{"id":2513,"date":"2020-11-08T17:32:52","date_gmt":"2020-11-08T16:32:52","guid":{"rendered":"https:\/\/aca-pl.com\/?page_id=2513"},"modified":"2020-11-12T22:10:03","modified_gmt":"2020-11-12T21:10:03","slug":"questionnaire-complentaire-sante","status":"publish","type":"page","link":"https:\/\/aca-pl.com\/?page_id=2513","title":{"rendered":"QUESTIONNAIRE compl\u00e9mentaire SANT\u00c9"},"content":{"rendered":"\n<p class=\"has-background\" 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<p><\/p>\n\n\n\n<div class=\"forminator-guttenberg\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-2501 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-2501\" data-uid=\"69f3603202915\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-2501\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-2501 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=\"2501\"\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=\"69f3603202915\"\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=\"html-6\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-6\"><label class=\"forminator-label\">Questionnaire compl\u00e9mentaire sant\u00e9<\/label><p>Afin de pouvoir vous adresser un projet personnalis\u00e9, merci de compl\u00e9ter le questionnaire ci-dessous.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12 \"><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-2501__field--name-1_69f3603202915\" id=\"forminator-form-2501__field--name-1_69f3603202915-label\" class=\"forminator-label\">Pr\u00e9fixe<\/label><select name=\"name-1-prefix\" id=\"forminator-form-2501__field--name-1_69f3603202915\" class=\"forminator-select2\" data-multi=\"1\" aria-labelledby=\"forminator-form-2501__field--name-1_69f3603202915-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_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-first-name-1_69f3603202915-label\">Nom <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-first-name\" placeholder=\"\" id=\"forminator-field-first-name-1_69f3603202915\" 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_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-last-name-1_69f3603202915-label\">Pr\u00e9nom <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-last-name\" placeholder=\"\" id=\"forminator-field-last-name-1_69f3603202915\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" value=\"\" \/><\/div><\/div><\/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_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-address-1-street_address_69f3603202915-label\">Rue<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"\" id=\"forminator-field-address-1-street_address_69f3603202915\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" 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_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-address-1-address_line_69f3603202915-label\">Appartement, suite, etc.<\/label><input type=\"text\" name=\"address-1-address_line\" placeholder=\"\" id=\"forminator-field-address-1-address_line_69f3603202915\" 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_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-address-1-city_69f3603202915-label\">Ville<\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"\" id=\"forminator-field-address-1-city_69f3603202915\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" 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_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-address-1-zip_69f3603202915-label\">Code postal<\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"\" id=\"forminator-field-address-1-zip_69f3603202915\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/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_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-phone-1_69f3603202915-label\">Num\u00e9ro de t\u00e9l\u00e9phone <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"Par exemple\u00a0: +1 3004005000\" id=\"forminator-field-phone-1_69f3603202915\" 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_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-email-1_69f3603202915-label\">Adresse de messagerie <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"jacques@martin.com\" id=\"forminator-field-email-1_69f3603202915\" class=\"forminator-input forminator-email--field\" data-required=\"true\" aria-required=\"true\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-2_69f3603202915\" id=\"forminator-form-2501__field--select-2_69f3603202915-label\" class=\"forminator-label\">Quel est votre statut familial ?<\/label><select id=\"forminator-form-2501__field--select-2_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-2\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-2_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-2_69f3603202915-description\"><option value=\"C\u00e9libataire\"  data-calculation=\"0\">C\u00e9libataire<\/option><option value=\"Mari\u00e9\"  data-calculation=\"0\">Mari\u00e9<\/option><option value=\"Pasc\u00e9\"  data-calculation=\"0\">Pasc\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=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-text-1_69f3603202915-label\">Quelle est votre profession ? