" id=\"forminator-field-number-1_69e5c6049fcef\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"2\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;.&#039;, &#039;digits&#039;: &#039;2&#039;\" type=\"number\" step=\"any\" min=\"\" aria-describedby=\"forminator-field-number-1_69e5c6049fcef-description\" \/><span id=\"forminator-field-number-1_69e5c6049fcef-description\" class=\"forminator-description\">Valeur du v\u00e9hicule<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-19\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-19_69e5c6049fcef\" id=\"forminator-form-2444__field--select-19_69e5c6049fcef-label\" class=\"forminator-label\">Achet\u00e9e \u00e0 un professionnel de l&#039;automobile ?<\/label><select id=\"forminator-form-2444__field--select-19_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-19\" data-default-value=\"faire-un-choix\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-19_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-19_69e5c6049fcef-description\"><option value=\"oui\"  data-calculation=\"0\">OUI<\/option><option value=\"non\"  data-calculation=\"0\">NON<\/option><option value=\"faire-un-choix\" selected=\"selected\" data-calculation=\"0\">Faire un choix<\/option><\/select><\/div><\/div><div id=\"select-7\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-7_69e5c6049fcef\" id=\"forminator-form-2444__field--select-7_69e5c6049fcef-label\" class=\"forminator-label\">Mode de financement du v\u00e9hicule<\/label><select id=\"forminator-form-2444__field--select-7_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-7\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-7_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-7_69e5c6049fcef-description\"><option value=\"Paiement comptant\"  data-calculation=\"0\">Paiement comptant<\/option><option value=\"Cr\u00e9dit\"  data-calculation=\"0\">Cr\u00e9dit<\/option><option value=\"location-avec-option-dachat\"  data-calculation=\"0\">Location avec option d'achat<\/option><option value=\"Location longue dur\u00e9e\"  data-calculation=\"0\">Location longue dur\u00e9e<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-text-5_69e5c6049fcef-label\">Code postal et ville du lieu de garage<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"Par exemple\u00a0: 75000 Paris\" id=\"forminator-field-text-5_69e5c6049fcef\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-3\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-3_69e5c6049fcef\" id=\"forminator-form-2444__field--select-3_69e5c6049fcef-label\" class=\"forminator-label\">Lieu ou le v\u00e9hicule est remis\u00e9 la nuit<\/label><select id=\"forminator-form-2444__field--select-3_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-3\" data-default-value=\"Rue\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-3_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-3_69e5c6049fcef-description\"><option value=\"garage-clos\"  data-calculation=\"0\">Garage clos<\/option><option value=\"box-ferm\"  data-calculation=\"0\">Box ferm\u00e9 <\/option><option value=\"emplacement-dans-un-parking-couvert\"  data-calculation=\"0\">Emplacement dans un parking couvert<\/option><option value=\"emplacement-dans-un-parking-arien-non-clos\"  data-calculation=\"0\">Emplacement dans un parking  a\u00e9rien non clos<\/option><option value=\"terrain-clos\"  data-calculation=\"0\">Terrain clos<\/option><option value=\"terrain-non-clos\"  data-calculation=\"0\">Terrain non clos<\/option><option value=\"Rue\" selected=\"selected\" data-calculation=\"0\">Rue<\/option><\/select><\/div><\/div><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69e5c6049fcef-label\" aria-describedby=\"forminator-radiogroup-69e5c6049fcef-description\"><span id=\"forminator-radiogroup-69e5c6049fcef-label\" class=\"forminator-label\">Remorque\/caravane<\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-69e5c6049fcef\" class=\"forminator-radio\" title=\"Remorque &lt; 750 kgs\"><input type=\"radio\" name=\"radio-1\" value=\"remorque-750-kgs\" id=\"forminator-field-radio-1-1-69e5c6049fcef\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\" checked=\"checked\"  aria-describedby=\"forminator-field-radio-1-69e5c6049fcef-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Remorque &lt; 750 kgs<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-69e5c6049fcef\" class=\"forminator-radio\" title=\"Remorque &gt; 750 kgs\"><input type=\"radio\" name=\"radio-1\" value=\"remorque &gt;750-kgs\" id=\"forminator-field-radio-1-2-69e5c6049fcef\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-1-69e5c6049fcef-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Remorque &gt; 750 kgs<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-4\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-4_69e5c6049fcef\" id=\"forminator-form-2444__field--select-4_69e5c6049fcef-label\" class=\"forminator-label\">Usage du v\u00e9hicule <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-2444__field--select-4_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-4\" data-default-value=\"Salari\u00e9s d\u00e9placements priv\u00e9s et trajets\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-4_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-4_69e5c6049fcef-description\"><option value=\"\">Merci de choisir une option<\/option><option value=\"D\u00e9placements priv\u00e9s\"  data-calculation=\"0\">D\u00e9placements priv\u00e9s<\/option><option value=\"Salari\u00e9s d\u00e9placements priv\u00e9s et trajets\" selected=\"selected\" data-calculation=\"0\">Salari\u00e9s d\u00e9placements priv\u00e9s et trajets<\/option><option value=\"Fonctionnaires\"  data-calculation=\"0\">Fonctionnaires<\/option><option value=\"Artisans\"  data-calculation=\"0\">Artisans<\/option><option value=\"Affaires, commerces\"  data-calculation=\"0\">Affaires, commerces<\/option><option value=\"Tous d\u00e9placements\"  data-calculation=\"0\">Tous d\u00e9placements<\/option><option value=\"Professions agricoles\"  data-calculation=\"0\">Professions agricoles<\/option><option value=\"Retrait\u00e9s\"  data-calculation=\"0\">Retrait\u00e9s<\/option><option value=\"Etudiant\"  data-calculation=\"0\">Etudiant<\/option><\/select><span id=\"forminator-form-2444__field--select-4_69e5c6049fcef-description\" class=\"forminator-description\">Ex: promenade trajet domicile travail<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-4\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">ANTECEDENTS ASSURE<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-18\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-18_69e5c6049fcef\" id=\"forminator-form-2444__field--select-18_69e5c6049fcef-label\" class=\"forminator-label\">Nombre de mois