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69f3603202915\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-3\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-3_69f3603202915\" id=\"forminator-form-2501__field--select-3_69f3603202915-label\" class=\"forminator-label\">Etes vous salari\u00e9 ou travailleur non salari\u00e9 ? <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-2501__field--select-3_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-3\" data-default-value=\"\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-3_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-3_69f3603202915-description\"><option value=\"\">Merci de choisir une option<\/option><option value=\"Salari\u00e9\"  data-calculation=\"0\">Salari\u00e9<\/option><option value=\"Travailleur non salari\u00e9\"  data-calculation=\"0\">Travailleur non salari\u00e9<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-5\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-5_69f3603202915\" id=\"forminator-form-2501__field--select-5_69f3603202915-label\" class=\"forminator-label\">Etes vous Frontalier Suisse ?<\/label><select id=\"forminator-form-2501__field--select-5_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-5\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-5_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-5_69f3603202915-description\"><option value=\"oui\"  data-calculation=\"0\">OUI<\/option><option value=\"non\"  data-calculation=\"0\">NON<\/option><\/select><\/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\">PERSONNES A GARANTIR<\/h2><\/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\">SOUSCRIPTEUR<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-3 \"><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-field-first-name-2_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-first-name-2_69f3603202915-label\">Nom Souscripteur <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2-first-name\" placeholder=\"\" id=\"forminator-field-first-name-2_69f3603202915\" 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_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-last-name-2_69f3603202915-label\">Pr\u00e9nom Souscripteur <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2-last-name\" placeholder=\"\" id=\"forminator-field-last-name-2_69f3603202915\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-3 \"><label for=\"forminator-field-date-2\" class=\"forminator-label\">Date de Naissance<\/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_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-2-day_69f3603202915-label\">Jour<\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-2-day\" value=\"\" placeholder=\"01\" id=\"forminator-field-date-2-day_69f3603202915\" class=\"forminator-input\" data-field=\"day\" data-format=\"dd-mm-yy\" data-parent=\"date-2\" aria-describedby=\"forminator-field-date-2_69f3603202915-description\" \/><\/div><\/div><div id=\"date-2-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-month_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-2-month_69f3603202915-label\">Mois<\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-2-month\" value=\"\" placeholder=\"01\" id=\"forminator-field-date-2-month_69f3603202915\" class=\"forminator-input\" data-field=\"month\" data-format=\"dd-mm-yy\" data-parent=\"date-2\" aria-describedby=\"forminator-field-date-2_69f3603202915-description\" \/><\/div><\/div><div id=\"date-2-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-year_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-2-year_69f3603202915-label\">Ann\u00e9e<\/label><input type=\"number\" min=\"1\" name=\"date-2-year\" placeholder=\"2000\" id=\"forminator-field-date-2-year_69f3603202915\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"dd-mm-yy\" data-parent=\"date-2\" aria-describedby=\"forminator-field-date-2_69f3603202915-description\" \/><\/div><\/div><\/div><\/div><\/div><div id=\"select-14\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-14_69f3603202915\" id=\"forminator-form-2501__field--select-14_69f3603202915-label\" class=\"forminator-label\">Sexe<\/label><select id=\"forminator-form-2501__field--select-14_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-14\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-14_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-14_69f3603202915-description\"><option value=\"masculin\"  data-calculation=\"0\">Masculin<\/option><option value=\"F\u00e9minin\"  data-calculation=\"0\">F\u00e9minin<\/option><\/select><\/div><\/div><div id=\"select-4\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-4_69f3603202915\" id=\"forminator-form-2501__field--select-4_69f3603202915-label\" class=\"forminator-label\">R\u00e9gime obligatoire <\/label><select id=\"forminator-form-2501__field--select-4_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-4\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-4_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-4_69f3603202915-description\"><option value=\"cpam\"  data-calculation=\"0\">CPAM<\/option><option value=\"S\u00e9curit\u00e9 sociale des ind\u00e9pendants\"  data-calculation=\"0\">S\u00e9curit\u00e9 sociale des ind\u00e9pendants<\/option><option value=\"R\u00e9gime agricole\"  data-calculation=\"0\">R\u00e9gime agricole<\/option><option value=\"Alsace\/Moselle\"  data-calculation=\"0\">Alsace\/Moselle<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-5\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">CONJOINT DU SOUSCRIPTEUR<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-3 \"><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-field-first-name-3_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-first-name-3_69f3603202915-label\">Nom Conjoint<\/label><input type=\"text\" name=\"name-3-first-name\" placeholder=\"\" id=\"forminator-field-first-name-3_69f3603202915\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-3_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-last-name-3_69f3603202915-label\">Pr\u00e9nom