d&#039;assurance au cours des 36 derniers mois<\/label><select id=\"forminator-form-2444__field--select-18_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-18\" data-default-value=\"S\u00e9lectionner\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-18_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-18_69e5c6049fcef-description\"><option value=\"S\u00e9lectionner\" selected=\"selected\" data-calculation=\"0\">S\u00e9lectionner<\/option><option value=\"Jamais assur\u00e9\"  data-calculation=\"0\">Jamais assur\u00e9<\/option><option value=\"Moins de 9  mois\"  data-calculation=\"0\">Moins de 9  mois<\/option><option value=\"Plus de 9 mois\"  data-calculation=\"0\">Plus de 9 mois<\/option><option value=\"12 mois\"  data-calculation=\"0\">12 mois<\/option><option value=\"24 mois\"  data-calculation=\"0\">24 mois<\/option><option value=\"36 mois\"  data-calculation=\"0\">36 mois<\/option><\/select><\/div><\/div><div id=\"number-3\" class=\"forminator-field-number forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-3_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-number-3_69e5c6049fcef-label\">Taux de bonus\/malus <span class=\"forminator-required\">*<\/span><\/label><input name=\"number-3\" value=\"\" placeholder=\"Ex 0.50 pour 50% de bonus\" id=\"forminator-field-number-3_69e5c6049fcef\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"1\" data-decimals=\"2\" aria-required=\"true\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;.&#039;, &#039;digits&#039;: &#039;2&#039;\" type=\"number\" step=\"any\" min=\"0.50\" max=\"3.50\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-4\" class=\"forminator-field-number forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-4_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-number-4_69e5c6049fcef-label\">Si coefficient bonus \u00e0 0.50, depuis combien d&#039;ann\u00e9es ?<\/label><input name=\"number-4\" value=\"\" placeholder=\"Ex: 5\" id=\"forminator-field-number-4_69e5c6049fcef\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"2\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;.&#039;, &#039;digits&#039;: &#039;2&#039;\" type=\"number\" step=\"any\" min=\"1\" max=\"20\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-20\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-20_69e5c6049fcef\" id=\"forminator-form-2444__field--select-20_69e5c6049fcef-label\" class=\"forminator-label\">R\u00e9siliation par une compagnie pr\u00e9c\u00e9dente au cours des 36 derniers mois ?<\/label><select id=\"forminator-form-2444__field--select-20_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-20\" data-default-value=\"S\u00e9lectionner une r\u00e9ponse\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-20_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-20_69e5c6049fcef-description\"><option value=\"S\u00e9lectionner une r\u00e9ponse\" selected=\"selected\" data-calculation=\"0\">S\u00e9lectionner une r\u00e9ponse<\/option><option value=\"OUI\"  data-calculation=\"0\">OUI<\/option><option value=\"non\"  data-calculation=\"0\">NON<\/option><\/select><\/div><\/div><div id=\"textarea-4\" class=\"forminator-field-textarea forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-4_69e5c6049fcef\" id=\"forminator-field-textarea-4_69e5c6049fcef-label\" class=\"forminator-label\">Si oui pour quelle raison ?<\/label><textarea name=\"textarea-4\" placeholder=\"\" id=\"forminator-field-textarea-4_69e5c6049fcef\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" aria-describedby=\"forminator-field-textarea-4_69e5c6049fcef-description\" ><\/textarea><span id=\"forminator-field-textarea-4_69e5c6049fcef-description\" class=\"forminator-description\">Merci de pr\u00e9ciser la raison<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-2\" class=\"forminator-field-number forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-2_69e5c6049fcef\" class=\"forminator-label\" id=\"forminator-field-number-2_69e5c6049fcef-label\">Nombre de sinistres sur les 48 derniers mois <span class=\"forminator-required\">*<\/span><\/label><input name=\"number-2\" value=\"\" placeholder=\"Ex: 1\" id=\"forminator-field-number-2_69e5c6049fcef\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"1\" data-decimals=\"2\" aria-required=\"true\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;.&#039;, &#039;digits&#039;: &#039;2&#039;\" type=\"number\" step=\"any\" min=\"0\" max=\"150\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-8\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-8_69e5c6049fcef\" id=\"forminator-form-2444__field--select-8_69e5c6049fcef-label\" class=\"forminator-label\">Sinistre 1 <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-2444__field--select-8_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-8\" data-default-value=\"Choisir dans la liste ci-dessous\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-8_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-8_69e5c6049fcef-description\"><option value=\"\">Merci de choisir une option<\/option><option value=\"Choisir dans la liste ci-dessous\" selected=\"selected\" data-calculation=\"0\">Choisir dans la liste ci-dessous<\/option><option value=\"bris-de-glace\"  data-calculation=\"0\"> Bris de glace <\/option><option value=\"Vol\/Vandalisme\"  data-calculation=\"0\">Vol\/Vandalisme<\/option><option value=\"Incendie\"  data-calculation=\"0\">Incendie<\/option><option value=\"dommage-matriel-responsable\"  data-calculation=\"0\">Dommage Mat\u00e9riel Responsable<\/option><option value=\"Dommage Mat\u00e9riel Non Responsable\"  data-calculation=\"0\">Dommage Mat\u00e9riel Non Responsable<\/option><option value=\"dommages-corporels-responsables\"  data-calculation=\"0\">Dommages Corporels  Responsables<\/option><option value=\"Dommages Corporels Non Responsables\"  data-calculation=\"0\">Dommages Corporels Non Responsables<\/option><option value=\"Autres Dommages Responsables \"  data-calculation=\"0\">Autres Dommages Responsables <\/option><option value=\"Autres Dommages Non Responsables \"  data-calculation=\"0\">Autres Dommages Non Responsables <\/option><\/select><\/div><\/div><div id=\"date-4\" class=\"forminator-field-date forminator-col forminator-col-6 \"><label for=\"forminator-field-date-4\" class=\"forminator-label\">Date<\/label><div class=\"forminator-date-select\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-4-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--date-4-day_69e5c6049fcef\" id=\"forminator-form-2444__field--date-4-day_69e5c6049fcef-label\" class=\"forminator-label\">Jour<\/label><select