Conjoint<\/label><input type=\"text\" name=\"name-3-last-name\" placeholder=\"\" id=\"forminator-field-last-name-3_69f3603202915\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-3 \"><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_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-3-day_69f3603202915-label\">Jour<\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-3-day\" value=\"\" placeholder=\"01\" id=\"forminator-field-date-3-day_69f3603202915\" class=\"forminator-input\" data-field=\"day\" data-format=\"dd-mm-yy\" data-parent=\"date-3\" aria-describedby=\"forminator-field-date-3_69f3603202915-description\" \/><\/div><\/div><div id=\"date-3-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-month_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-3-month_69f3603202915-label\">Mois<\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-3-month\" value=\"\" placeholder=\"01\" id=\"forminator-field-date-3-month_69f3603202915\" class=\"forminator-input\" data-field=\"month\" data-format=\"dd-mm-yy\" data-parent=\"date-3\" aria-describedby=\"forminator-field-date-3_69f3603202915-description\" \/><\/div><\/div><div id=\"date-3-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-year_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-3-year_69f3603202915-label\">Ann\u00e9e<\/label><input type=\"number\" min=\"1\" name=\"date-3-year\" placeholder=\"2000\" id=\"forminator-field-date-3-year_69f3603202915\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"dd-mm-yy\" data-parent=\"date-3\" aria-describedby=\"forminator-field-date-3_69f3603202915-description\" \/><\/div><\/div><\/div><\/div><\/div><div id=\"select-6\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-6_69f3603202915\" id=\"forminator-form-2501__field--select-6_69f3603202915-label\" class=\"forminator-label\">Sexe<\/label><select id=\"forminator-form-2501__field--select-6_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-6\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-6_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-6_69f3603202915-description\"><option value=\"masculin\"  data-calculation=\"0\">Masculin<\/option><option value=\"F\u00e9minin\"  data-calculation=\"0\">F\u00e9minin<\/option><\/select><\/div><\/div><div id=\"select-15\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-15_69f3603202915\" id=\"forminator-form-2501__field--select-15_69f3603202915-label\" class=\"forminator-label\">R\u00e9gime obligatoire <\/label><select id=\"forminator-form-2501__field--select-15_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-15\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-15_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-15_69f3603202915-description\"><option value=\"cpam\"  data-calculation=\"0\">CPAM<\/option><option value=\"S\u00e9curit\u00e9 sociale des ind\u00e9pendants\"  data-calculation=\"0\">S\u00e9curit\u00e9 sociale des ind\u00e9pendants<\/option><option value=\"R\u00e9gime agricole\"  data-calculation=\"0\">R\u00e9gime agricole<\/option><option value=\"Alsace\/Moselle\"  data-calculation=\"0\">Alsace\/Moselle<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-6\" class=\"forminator-field-section forminator-col forminator-col-6 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">ENFANTS<\/h2><\/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_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-number-1_69f3603202915-label\">Nombre d&#039;enfants \u00e0 garantir<\/label><input name=\"number-1\" value=\"\" placeholder=\"\" id=\"forminator-field-number-1_69f3603202915\" 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=\"0\" max=\"15\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-text-2_69f3603202915-label\">Au del\u00e0  de 6 enfants nous appeler au 02 41 09 77 32<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_69f3603202915\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-4\" class=\"forminator-field-name forminator-col forminator-col-3 \"><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-field-first-name-4_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-first-name-4_69f3603202915-label\">Nom enfant N\u00b01<\/label><input type=\"text\" name=\"name-4-first-name\" placeholder=\"\" id=\"forminator-field-first-name-4_69f3603202915\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-4_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-last-name-4_69f3603202915-label\">Pr\u00e9nom Enfant N\u00b01<\/label><input type=\"text\" name=\"name-4-last-name\" placeholder=\"\" id=\"forminator-field-last-name-4_69f3603202915\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"date-4\" class=\"forminator-field-date forminator-col forminator-col-3 \"><label for=\"forminator-field-date-4\" class=\"forminator-label\">Date de Naissance<\/label><div class=\"forminator-date-input\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-4-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-day_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-4-day_69f3603202915-label\">Jour<\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-4-day\" value=\"\" placeholder=\" 01\" id=\"forminator-field-date-4-day_69f3603202915\" class=\"forminator-input\" data-field=\"day\" data-format=\"dd-mm-yy\" data-parent=\"date-4\" aria-describedby=\"forminator-field-date-4_69f3603202915-description\" \/><\/div><\/div><div