name=\"date-4-day\" id=\"forminator-form-2444__field--date-4-day_69e5c6049fcef\" class=\"forminator-select2\" data-format=\"dd-mm-yy\" data-parent=\"date-4\" aria-describedby=\"forminator-field-date-4_69e5c6049fcef-description\" aria-labelledby=\"forminator-form-2444__field--date-4-day_69e5c6049fcef-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">S\u00e9lectionner le jour<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><\/div><\/div><div id=\"date-4-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--date-4-month_69e5c6049fcef\" id=\"forminator-form-2444__field--date-4-month_69e5c6049fcef-label\" class=\"forminator-label\">Mois<\/label><select name=\"date-4-month\" id=\"forminator-form-2444__field--date-4-month_69e5c6049fcef\" class=\"forminator-select2\" data-format=\"dd-mm-yy\" data-parent=\"date-4\" aria-describedby=\"forminator-field-date-4_69e5c6049fcef-description\" aria-labelledby=\"forminator-form-2444__field--date-4-month_69e5c6049fcef-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">S\u00e9lectionner le mois<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><\/div><\/div><div id=\"date-4-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--date-4-year_69e5c6049fcef\" id=\"forminator-form-2444__field--date-4-year_69e5c6049fcef-label\" class=\"forminator-label\">Ann\u00e9e<\/label><select name=\"date-4-year\" id=\"forminator-form-2444__field--date-4-year_69e5c6049fcef\" class=\"forminator-select2\" data-format=\"dd-mm-yy\" data-parent=\"date-4\" aria-describedby=\"forminator-field-date-4_69e5c6049fcef-description\" aria-labelledby=\"forminator-form-2444__field--date-4-year_69e5c6049fcef-label\" data-default-value=\"2026\"><option value=\"\" >S\u00e9lectionner l\u2019ann\u00e9e<\/option><option value=\"2126\" >2126<\/option><option value=\"2125\" >2125<\/option><option value=\"2124\" >2124<\/option><option value=\"2123\" >2123<\/option><option value=\"2122\" >2122<\/option><option value=\"2121\" >2121<\/option><option value=\"2120\" >2120<\/option><option value=\"2119\" >2119<\/option><option value=\"2118\" >2118<\/option><option value=\"2117\" >2117<\/option><option value=\"2116\" >2116<\/option><option value=\"2115\" >2115<\/option><option value=\"2114\" >2114<\/option><option value=\"2113\" >2113<\/option><option value=\"2112\" >2112<\/option><option value=\"2111\" >2111<\/option><option value=\"2110\" >2110<\/option><option value=\"2109\" >2109<\/option><option value=\"2108\" >2108<\/option><option value=\"2107\" >2107<\/option><option value=\"2106\" >2106<\/option><option value=\"2105\" >2105<\/option><option value=\"2104\" >2104<\/option><option value=\"2103\" >2103<\/option><option value=\"2102\" >2102<\/option><option value=\"2101\" >2101<\/option><option value=\"2100\" >2100<\/option><option value=\"2099\" >2099<\/option><option value=\"2098\" >2098<\/option><option value=\"2097\" >2097<\/option><option value=\"2096\" >2096<\/option><option value=\"2095\" >2095<\/option><option value=\"2094\" >2094<\/option><option value=\"2093\" >2093<\/option><option value=\"2092\" >2092<\/option><option value=\"2091\" >2091<\/option><option value=\"2090\" >2090<\/option><option value=\"2089\" >2089<\/option><option value=\"2088\" >2088<\/option><option value=\"2087\" >2087<\/option><option value=\"2086\" >2086<\/option><option value=\"2085\" >2085<\/option><option value=\"2084\" >2084<\/option><option value=\"2083\" >2083<\/option><option value=\"2082\" >2082<\/option><option value=\"2081\" >2081<\/option><option value=\"2080\" >2080<\/option><option value=\"2079\" >2079<\/option><option value=\"2078\" >2078<\/option><option value=\"2077\" >2077<\/option><option value=\"2076\" >2076<\/option><option value=\"2075\" >2075<\/option><option value=\"2074\" >2074<\/option><option value=\"2073\" >2073<\/option><option value=\"2072\" >2072<\/option><option value=\"2071\" >2071<\/option><option value=\"2070\" >2070<\/option><option value=\"2069\" >2069<\/option><option value=\"2068\" >2068<\/option><option value=\"2067\" >2067<\/option><option value=\"2066\" >2066<\/option><option value=\"2065\" >2065<\/option><option value=\"2064\" >2064<\/option><option value=\"2063\" >2063<\/option><option value=\"2062\" >2062<\/option><option value=\"2061\" >2061<\/option><option value=\"2060\" >2060<\/option><option value=\"2059\" >2059<\/option><option value=\"2058\" >2058<\/option><option value=\"2057\" >2057<\/option><option value=\"2056\" >2056<\/option><option value=\"2055\" >2055<\/option><option value=\"2054\" >2054<\/option><option value=\"2053\" >2053<\/option><option value=\"2052\" >2052<\/option><option value=\"2051\" >2051<\/option><option value=\"2050\" >2050<\/option><option value=\"2049\" >2049<\/option><option value=\"2048\" >2048<\/option><option value=\"2047\" >2047<\/option><option value=\"2046\" >2046<\/option><option value=\"2045\" >2045<\/option><option value=\"2044\" >2044<\/option><option value=\"2043\" >2043<\/option><option value=\"2042\" >2042<\/option><option value=\"2041\" >2041<\/option><option value=\"2040\" >2040<\/option><option value=\"2039\" >2039<\/option><option value=\"2038\" >2038<\/option><option value=\"2037\" >2037<\/option><option value=\"2036\" >2036<\/option><option value=\"2035\" >2035<\/option><option value=\"2034\" >2034<\/option><option value=\"2033\" >2033<\/option><option value=\"2032\" >2032<\/option><option value=\"2031\" >2031<\/option><option value=\"2030\" >2030<\/option><option value=\"2029\" >2029<\/option><option value=\"2028\" >2028<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" selected=\"selected\">2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-12\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-12_69e5c6049fcef\" id=\"forminator-form-2444__field--select-12_69e5c6049fcef-label\" class=\"forminator-label\">Sinistre 2 <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-2444__field--select-12_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-12\" data-default-value=\"Choisir dans la liste ci-dessous\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-12_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-12_69e5c6049fcef-description\"><option value=\"\">Merci de choisir une option<\/option><option value=\"Choisir dans la liste ci-dessous\" selected=\"selected\" data-calculation=\"0\">Choisir dans la liste ci-dessous<\/option><option value=\"bris-de-glace\"  data-calculation=\"0\"> Bris de glace <\/option><option value=\"Vol\/Vandalisme\"  data-calculation=\"0\">Vol\/Vandalisme<\/option><option value=\"Incendie\"  data-calculation=\"0\">Incendie<\/option><option value=\"dommage-matriel-responsable\"  data-calculation=\"0\">Dommage Mat\u00e9riel Responsable<\/option><option value=\"Dommage Mat\u00e9riel Non Responsable\"  data-calculation=\"0\">Dommage Mat\u00e9riel Non Responsable<\/option><option value=\"dommages-corporels-responsables\"  