id=\"date-4-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-month_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-4-month_69f3603202915-label\">Mois<\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-4-month\" value=\"\" placeholder=\"01\" id=\"forminator-field-date-4-month_69f3603202915\" class=\"forminator-input\" data-field=\"month\" data-format=\"dd-mm-yy\" data-parent=\"date-4\" aria-describedby=\"forminator-field-date-4_69f3603202915-description\" \/><\/div><\/div><div id=\"date-4-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-year_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-4-year_69f3603202915-label\">Ann\u00e9e<\/label><input type=\"number\" min=\"1\" name=\"date-4-year\" placeholder=\" 2000\" id=\"forminator-field-date-4-year_69f3603202915\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"dd-mm-yy\" data-parent=\"date-4\" aria-describedby=\"forminator-field-date-4_69f3603202915-description\" \/><\/div><\/div><\/div><\/div><\/div><div id=\"select-12\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-12_69f3603202915\" id=\"forminator-form-2501__field--select-12_69f3603202915-label\" class=\"forminator-label\">Sexe<\/label><select id=\"forminator-form-2501__field--select-12_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-12\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-12_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-12_69f3603202915-description\"><option value=\"masculin\"  data-calculation=\"0\">Masculin<\/option><option value=\"F\u00e9minin\"  data-calculation=\"0\">F\u00e9minin<\/option><\/select><\/div><\/div><div id=\"select-16\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-16_69f3603202915\" id=\"forminator-form-2501__field--select-16_69f3603202915-label\" class=\"forminator-label\">R\u00e9gime obligatoire <\/label><select id=\"forminator-form-2501__field--select-16_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-16\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-16_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-16_69f3603202915-description\"><option value=\"cpam\"  data-calculation=\"0\">CPAM<\/option><option value=\"S\u00e9curit\u00e9 sociale des ind\u00e9pendants\"  data-calculation=\"0\">S\u00e9curit\u00e9 sociale des ind\u00e9pendants<\/option><option value=\"R\u00e9gime agricole\"  data-calculation=\"0\">R\u00e9gime agricole<\/option><option value=\"Alsace\/Moselle\"  data-calculation=\"0\">Alsace\/Moselle<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-5\" class=\"forminator-field-name forminator-col forminator-col-3 \"><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-field-first-name-5_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-first-name-5_69f3603202915-label\">Nom Enfant N\u00b02<\/label><input type=\"text\" name=\"name-5-first-name\" placeholder=\"\" id=\"forminator-field-first-name-5_69f3603202915\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-5_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-last-name-5_69f3603202915-label\">Pr\u00e9nom Enfant N\u00b02<\/label><input type=\"text\" name=\"name-5-last-name\" placeholder=\"\" id=\"forminator-field-last-name-5_69f3603202915\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"date-5\" class=\"forminator-field-date forminator-col forminator-col-3 \"><label for=\"forminator-field-date-5\" class=\"forminator-label\">Date de Naissance<\/label><div class=\"forminator-date-input\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-5-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-5-day_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-5-day_69f3603202915-label\">Jour<\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-5-day\" value=\"\" placeholder=\" 01\" id=\"forminator-field-date-5-day_69f3603202915\" class=\"forminator-input\" data-field=\"day\" data-format=\"dd-mm-yy\" data-parent=\"date-5\" aria-describedby=\"forminator-field-date-5_69f3603202915-description\" \/><\/div><\/div><div id=\"date-5-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-5-month_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-5-month_69f3603202915-label\">Mois<\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-5-month\" value=\"\" placeholder=\"01\" id=\"forminator-field-date-5-month_69f3603202915\" class=\"forminator-input\" data-field=\"month\" data-format=\"dd-mm-yy\" data-parent=\"date-5\" aria-describedby=\"forminator-field-date-5_69f3603202915-description\" \/><\/div><\/div><div id=\"date-5-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-5-year_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-5-year_69f3603202915-label\">Ann\u00e9e<\/label><input type=\"number\" min=\"1\" name=\"date-5-year\" placeholder=\"2000\" id=\"forminator-field-date-5-year_69f3603202915\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"dd-mm-yy\" data-parent=\"date-5\" aria-describedby=\"forminator-field-date-5_69f3603202915-description\" \/><\/div><\/div><\/div><\/div><\/div><div id=\"select-11\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-11_69f3603202915\" id=\"forminator-form-2501__field--select-11_69f3603202915-label\" class=\"forminator-label\">Sexe<\/label><select id=\"forminator-form-2501__field--select-11_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-11\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-11_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-11_69f3603202915-description\"><option value=\"masculin\"  data-calculation=\"0\">Masculin<\/option><option value=\"F\u00e9minin\"  data-calculation=\"0\">F\u00e9minin<\/option><\/select><\/div><\/div><div id=\"select-17\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-17_69f3603202915\" id=\"forminator-form-2501__field--select-17_69f3603202915-label\" class=\"forminator-label\">R\u00e9gime obligatoire <\/label><select