data-calculation=\"0\">Dommages Corporels  Responsables<\/option><option value=\"Dommages Corporels Non Responsables\"  data-calculation=\"0\">Dommages Corporels Non Responsables<\/option><option value=\"Autres Dommages Responsables \"  data-calculation=\"0\">Autres Dommages Responsables <\/option><option value=\"Autres Dommages Non Responsables \"  data-calculation=\"0\">Autres Dommages Non Responsables <\/option><\/select><\/div><\/div><div id=\"date-5\" class=\"forminator-field-date forminator-col forminator-col-6 \"><label for=\"forminator-field-date-5\" class=\"forminator-label\">Date<\/label><div class=\"forminator-date-select\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-5-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--date-5-day_69e5c6049fcef\" id=\"forminator-form-2444__field--date-5-day_69e5c6049fcef-label\" class=\"forminator-label\">Jour<\/label><select name=\"date-5-day\" id=\"forminator-form-2444__field--date-5-day_69e5c6049fcef\" class=\"forminator-select2\" data-format=\"dd-mm-yy\" data-parent=\"date-5\" aria-describedby=\"forminator-field-date-5_69e5c6049fcef-description\" aria-labelledby=\"forminator-form-2444__field--date-5-day_69e5c6049fcef-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">S\u00e9lectionner le jour<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><\/div><\/div><div id=\"date-5-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--date-5-month_69e5c6049fcef\" id=\"forminator-form-2444__field--date-5-month_69e5c6049fcef-label\" class=\"forminator-label\">Mois<\/label><select name=\"date-5-month\" id=\"forminator-form-2444__field--date-5-month_69e5c6049fcef\" class=\"forminator-select2\" data-format=\"dd-mm-yy\" data-parent=\"date-5\" aria-describedby=\"forminator-field-date-5_69e5c6049fcef-description\" aria-labelledby=\"forminator-form-2444__field--date-5-month_69e5c6049fcef-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">S\u00e9lectionner le mois<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><\/div><\/div><div id=\"date-5-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--date-5-year_69e5c6049fcef\" id=\"forminator-form-2444__field--date-5-year_69e5c6049fcef-label\" class=\"forminator-label\">Ann\u00e9e<\/label><select name=\"date-5-year\" id=\"forminator-form-2444__field--date-5-year_69e5c6049fcef\" class=\"forminator-select2\" data-format=\"dd-mm-yy\" data-parent=\"date-5\" aria-describedby=\"forminator-field-date-5_69e5c6049fcef-description\" aria-labelledby=\"forminator-form-2444__field--date-5-year_69e5c6049fcef-label\" data-default-value=\"2026\"><option value=\"\" >S\u00e9lectionner l\u2019ann\u00e9e<\/option><option value=\"2126\" >2126<\/option><option value=\"2125\" >2125<\/option><option value=\"2124\" >2124<\/option><option value=\"2123\" >2123<\/option><option value=\"2122\" >2122<\/option><option value=\"2121\" >2121<\/option><option value=\"2120\" >2120<\/option><option value=\"2119\" >2119<\/option><option value=\"2118\" >2118<\/option><option value=\"2117\" >2117<\/option><option value=\"2116\" >2116<\/option><option value=\"2115\" >2115<\/option><option value=\"2114\" >2114<\/option><option value=\"2113\" >2113<\/option><option value=\"2112\" >2112<\/option><option value=\"2111\" >2111<\/option><option value=\"2110\" >2110<\/option><option value=\"2109\" >2109<\/option><option value=\"2108\" >2108<\/option><option value=\"2107\" >2107<\/option><option value=\"2106\" >2106<\/option><option value=\"2105\" >2105<\/option><option value=\"2104\" >2104<\/option><option value=\"2103\" >2103<\/option><option value=\"2102\" >2102<\/option><option value=\"2101\" >2101<\/option><option value=\"2100\" >2100<\/option><option value=\"2099\" >2099<\/option><option value=\"2098\" >2098<\/option><option value=\"2097\" >2097<\/option><option value=\"2096\" >2096<\/option><option value=\"2095\" >2095<\/option><option value=\"2094\" >2094<\/option><option value=\"2093\" >2093<\/option><option value=\"2092\" >2092<\/option><option value=\"2091\" >2091<\/option><option value=\"2090\" >2090<\/option><option value=\"2089\" >2089<\/option><option value=\"2088\" >2088<\/option><option value=\"2087\" >2087<\/option><option value=\"2086\" >2086<\/option><option value=\"2085\" >2085<\/option><option value=\"2084\" >2084<\/option><option value=\"2083\" >2083<\/option><option value=\"2082\" >2082<\/option><option value=\"2081\" >2081<\/option><option value=\"2080\" >2080<\/option><option value=\"2079\" >2079<\/option><option value=\"2078\" >2078<\/option><option value=\"2077\" >2077<\/option><option value=\"2076\" >2076<\/option><option value=\"2075\" >2075<\/option><option value=\"2074\" >2074<\/option><option value=\"2073\" >2073<\/option><option value=\"2072\" >2072<\/option><option value=\"2071\" >2071<\/option><option value=\"2070\" >2070<\/option><option value=\"2069\" >2069<\/option><option value=\"2068\" >2068<\/option><option value=\"2067\" >2067<\/option><option value=\"2066\" >2066<\/option><option value=\"2065\" >2065<\/option><option value=\"2064\" >2064<\/option><option value=\"2063\" >2063<\/option><option value=\"2062\" >2062<\/option><option value=\"2061\" >2061<\/option><option value=\"2060\" >2060<\/option><option value=\"2059\" >2059<\/option><option value=\"2058\" >2058<\/option><option value=\"2057\" >2057<\/option><option value=\"2056\" >2056<\/option><option value=\"2055\" >2055<\/option><option value=\"2054\" >2054<\/option><option value=\"2053\" >2053<\/option><option value=\"2052\" >2052<\/option><option value=\"2051\" >2051<\/option><option value=\"2050\" >2050<\/option><option value=\"2049\" >2049<\/option><option value=\"2048\" >2048<\/option><option value=\"2047\" >2047<\/option><option value=\"2046\" >2046<\/option><option value=\"2045\" >2045<\/option><option value=\"2044\" >2044<\/option><option value=\"2043\" >2043<\/option><option value=\"2042\" >2042<\/option><option value=\"2041\" >2041<\/option><option value=\"2040\" >2040<\/option><option value=\"2039\" >2039<\/option><option value=\"2038\" >2038<\/option><option value=\"2037\" >2037<\/option><option value=\"2036\" >2036<\/option><option value=\"2035\" >2035<\/option><option value=\"2034\" >2034<\/option><option value=\"2033\" >2033<\/option><option value=\"2032\" >2032<\/option><option value=\"2031\" >2031<\/option><option value=\"2030\" >2030<\/option><option value=\"2029\" >2029<\/option><option value=\"2028\" >2028<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" selected=\"selected\">2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-11\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-11_69e5c6049fcef\" id=\"forminator-form-2444__field--select-11_69e5c6049fcef-label\" class=\"forminator-label\">Sinistre 3 <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-2444__field--select-11_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-11\" data-default-value=\"\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-11_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-11_69e5c6049fcef-description\"><option value=\"\">Merci de choisir une option<\/option><option value=\"bris-de-glace\"  data-calculation=\"0\"> Bris de glace <\/option><option value=\"Vol\/Vandalisme\"  data-calculation=\"0\">Vol\/Vandalisme<\/option><option value=\"Incendie\"  data-calculation=\"0\">Incendie<\/option><option value=\"dommage-matriel-responsable\"  data-calculation=\"0\">Dommage Mat\u00e9riel Responsable<\/option><option value=\"Dommage Mat\u00e9riel Non Responsable\"  data-calculation=\"0\">Dommage Mat\u00e9riel Non Responsable<\/option><option value=\"dommages-corporels-responsables\"  data-calculation=\"0\">Dommages Corporels  Responsables<\/option><option value=\"Dommages Corporels Non Responsables\"  data-calculation=\"0\">Dommages Corporels Non Responsables<\/option><option value=\"Autres Dommages Responsables \"  data-calculation=\"0\">Autres Dommages Responsables <\/option><option value=\"Autres Dommages Non Responsables \"  data-calculation=\"0\">Autres Dommages Non Responsables <\/option><\/select><\/div><\/div><div id=\"date-6\" class=\"forminator-field-date forminator-col forminator-col-6 \"><label for=\"forminator-field-date-6\" class=\"forminator-label\">Date<\/label><div class=\"forminator-date-select\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-6-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--date-6-day_69e5c6049fcef\" id=\"forminator-form-2444__field--date-6-day_69e5c6049fcef-label\" class=\"forminator-label\">Jour<\/label><select name=\"date-6-day\" id=\"forminator-form-2444__field--date-6-day_69e5c6049fcef\" class=\"forminator-select2\" data-format=\"dd-mm-yy\" data-parent=\"date-6\" aria-describedby=\"forminator-field-date-6_69e5c6049fcef-description\" aria-labelledby=\"forminator-form-2444__field--date-6-day_69e5c6049fcef-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">S\u00e9lectionner le jour<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><\/div><\/div><div id=\"date-6-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--date-6-month_69e5c6049fcef\" id=\"forminator-form-2444__field--date-6-month_69e5c6049fcef-label\" class=\"forminator-label\">Mois<\/label><select name=\"date-6-month\" id=\"forminator-form-2444__field--date-6-month_69e5c6049fcef\" class=\"forminator-select2\" data-format=\"dd-mm-yy\" data-parent=\"date-6\" aria-describedby=\"forminator-field-date-6_69e5c6049fcef-description\" aria-labelledby=\"forminator-form-2444__field--date-6-month_69e5c6049fcef-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">S\u00e9lectionner le mois<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><\/div><\/div><div id=\"date-6-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--date-6-year_69e5c6049fcef\" id=\"forminator-form-2444__field--date-6-year_69e5c6049fcef-label\" class=\"forminator-label\">Ann\u00e9e<\/label><select name=\"date-6-year\" id=\"forminator-form-2444__field--date-6-year_69e5c6049fcef\" class=\"forminator-select2\" data-format=\"dd-mm-yy\" data-parent=\"date-6\" aria-describedby=\"forminator-field-date-6_69e5c6049fcef-description\" aria-labelledby=\"forminator-form-2444__field--date-6-year_69e5c6049fcef-label\" data-default-value=\"2026\"><option value=\"\" >S\u00e9lectionner l\u2019ann\u00e9e<\/option><option value=\"2126\" >2126<\/option><option value=\"2125\" >2125<\/option><option value=\"2124\" >2124<\/option><option value=\"2123\" >2123<\/option><option value=\"2122\" >2122<\/option><option value=\"2121\" >2121<\/option><option value=\"2120\" >2120<\/option><option value=\"2119\" >2119<\/option><option value=\"2118\" >2118<\/option><option value=\"2117\" >2117<\/option><option value=\"2116\" >2116<\/option><option value=\"2115\" >2115<\/option><option value=\"2114\" >2114<\/option><option value=\"2113\" >2113<\/option><option value=\"2112\" >2112<\/option><option value=\"2111\" >2111<\/option><option value=\"2110\" >2110<\/option><option value=\"2109\" >2109<\/option><option value=\"2108\" >2108<\/option><option value=\"2107\" >2107<\/option><option value=\"2106\" >2106<\/option><option value=\"2105\" >2105<\/option><option value=\"2104\" >2104<\/option><option value=\"2103\" >2103<\/option><option value=\"2102\" >2102<\/option><option value=\"2101\" >2101<\/option><option value=\"2100\" >2100<\/option><option value=\"2099\" >2099<\/option><option value=\"2098\" >2098<\/option><option value=\"2097\" >2097<\/option><option value=\"2096\" >2096<\/option><option value=\"2095\" >2095<\/option><option value=\"2094\" >2094<\/option><option value=\"2093\" >2093<\/option><option value=\"2092\" >2092<\/option><option value=\"2091\" >2091<\/option><option value=\"2090\" >2090<\/option><option value=\"2089\" >2089<\/option><option value=\"2088\" >2088<\/option><option value=\"2087\" >2087<\/option><option value=\"2086\" >2086<\/option><option value=\"2085\" >2085<\/option><option value=\"2084\" >2084<\/option><option value=\"2083\" >2083<\/option><option value=\"2082\" >2082<\/option><option value=\"2081\" >2081<\/option><option value=\"2080\" >2080<\/option><option value=\"2079\" >2079<\/option><option value=\"2078\" >2078<\/option><option value=\"2077\" >2077<\/option><option value=\"2076\" >2076<\/option><option value=\"2075\" >2075<\/option><option value=\"2074\" >2074<\/option><option value=\"2073\" >2073<\/option><option value=\"2072\" >2072<\/option><option value=\"2071\" >2071<\/option><option value=\"2070\" >2070<\/option><option value=\"2069\" >2069<\/option><option value=\"2068\" >2068<\/option><option value=\"2067\" >2067<\/option><option value=\"2066\" >2066<\/option><option value=\"2065\" >2065<\/option><option value=\"2064\" >2064<\/option><option value=\"2063\" >2063<\/option><option value=\"2062\" >2062<\/option><option value=\"2061\" >2061<\/option><option value=\"2060\" >2060<\/option><option value=\"2059\" >2059<\/option><option value=\"2058\" >2058<\/option><option value=\"2057\" >2057<\/option><option value=\"2056\" >2056<\/option><option value=\"2055\" >2055<\/option><option value=\"2054\" >2054<\/option><option value=\"2053\" >2053<\/option><option value=\"2052\" >2052<\/option><option value=\"2051\" >2051<\/option><option value=\"2050\" >2050<\/option><option value=\"2049\" >2049<\/option><option value=\"2048\" >2048<\/option><option value=\"2047\" >2047<\/option><option value=\"2046\" >2046<\/option><option value=\"2045\" >2045<\/option><option value=\"2044\" >2044<\/option><option value=\"2043\" >2043<\/option><option value=\"2042\" >2042<\/option><option value=\"2041\" >2041<\/option><option value=\"2040\" >2040<\/option><option value=\"2039\" >2039<\/option><option value=\"2038\" >2038<\/option><option value=\"2037\" >2037<\/option><option value=\"2036\" >2036<\/option><option value=\"2035\" >2035<\/option><option value=\"2034\" >2034<\/option><option value=\"2033\" >2033<\/option><option value=\"2032\" >2032<\/option><option value=\"2031\" >2031<\/option><option value=\"2030\" >2030<\/option><option value=\"2029\" >2029<\/option><option value=\"2028\" >2028<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" selected=\"selected\">2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-10\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-10_69e5c6049fcef\" id=\"forminator-form-2444__field--select-10_69e5c6049fcef-label\" class=\"forminator-label\">Sinistre 4 <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-2444__field--select-10_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-10\" data-default-value=\"\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-10_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-10_69e5c6049fcef-description\"><option value=\"\">Merci de choisir une option<\/option><option value=\"bris-de-glace\"  data-calculation=\"0\"> Bris de glace <\/option><option value=\"Vol\/Vandalisme\"  data-calculation=\"0\">Vol\/Vandalisme<\/option><option value=\"Incendie\"  data-calculation=\"0\">Incendie<\/option><option value=\"dommage-matriel-responsable\"  data-calculation=\"0\">Dommage Mat\u00e9riel Responsable<\/option><option value=\"Dommage Mat\u00e9riel Non Responsable\"  data-calculation=\"0\">Dommage Mat\u00e9riel Non Responsable<\/option><option value=\"dommages-corporels-responsables\"  data-calculation=\"0\">Dommages Corporels  Responsables<\/option><option value=\"Dommages Corporels Non Responsables\"  data-calculation=\"0\">Dommages Corporels Non Responsables<\/option><option value=\"Autres Dommages Responsables \"  data-calculation=\"0\">Autres Dommages Responsables <\/option><option value=\"Autres Dommages Non Responsables \"  data-calculation=\"0\">Autres Dommages Non Responsables <\/option><\/select><\/div><\/div><div id=\"date-7\" class=\"forminator-field-date forminator-col forminator-col-6 \"><label for=\"forminator-field-date-7\" class=\"forminator-label\">Date<\/label><div class=\"forminator-date-select\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-7-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--date-7-day_69e5c6049fcef\" id=\"forminator-form-2444__field--date-7-day_69e5c6049fcef-label\" class=\"forminator-label\">Jour<\/label><select name=\"date-7-day\" id=\"forminator-form-2444__field--date-7-day_69e5c6049fcef\" class=\"forminator-select2\" data-format=\"dd-mm-yy\" data-parent=\"date-7\" aria-describedby=\"forminator-field-date-7_69e5c6049fcef-description\" aria-labelledby=\"forminator-form-2444__field--date-7-day_69e5c6049fcef-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">S\u00e9lectionner le jour<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><\/div><\/div><div id=\"date-7-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--date-7-month_69e5c6049fcef\" id=\"forminator-form-2444__field--date-7-month_69e5c6049fcef-label\" class=\"forminator-label\">Mois<\/label><select name=\"date-7-month\" id=\"forminator-form-2444__field--date-7-month_69e5c6049fcef\" class=\"forminator-select2\" data-format=\"dd-mm-yy\" data-parent=\"date-7\" aria-describedby=\"forminator-field-date-7_69e5c6049fcef-description\" aria-labelledby=\"forminator-form-2444__field--date-7-month_69e5c6049fcef-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">S\u00e9lectionner le mois<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><\/div><\/div><div id=\"date-7-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--date-7-year_69e5c6049fcef\" id=\"forminator-form-2444__field--date-7-year_69e5c6049fcef-label\" class=\"forminator-label\">Ann\u00e9e<\/label><select name=\"date-7-year\" id=\"forminator-form-2444__field--date-7-year_69e5c6049fcef\" class=\"forminator-select2\" data-format=\"dd-mm-yy\" data-parent=\"date-7\" aria-describedby=\"forminator-field-date-7_69e5c6049fcef-description\" aria-labelledby=\"forminator-form-2444__field--date-7-year_69e5c6049fcef-label\" data-default-value=\"2026\"><option value=\"\" >S\u00e9lectionner l\u2019ann\u00e9e<\/option><option value=\"2126\" >2126<\/option><option value=\"2125\" >2125<\/option><option value=\"2124\" >2124<\/option><option value=\"2123\" >2123<\/option><option value=\"2122\" >2122<\/option><option value=\"2121\" >2121<\/option><option value=\"2120\" >2120<\/option><option value=\"2119\" >2119<\/option><option value=\"2118\" >2118<\/option><option value=\"2117\" >2117<\/option><option value=\"2116\" >2116<\/option><option value=\"2115\" >2115<\/option><option value=\"2114\" >2114<\/option><option value=\"2113\" >2113<\/option><option value=\"2112\" >2112<\/option><option value=\"2111\" >2111<\/option><option value=\"2110\" >2110<\/option><option value=\"2109\" >2109<\/option><option value=\"2108\" >2108<\/option><option value=\"2107\" >2107<\/option><option value=\"2106\" >2106<\/option><option value=\"2105\" >2105<\/option><option value=\"2104\" >2104<\/option><option value=\"2103\" >2103<\/option><option value=\"2102\" >2102<\/option><option value=\"2101\" >2101<\/option><option value=\"2100\" >2100<\/option><option value=\"2099\" >2099<\/option><option value=\"2098\" >2098<\/option><option value=\"2097\" >2097<\/option><option value=\"2096\" >2096<\/option><option value=\"2095\" >2095<\/option><option value=\"2094\" >2094<\/option><option value=\"2093\" >2093<\/option><option value=\"2092\" >2092<\/option><option value=\"2091\" >2091<\/option><option value=\"2090\" >2090<\/option><option value=\"2089\" >2089<\/option><option value=\"2088\" >2088<\/option><option value=\"2087\" >2087<\/option><option value=\"2086\" >2086<\/option><option value=\"2085\" >2085<\/option><option value=\"2084\" >2084<\/option><option value=\"2083\" >2083<\/option><option value=\"2082\" >2082<\/option><option value=\"2081\" >2081<\/option><option value=\"2080\" >2080<\/option><option value=\"2079\" >2079<\/option><option value=\"2078\" >2078<\/option><option value=\"2077\" >2077<\/option><option value=\"2076\" >2076<\/option><option value=\"2075\" >2075<\/option><option value=\"2074\" >2074<\/option><option value=\"2073\" >2073<\/option><option value=\"2072\" >2072<\/option><option value=\"2071\" >2071<\/option><option value=\"2070\" >2070<\/option><option value=\"2069\" >2069<\/option><option value=\"2068\" >2068<\/option><option value=\"2067\" >2067<\/option><option value=\"2066\" >2066<\/option><option value=\"2065\" >2065<\/option><option value=\"2064\" >2064<\/option><option