id=\"forminator-form-2501__field--select-17_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-17\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-17_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-17_69f3603202915-description\"><option value=\"cpam\"  data-calculation=\"0\">CPAM<\/option><option value=\"S\u00e9curit\u00e9 sociale des ind\u00e9pendants\"  data-calculation=\"0\">S\u00e9curit\u00e9 sociale des ind\u00e9pendants<\/option><option value=\"R\u00e9gime agricole\"  data-calculation=\"0\">R\u00e9gime agricole<\/option><option value=\"Alsace\/Moselle\"  data-calculation=\"0\">Alsace\/Moselle<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-6\" class=\"forminator-field-name forminator-col forminator-col-3 \"><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-field-first-name-6_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-first-name-6_69f3603202915-label\">Nom Enfant N\u00b03<\/label><input type=\"text\" name=\"name-6-first-name\" placeholder=\"\" id=\"forminator-field-first-name-6_69f3603202915\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-6_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-last-name-6_69f3603202915-label\">Pr\u00e9nom Enfant N\u00b03<\/label><input type=\"text\" name=\"name-6-last-name\" placeholder=\"\" id=\"forminator-field-last-name-6_69f3603202915\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"date-6\" class=\"forminator-field-date forminator-col forminator-col-3 \"><label for=\"forminator-field-date-6\" class=\"forminator-label\">Date de Naissance<\/label><div class=\"forminator-date-input\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-6-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-6-day_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-6-day_69f3603202915-label\">Jour<\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-6-day\" value=\"\" placeholder=\"01\" id=\"forminator-field-date-6-day_69f3603202915\" class=\"forminator-input\" data-field=\"day\" data-format=\"dd-mm-yy\" data-parent=\"date-6\" aria-describedby=\"forminator-field-date-6_69f3603202915-description\" \/><\/div><\/div><div id=\"date-6-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-6-month_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-6-month_69f3603202915-label\">Mois<\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-6-month\" value=\"\" placeholder=\" 01\" id=\"forminator-field-date-6-month_69f3603202915\" class=\"forminator-input\" data-field=\"month\" data-format=\"dd-mm-yy\" data-parent=\"date-6\" aria-describedby=\"forminator-field-date-6_69f3603202915-description\" \/><\/div><\/div><div id=\"date-6-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-6-year_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-6-year_69f3603202915-label\">Ann\u00e9e<\/label><input type=\"number\" min=\"1\" name=\"date-6-year\" placeholder=\"2000\" id=\"forminator-field-date-6-year_69f3603202915\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"dd-mm-yy\" data-parent=\"date-6\" aria-describedby=\"forminator-field-date-6_69f3603202915-description\" \/><\/div><\/div><\/div><\/div><\/div><div id=\"select-10\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-10_69f3603202915\" id=\"forminator-form-2501__field--select-10_69f3603202915-label\" class=\"forminator-label\">Sexe<\/label><select id=\"forminator-form-2501__field--select-10_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-10\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-10_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-10_69f3603202915-description\"><option value=\"masculin\"  data-calculation=\"0\">Masculin<\/option><option value=\"F\u00e9minin\"  data-calculation=\"0\">F\u00e9minin<\/option><\/select><\/div><\/div><div id=\"select-19\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-19_69f3603202915\" id=\"forminator-form-2501__field--select-19_69f3603202915-label\" class=\"forminator-label\">R\u00e9gime obligatoire <\/label><select id=\"forminator-form-2501__field--select-19_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-19\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-19_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-19_69f3603202915-description\"><option value=\"cpam\"  data-calculation=\"0\">CPAM<\/option><option value=\"S\u00e9curit\u00e9 sociale des ind\u00e9pendants\"  data-calculation=\"0\">S\u00e9curit\u00e9 sociale des ind\u00e9pendants<\/option><option value=\"R\u00e9gime agricole\"  data-calculation=\"0\">R\u00e9gime agricole<\/option><option value=\"Alsace\/Moselle\"  data-calculation=\"0\">Alsace\/Moselle<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-7\" class=\"forminator-field-name forminator-col forminator-col-3 \"><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-field-first-name-7_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-first-name-7_69f3603202915-label\">Nom Enfant N\u00b04<\/label><input type=\"text\" name=\"name-7-first-name\" placeholder=\"\" id=\"forminator-field-first-name-7_69f3603202915\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-7_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-last-name-7_69f3603202915-label\">Pr\u00e9nom Enfant N\u00b04<\/label><input type=\"text\" name=\"name-7-last-name\" placeholder=\"\" id=\"forminator-field-last-name-7_69f3603202915\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"date-7\" class=\"forminator-field-date forminator-col forminator-col-3 \"><label for=\"forminator-field-date-7\" class=\"forminator-label\">Date de Naissance<\/label><div class=\"forminator-date-input\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-7-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-7-day_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-7-day_69f3603202915-label\">Jour<\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-7-day\" value=\"\" placeholder=\"01\" id=\"forminator-field-date-7-day_69f3603202915\" class=\"forminator-input\" data-field=\"day\" data-format=\"dd-mm-yy\" data-parent=\"date-7\" aria-describedby=\"forminator-field-date-7_69f3603202915-description\" \/><\/div><\/div><div id=\"date-7-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-7-month_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-7-month_69f3603202915-label\">Mois<\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-7-month\" value=\"\" placeholder=\"01\" id=\"forminator-field-date-7-month_69f3603202915\" class=\"forminator-input\" data-field=\"month\" data-format=\"dd-mm-yy\" data-parent=\"date-7\" aria-describedby=\"forminator-field-date-7_69f3603202915-description\" \/><\/div><\/div><div id=\"date-7-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-7-year_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-7-year_69f3603202915-label\">Ann\u00e9e<\/label><input type=\"number\" min=\"1\" name=\"date-7-year\" placeholder=\"2000\" id=\"forminator-field-date-7-year_69f3603202915\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"dd-mm-yy\" data-parent=\"date-7\" aria-describedby=\"forminator-field-date-7_69f3603202915-description\" \/><\/div><\/div><\/div><\/div><\/div><div id=\"select-9\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-9_69f3603202915\" id=\"forminator-form-2501__field--select-9_69f3603202915-label\" class=\"forminator-label\">Sexe<\/label><select id=\"forminator-form-2501__field--select-9_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-9\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-9_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-9_69f3603202915-description\"><option value=\"masculin\"  data-calculation=\"0\">Masculin<\/option><option value=\"F\u00e9minin\"  data-calculation=\"0\">F\u00e9minin<\/option><\/select><\/div><\/div><div id=\"select-18\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-18_69f3603202915\" id=\"forminator-form-2501__field--select-18_69f3603202915-label\" class=\"forminator-label\">R\u00e9gime obligatoire <\/label><select id=\"forminator-form-2501__field--select-18_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-18\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-18_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-18_69f3603202915-description\"><option value=\"cpam\"  data-calculation=\"0\">CPAM<\/option><option value=\"S\u00e9curit\u00e9 sociale des ind\u00e9pendants\"  data-calculation=\"0\">S\u00e9curit\u00e9 sociale des ind\u00e9pendants<\/option><option value=\"R\u00e9gime agricole\"  data-calculation=\"0\">R\u00e9gime agricole<\/option><option value=\"Alsace\/Moselle\"  data-calculation=\"0\">Alsace\/Moselle<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-8\" class=\"forminator-field-name forminator-col forminator-col-3 \"><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-field-first-name-8_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-first-name-8_69f3603202915-label\">Nom Enfant N\u00b05<\/label><input type=\"text\" name=\"name-8-first-name\" placeholder=\"\" id=\"forminator-field-first-name-8_69f3603202915\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-8_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-last-name-8_69f3603202915-label\">Pr\u00e9nom Enfant N\u00b05<\/label><input type=\"text\" name=\"name-8-last-name\" placeholder=\"\" id=\"forminator-field-last-name-8_69f3603202915\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"date-8\" class=\"forminator-field-date forminator-col forminator-col-3 \"><label for=\"forminator-field-date-8\" class=\"forminator-label\">Date de Naissance<\/label><div class=\"forminator-date-input\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-8-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-8-day_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-8-day_69f3603202915-label\">Jour<\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-8-day\" value=\"\" placeholder=\"01\" id=\"forminator-field-date-8-day_69f3603202915\" class=\"forminator-input\" data-field=\"day\" data-format=\"dd-mm-yy\" data-parent=\"date-8\" aria-describedby=\"forminator-field-date-8_69f3603202915-description\" \/><\/div><\/div><div id=\"date-8-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-8-month_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-8-month_69f3603202915-label\">Mois<\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-8-month\" value=\"\" placeholder=\"01\" id=\"forminator-field-date-8-month_69f3603202915\" class=\"forminator-input\" data-field=\"month\" data-format=\"dd-mm-yy\" data-parent=\"date-8\" aria-describedby=\"forminator-field-date-8_69f3603202915-description\" \/><\/div><\/div><div id=\"date-8-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-8-year_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-8-year_69f3603202915-label\">Ann\u00e9e<\/label><input type=\"number\" min=\"1\" name=\"date-8-year\" placeholder=\"2000\" id=\"forminator-field-date-8-year_69f3603202915\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"dd-mm-yy\" data-parent=\"date-8\" aria-describedby=\"forminator-field-date-8_69f3603202915-description\" \/><\/div><\/div><\/div><\/div><\/div><div id=\"select-8\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-8_69f3603202915\" id=\"forminator-form-2501__field--select-8_69f3603202915-label\" class=\"forminator-label\">Sexe<\/label><select