value=\"2063\" >2063<\/option><option value=\"2062\" >2062<\/option><option value=\"2061\" >2061<\/option><option value=\"2060\" >2060<\/option><option value=\"2059\" >2059<\/option><option value=\"2058\" >2058<\/option><option value=\"2057\" >2057<\/option><option value=\"2056\" >2056<\/option><option value=\"2055\" >2055<\/option><option value=\"2054\" >2054<\/option><option value=\"2053\" >2053<\/option><option value=\"2052\" >2052<\/option><option value=\"2051\" >2051<\/option><option value=\"2050\" >2050<\/option><option value=\"2049\" >2049<\/option><option value=\"2048\" >2048<\/option><option value=\"2047\" >2047<\/option><option value=\"2046\" >2046<\/option><option value=\"2045\" >2045<\/option><option value=\"2044\" >2044<\/option><option value=\"2043\" >2043<\/option><option value=\"2042\" >2042<\/option><option value=\"2041\" >2041<\/option><option value=\"2040\" >2040<\/option><option value=\"2039\" >2039<\/option><option value=\"2038\" >2038<\/option><option value=\"2037\" >2037<\/option><option value=\"2036\" >2036<\/option><option value=\"2035\" >2035<\/option><option value=\"2034\" >2034<\/option><option value=\"2033\" >2033<\/option><option value=\"2032\" >2032<\/option><option value=\"2031\" >2031<\/option><option value=\"2030\" >2030<\/option><option value=\"2029\" >2029<\/option><option value=\"2028\" >2028<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" selected=\"selected\">2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-9\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--select-9_69e5c6049fcef\" id=\"forminator-form-2444__field--select-9_69e5c6049fcef-label\" class=\"forminator-label\">Sinistre 5 <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-2444__field--select-9_69e5c6049fcef\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-9\" data-default-value=\"\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-2444__field--select-9_69e5c6049fcef-label\" aria-describedby=\"forminator-form-2444__field--select-9_69e5c6049fcef-description\"><option value=\"\">Merci de choisir une option<\/option><option value=\"bris-de-glace\"  data-calculation=\"0\"> Bris de glace <\/option><option value=\"Vol\/Vandalisme\"  data-calculation=\"0\">Vol\/Vandalisme<\/option><option value=\"Incendie\"  data-calculation=\"0\">Incendie<\/option><option value=\"dommage-matriel-responsable\"  data-calculation=\"0\">Dommage Mat\u00e9riel Responsable<\/option><option value=\"Dommage Mat\u00e9riel Non Responsable\"  data-calculation=\"0\">Dommage Mat\u00e9riel Non Responsable<\/option><option value=\"dommages-corporels-responsables\"  data-calculation=\"0\">Dommages Corporels  Responsables<\/option><option value=\"Dommages Corporels Non Responsables\"  data-calculation=\"0\">Dommages Corporels Non Responsables<\/option><option value=\"Autres Dommages Responsables \"  data-calculation=\"0\">Autres Dommages Responsables <\/option><option value=\"Autres Dommages Non Responsables \"  data-calculation=\"0\">Autres Dommages Non Responsables <\/option><\/select><\/div><\/div><div id=\"date-9\" class=\"forminator-field-date forminator-col forminator-col-6 \"><label for=\"forminator-field-date-9\" class=\"forminator-label\">Date<\/label><div class=\"forminator-date-select\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-9-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--date-9-day_69e5c6049fcef\" id=\"forminator-form-2444__field--date-9-day_69e5c6049fcef-label\" class=\"forminator-label\">Jour<\/label><select name=\"date-9-day\" id=\"forminator-form-2444__field--date-9-day_69e5c6049fcef\" class=\"forminator-select2\" data-format=\"dd-mm-yy\" data-parent=\"date-9\" aria-describedby=\"forminator-field-date-9_69e5c6049fcef-description\" aria-labelledby=\"forminator-form-2444__field--date-9-day_69e5c6049fcef-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">S\u00e9lectionner le jour<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><\/div><\/div><div id=\"date-9-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--date-9-month_69e5c6049fcef\" id=\"forminator-form-2444__field--date-9-month_69e5c6049fcef-label\" class=\"forminator-label\">Mois<\/label><select name=\"date-9-month\" id=\"forminator-form-2444__field--date-9-month_69e5c6049fcef\" class=\"forminator-select2\" data-format=\"dd-mm-yy\" data-parent=\"date-9\" aria-describedby=\"forminator-field-date-9_69e5c6049fcef-description\" aria-labelledby=\"forminator-form-2444__field--date-9-month_69e5c6049fcef-label\" data-default-value=\"\"><option value=\"\" selected=\"selected\">S\u00e9lectionner le mois<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><\/div><\/div><div id=\"date-9-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-form-2444__field--date-9-year_69e5c6049fcef\" id=\"forminator-form-2444__field--date-9-year_69e5c6049fcef-label\" class=\"forminator-label\">Ann\u00e9e<\/label><select name=\"date-9-year\" id=\"forminator-form-2444__field--date-9-year_69e5c6049fcef\" class=\"forminator-select2\" data-format=\"dd-mm-yy\" data-parent=\"date-9\" aria-describedby=\"forminator-field-date-9_69e5c6049fcef-description\" aria-labelledby=\"forminator-form-2444__field--date-9-year_69e5c6049fcef-label\" data-default-value=\"2026\"><option value=\"\" >S\u00e9lectionner l\u2019ann\u00e9e<\/option><option value=\"2126\" >2126<\/option><option value=\"2125\" >2125<\/option><option value=\"2124\" >2124<\/option><option value=\"2123\" >2123<\/option><option value=\"2122\" >2122<\/option><option value=\"2121\" >2121<\/option><option value=\"2120\" >2120<\/option><option value=\"2119\" >2119<\/option><option value=\"2118\" >2118<\/option><option value=\"2117\" >2117<\/option><option value=\"2116\" >2116<\/option><option value=\"2115\" >2115<\/option><option value=\"2114\" >2114<\/option><option value=\"2113\" >2113<\/option><option value=\"2112\" >2112<\/option><option value=\"2111\" >2111<\/option><option value=\"2110\" >2110<\/option><option value=\"2109\" >2109<\/option><option value=\"2108\" >2108<\/option><option value=\"2107\" >2107<\/option><option value=\"2106\" >2106<\/option><option value=\"2105\" >2105<\/option><option value=\"2104\" >2104<\/option><option value=\"2103\" >2103<\/option><option value=\"2102\" >2102<\/option><option value=\"2101\" >2101<\/option><option value=\"2100\" >2100<\/option><option value=\"2099\" >2099<\/option><option value=\"2098\" >2098<\/option><option value=\"2097\" >2097<\/option><option value=\"2096\" >2096<\/option><option value=\"2095\" >2095<\/option><option value=\"2094\" >2094<\/option><option value=\"2093\" >2093<\/option><option value=\"2092\" >2092<\/option><option value=\"2091\" >2091<\/option><option value=\"2090\" >2090<\/option><option value=\"2089\" >2089<\/option><option