id=\"forminator-form-2501__field--select-8_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-8\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-8_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-8_69f3603202915-description\"><option value=\"masculin\"  data-calculation=\"0\">Masculin<\/option><option value=\"F\u00e9minin\"  data-calculation=\"0\">F\u00e9minin<\/option><\/select><\/div><\/div><div id=\"select-20\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-20_69f3603202915\" id=\"forminator-form-2501__field--select-20_69f3603202915-label\" class=\"forminator-label\">R\u00e9gime obligatoire <\/label><select id=\"forminator-form-2501__field--select-20_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-20\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-20_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-20_69f3603202915-description\"><option value=\"cpam\"  data-calculation=\"0\">CPAM<\/option><option value=\"S\u00e9curit\u00e9 sociale des ind\u00e9pendants\"  data-calculation=\"0\">S\u00e9curit\u00e9 sociale des ind\u00e9pendants<\/option><option value=\"R\u00e9gime agricole\"  data-calculation=\"0\">R\u00e9gime agricole<\/option><option value=\"Alsace\/Moselle\"  data-calculation=\"0\">Alsace\/Moselle<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-9\" class=\"forminator-field-name forminator-col forminator-col-3 \"><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-field-first-name-9_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-first-name-9_69f3603202915-label\">Nom Enfant N\u00b06<\/label><input type=\"text\" name=\"name-9-first-name\" placeholder=\"\" id=\"forminator-field-first-name-9_69f3603202915\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" value=\"\" \/><\/div><\/div><div class=\"forminator-col forminator-col-md-6\"><div class=\"forminator-field\"><label for=\"forminator-field-last-name-9_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-last-name-9_69f3603202915-label\">Pr\u00e9nom Enfant N\u00b06<\/label><input type=\"text\" name=\"name-9-last-name\" placeholder=\"\" id=\"forminator-field-last-name-9_69f3603202915\" class=\"forminator-input\" aria-required=\"false\" data-multi=\"1\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"date-9\" class=\"forminator-field-date forminator-col forminator-col-3 \"><label for=\"forminator-field-date-9\" class=\"forminator-label\">Date de Naissance<\/label><div class=\"forminator-date-input\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-9-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-9-day_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-9-day_69f3603202915-label\">Jour<\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-9-day\" value=\"\" placeholder=\"01\" id=\"forminator-field-date-9-day_69f3603202915\" class=\"forminator-input\" data-field=\"day\" data-format=\"dd-mm-yy\" data-parent=\"date-9\" aria-describedby=\"forminator-field-date-9_69f3603202915-description\" \/><\/div><\/div><div id=\"date-9-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-9-month_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-9-month_69f3603202915-label\">Mois<\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-9-month\" value=\"\" placeholder=\"01\" id=\"forminator-field-date-9-month_69f3603202915\" class=\"forminator-input\" data-field=\"month\" data-format=\"dd-mm-yy\" data-parent=\"date-9\" aria-describedby=\"forminator-field-date-9_69f3603202915-description\" \/><\/div><\/div><div id=\"date-9-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-9-year_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-9-year_69f3603202915-label\">Ann\u00e9e<\/label><input type=\"number\" min=\"1\" name=\"date-9-year\" placeholder=\"2000\" id=\"forminator-field-date-9-year_69f3603202915\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"dd-mm-yy\" data-parent=\"date-9\" aria-describedby=\"forminator-field-date-9_69f3603202915-description\" \/><\/div><\/div><\/div><\/div><\/div><div id=\"select-7\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-7_69f3603202915\" id=\"forminator-form-2501__field--select-7_69f3603202915-label\" class=\"forminator-label\">Sexe<\/label><select id=\"forminator-form-2501__field--select-7_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-7\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-7_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-7_69f3603202915-description\"><option value=\"masculin\"  data-calculation=\"0\">Masculin<\/option><option value=\"F\u00e9minin\"  data-calculation=\"0\">F\u00e9minin<\/option><\/select><\/div><\/div><div id=\"select-21\" class=\"forminator-field-select forminator-col forminator-col-3 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-21_69f3603202915\" id=\"forminator-form-2501__field--select-21_69f3603202915-label\" class=\"forminator-label\">R\u00e9gime obligatoire <\/label><select id=\"forminator-form-2501__field--select-21_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-21\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-21_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-21_69f3603202915-description\"><option value=\"cpam\"  data-calculation=\"0\">CPAM<\/option><option value=\"S\u00e9curit\u00e9 sociale des ind\u00e9pendants\"  data-calculation=\"0\">S\u00e9curit\u00e9 sociale des ind\u00e9pendants<\/option><option value=\"R\u00e9gime agricole\"  data-calculation=\"0\">R\u00e9gime agricole<\/option><option value=\"Alsace\/Moselle\"  data-calculation=\"0\">Alsace\/Moselle<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-7\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Garanties propos\u00e9es<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-22\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-2501__field--select-22_69f3603202915\" id=\"forminator-form-2501__field--select-22_69f3603202915-label\" class=\"forminator-label\">FORMULES DE GARANTIES<\/label><select id=\"forminator-form-2501__field--select-22_69f3603202915\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-22\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-2501__field--select-22_69f3603202915-label\" aria-describedby=\"forminator-form-2501__field--select-22_69f3603202915-description\"><option value=\"100-du-ticket-modrateur\"  data-calculation=\"0\">100% du Ticket mod\u00e9rateur<\/option><option value=\"formule-125\"  data-calculation=\"0\">Formule 125%<\/option><option value=\"formule-150\"  data-calculation=\"0\">Formule 150%<\/option><option value=\"formule-200\"  data-calculation=\"0\">Formule 200%<\/option><option value=\"formule-300\"  data-calculation=\"0\">Formule 300%<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><label class=\"forminator-label\">Formule 100% du Ticket mod\u00e9rateur<\/label><p>Il s'agit d'un contrat basique garantissant les frais de sant\u00e9, l'hospitalisation et les soins courants sans aucun d\u00e9passement.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-2\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-2\"><label class=\"forminator-label\">Formule 125%<\/label><p>Des d\u00e9passements d'honoraires pris en charge jusqu'\u00e0 125% du bar\u00eame de remboursement de la s\u00e9curit\u00e9 sociale. <\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-3\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-3\"><label class=\"forminator-label\">Formule 150%<\/label><p>Des d\u00e9passements d'honoraires pris en charge jusqu'\u00e0 150% du bar\u00eame de remboursement de la s\u00e9curit\u00e9 sociale.<\/p>\n<\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-4\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-4\"><label class=\"forminator-label\">Formule 200%<\/label><p>Des d\u00e9passements d'honoraires pris en charge jusqu'\u00e0 200% du bar\u00eame de remboursement de la s\u00e9curit\u00e9 sociale.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-5\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-5\"><label class=\"forminator-label\">Formule 300%<\/label><p>Des d\u00e9passements d'honoraires pris en charge jusqu'\u00e0 300% du bar\u00eame de remboursement de la s\u00e9curit\u00e9 sociale.<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-10\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-10-picker_69f3603202915\" class=\"forminator-label\" id=\"forminator-field-date-10-picker_69f3603202915-label\">Ech\u00e9ance anniversaire de votre contrat<\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-10-picker_69f3603202915\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-10\" value=\"\" placeholder=\"Choisissez une date\" id=\"forminator-field-date-10-picker_69f3603202915\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd\/mm\/yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_69f3603202915\" id=\"forminator-field-textarea-2_69f3603202915-label\" class=\"forminator-label\">Informations compl\u00e9mentaires<\/label><textarea name=\"textarea-2\" placeholder=\"Vous souhaitez apporter des pr\u00e9cisions ? \n\u00c9crivez les ici\" id=\"forminator-field-textarea-2_69f3603202915\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/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_69f3603202915\" class=\"forminator-label\">T\u00e9l\u00e9chargez votre attestation de s\u00e9curit\u00e9 sociale<\/label><div class=\"forminator-file-upload \" data-element=\"upload-1_69f3603202915\" aria-describedby=\"forminator-field-upload-1_69f3603202915-description\"><input type=\"file\" name=\"upload-1\" id=\"forminator-field-upload-1_69f3603202915\" 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_69f3603202915_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-1_69f3603202915\">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><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Envoyez la demande de devis<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"dabebe8f06\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F2513\" \/><input type=\"hidden\" name=\"form_id\" value=\"2501\"><input type=\"hidden\" name=\"page_id\" value=\"2513\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/aca-pl.com\/?page_id=2513\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form><\/div>\n\n\n\n<p><\/p>\n\n\n\n<p><\/p>\n\n\n\n<p class=\"has-background\" style=\"background-color:#f1e830\">Des documents compl\u00e9mentaires pourront vous \u00eatre demand\u00e9s dans le cadre de cette \u00e9tude, en compl\u00e9ment de la copie du permis de conduire et de la carte grise qui seront demand\u00e9s obligatoirement en cas de souscription, de m\u00eame que le relev\u00e9 d\u2019information de la ou des compagnies pr\u00e9c\u00e9dentes. Les donn\u00e9es communiqu\u00e9es sont strictement confidentielles et ne seront utilis\u00e9es que dans le cadre de l\u2019\u00e9tude de ce projet.<\/p>\n\n\n\n<p><\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"125\" height=\"125\" src=\"https:\/\/aca-pl.com\/wp-content\/uploads\/2019\/11\/ACA-15pxX15px-1.png\" alt=\"LOGO ACA\" class=\"wp-image-33\"\/><\/figure><\/div>\n\n\n\n<p class=\"has-text-align-center\"><strong>Quand la passion est un m\u00e9tier<\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"<p>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. 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