value=\"2088\" >2088<\/option><option value=\"2087\" >2087<\/option><option value=\"2086\" >2086<\/option><option value=\"2085\" >2085<\/option><option value=\"2084\" >2084<\/option><option value=\"2083\" >2083<\/option><option value=\"2082\" >2082<\/option><option value=\"2081\" >2081<\/option><option value=\"2080\" >2080<\/option><option value=\"2079\" >2079<\/option><option value=\"2078\" >2078<\/option><option value=\"2077\" >2077<\/option><option value=\"2076\" >2076<\/option><option value=\"2075\" >2075<\/option><option value=\"2074\" >2074<\/option><option value=\"2073\" >2073<\/option><option value=\"2072\" >2072<\/option><option value=\"2071\" >2071<\/option><option value=\"2070\" >2070<\/option><option value=\"2069\" >2069<\/option><option value=\"2068\" >2068<\/option><option value=\"2067\" >2067<\/option><option value=\"2066\" >2066<\/option><option value=\"2065\" >2065<\/option><option value=\"2064\" >2064<\/option><option value=\"2063\" >2063<\/option><option value=\"2062\" >2062<\/option><option value=\"2061\" >2061<\/option><option value=\"2060\" >2060<\/option><option value=\"2059\" >2059<\/option><option value=\"2058\" >2058<\/option><option value=\"2057\" >2057<\/option><option value=\"2056\" >2056<\/option><option value=\"2055\" >2055<\/option><option value=\"2054\" >2054<\/option><option value=\"2053\" >2053<\/option><option value=\"2052\" >2052<\/option><option value=\"2051\" >2051<\/option><option value=\"2050\" >2050<\/option><option value=\"2049\" >2049<\/option><option value=\"2048\" >2048<\/option><option value=\"2047\" >2047<\/option><option value=\"2046\" >2046<\/option><option value=\"2045\" >2045<\/option><option value=\"2044\" >2044<\/option><option value=\"2043\" >2043<\/option><option value=\"2042\" >2042<\/option><option value=\"2041\" >2041<\/option><option value=\"2040\" >2040<\/option><option value=\"2039\" >2039<\/option><option value=\"2038\" >2038<\/option><option value=\"2037\" >2037<\/option><option value=\"2036\" >2036<\/option><option value=\"2035\" >2035<\/option><option value=\"2034\" >2034<\/option><option value=\"2033\" >2033<\/option><option value=\"2032\" >2032<\/option><option value=\"2031\" >2031<\/option><option value=\"2030\" >2030<\/option><option value=\"2029\" >2029<\/option><option value=\"2028\" >2028<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" selected=\"selected\">2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-1\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-1_69e5c6049fcef\" class=\"forminator-label\">T\u00e9l\u00e9charger le Permis de conduire<\/label><div class=\"forminator-file-upload \" data-element=\"upload-1_69e5c6049fcef\" aria-describedby=\"forminator-field-upload-1_69e5c6049fcef-description\"><input type=\"file\" name=\"upload-1\" id=\"forminator-field-upload-1_69e5c6049fcef\" class=\"forminator-input-file\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.ico,.heic,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.flv,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.css,.htm,.html,.vtt,.dfxp,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.js,.pdf,.class,.tar,.zip,.gz,.gzip,.rar,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mdb,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onetmp,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages\"><button id=\"forminator-field-upload-1_69e5c6049fcef_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-1_69e5c6049fcef\">Choisissez un fichier<\/button><span data-empty-text=\"Aucun fichier s\u00e9lectionn\u00e9\">Aucun fichier s\u00e9lectionn\u00e9<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Supprimer le fichier t\u00e9l\u00e9vers\u00e9<\/span><\/button><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-2\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-2_69e5c6049fcef\" class=\"forminator-label\">T\u00e9l\u00e9charger la carte grise<\/label><div class=\"forminator-file-upload \" data-element=\"upload-2_69e5c6049fcef\" aria-describedby=\"forminator-field-upload-2_69e5c6049fcef-description\"><input type=\"file\" name=\"upload-2\" id=\"forminator-field-upload-2_69e5c6049fcef\" class=\"forminator-input-file\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.ico,.heic,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.flv,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.css,.htm,.html,.vtt,.dfxp,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.js,.pdf,.class,.tar,.zip,.gz,.gzip,.rar,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mdb,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onetmp,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages\"><button id=\"forminator-field-upload-2_69e5c6049fcef_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-2_69e5c6049fcef\">Choisissez un fichier<\/button><span data-empty-text=\"Aucun fichier s\u00e9lectionn\u00e9\">Aucun fichier s\u00e9lectionn\u00e9<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Supprimer le fichier t\u00e9l\u00e9vers\u00e9<\/span><\/button><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-3\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-3_69e5c6049fcef\" class=\"forminator-label\">T\u00e9l\u00e9charger le relev\u00e9 d&#039;information<\/label><div class=\"forminator-file-upload \" data-element=\"upload-3_69e5c6049fcef\" aria-describedby=\"forminator-field-upload-3_69e5c6049fcef-description\"><input type=\"file\" name=\"upload-3\" id=\"forminator-field-upload-3_69e5c6049fcef\" class=\"forminator-input-file\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.ico,.heic,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.flv,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.css,.htm,.html,.vtt,.dfxp,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.js,.pdf,.class,.tar,.zip,.gz,.gzip,.rar,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mdb,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onetmp,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages\"><button id=\"forminator-field-upload-3_69e5c6049fcef_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-3_69e5c6049fcef\">Choisissez un fichier<\/button><span data-empty-text=\"Aucun fichier s\u00e9lectionn\u00e9\">Aucun fichier s\u00e9lectionn\u00e9<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Supprimer le fichier t\u00e9l\u00e9vers\u00e9<\/span><\/button><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-5\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-5_69e5c6049fcef\" id=\"forminator-field-textarea-5_69e5c6049fcef-label\" class=\"forminator-label\">Message compl\u00e9mentaire<\/label><textarea name=\"textarea-5\" placeholder=\"Vous souhaitez nous apporter des pr\u00e9cisions ? 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