{"id":2573,"date":"2020-11-16T15:38:50","date_gmt":"2020-11-16T14:38:50","guid":{"rendered":"https:\/\/aca-pl.com\/?page_id=2573"},"modified":"2020-11-16T15:45:22","modified_gmt":"2020-11-16T14:45:22","slug":"multirisque-habitation","status":"publish","type":"page","link":"https:\/\/aca-pl.com\/?page_id=2573","title":{"rendered":"MULTIRISQUE HABITATION"},"content":{"rendered":"\n<p><\/p>\n\n\n\n<p class=\"has-background\" style=\"background-color:#f1e830\">L\u2019objectif de ce questionnaire est d\u2019obtenir 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\u2019envoi.<\/p>\n\n\n\n<div class=\"forminator-guttenberg\"><div class=\"forminator-ui forminator-custom-form forminator-custom-form-477 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-477\" data-uid=\"69fb3cc5c2334\"><br\/><\/div><form\n\t\t\t\tid=\"forminator-module-477\"\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-477 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=\"477\"\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=\"69fb3cc5c2334\"\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\">CIVILITE ET COMPOSITION DE LA FAMILLE<\/h2><\/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-477__field--name-1_69fb3cc5c2334\" id=\"forminator-form-477__field--name-1_69fb3cc5c2334-label\" class=\"forminator-label\">Civilit\u00e9<\/label><select name=\"name-1-prefix\" id=\"forminator-form-477__field--name-1_69fb3cc5c2334\" class=\"forminator-select2\" data-multi=\"1\" aria-labelledby=\"forminator-form-477__field--name-1_69fb3cc5c2334-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_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-first-name-1_69fb3cc5c2334-label\">Nom de famille <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-first-name\" placeholder=\"\" id=\"forminator-field-first-name-1_69fb3cc5c2334\" 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_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-last-name-1_69fb3cc5c2334-label\">Pr\u00e9nom <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-1-last-name\" placeholder=\"\" id=\"forminator-field-last-name-1_69fb3cc5c2334\" class=\"forminator-input\" aria-required=\"true\" data-multi=\"1\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-12 \"><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_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-date-1-day_69fb3cc5c2334-label\">Jour<\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-1-day\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-day_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"day\" data-format=\"dd\/mm\/yy\" data-parent=\"date-1\" aria-describedby=\"forminator-field-date-1_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-1-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-month_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-date-1-month_69fb3cc5c2334-label\">Mois<\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-1-month\" value=\"\" placeholder=\"\" id=\"forminator-field-date-1-month_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"month\" data-format=\"dd\/mm\/yy\" data-parent=\"date-1\" aria-describedby=\"forminator-field-date-1_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-1-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-year_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-date-1-year_69fb3cc5c2334-label\">Ann\u00e9e<\/label><input type=\"number\" min=\"1\" name=\"date-1-year\" placeholder=\"\" id=\"forminator-field-date-1-year_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"dd\/mm\/yy\" data-parent=\"date-1\" aria-describedby=\"forminator-field-date-1_69fb3cc5c2334-description\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-6 \"><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_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-address-1-street_address_69fb3cc5c2334-label\">Adresse  <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"Rue\" id=\"forminator-field-address-1-street_address_69fb3cc5c2334\" class=\"forminator-input\" data-required=\"1\" aria-required=\"true\" 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_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-address-1-city_69fb3cc5c2334-label\">Ville<\/label><input type=\"text\" name=\"address-1-city\" placeholder=\"Paris\" id=\"forminator-field-address-1-city_69fb3cc5c2334\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"address-1-zip\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-zip_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-address-1-zip_69fb3cc5c2334-label\">Code postal<\/label><input type=\"text\" name=\"address-1-zip\" placeholder=\"Code postal\" id=\"forminator-field-address-1-zip_69fb3cc5c2334\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><div id=\"address-1-country\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--address-1-country_69fb3cc5c2334\" class=\"forminator-label\">Pays <\/label><select name=\"address-1-country\" id=\"forminator-form-477__field--address-1-country_69fb3cc5c2334\" class=\"forminator-select2\" data-search=\"true\" data-placeholder=\"S\u00e9lectionner un pays\" data-default-value=\"France\"><option value=\"\" data-country-code=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" data-country-code=\"AF\" >Afghanistan<\/option><option value=\"Albanie\" data-country-code=\"AL\" >Albanie<\/option><option value=\"Alg\u00e9rie\" data-country-code=\"DZ\" >Alg\u00e9rie<\/option><option value=\"Samoa am\u00e9ricaines\" data-country-code=\"AS\" >Samoa am\u00e9ricaines<\/option><option value=\"Andorre\" data-country-code=\"AD\" >Andorre<\/option><option value=\"Angola\" data-country-code=\"AO\" >Angola<\/option><option value=\"Anguilla\" data-country-code=\"AI\" >Anguilla<\/option><option value=\"Antarctique\" data-country-code=\"AQ\" >Antarctique<\/option><option value=\"Antigua-et-Barbuda\" data-country-code=\"AG\" >Antigua-et-Barbuda<\/option><option value=\"Argentine\" data-country-code=\"AR\" >Argentine<\/option><option value=\"Arm\u00e9nie\" data-country-code=\"AM\" >Arm\u00e9nie<\/option><option value=\"Australie\" data-country-code=\"AU\" >Australie<\/option><option value=\"Aruba\" data-country-code=\"AW\" >Aruba<\/option><option value=\"Autriche\" data-country-code=\"AT\" >Autriche<\/option><option value=\"Azerba\u00efdjan\" data-country-code=\"AZ\" >Azerba\u00efdjan<\/option><option value=\"Bahamas\" data-country-code=\"BS\" >Bahamas<\/option><option value=\"Bahre\u00efn\" data-country-code=\"BH\" >Bahre\u00efn<\/option><option value=\"Bangladesh\" data-country-code=\"BD\" >Bangladesh<\/option><option value=\"La Barbade\" data-country-code=\"BB\" >La Barbade<\/option><option value=\"Bi\u00e9lorussie\" data-country-code=\"BY\" >Bi\u00e9lorussie<\/option><option value=\"Belgique\" data-country-code=\"BE\" >Belgique<\/option><option value=\"B\u00e9lize\" data-country-code=\"BZ\" >B\u00e9lize<\/option><option value=\"B\u00e9nin\" data-country-code=\"BJ\" >B\u00e9nin<\/option><option value=\"Bermudes\" data-country-code=\"BM\" >Bermudes<\/option><option value=\"Bhoutan\" data-country-code=\"BT\" >Bhoutan<\/option><option value=\"Bolivie\" data-country-code=\"BO\" >Bolivie<\/option><option value=\"Bosnie-Herz\u00e9govine\" data-country-code=\"BA\" >Bosnie-Herz\u00e9govine<\/option><option value=\"Botswana\" data-country-code=\"BW\" >Botswana<\/option><option value=\"\u00cele Bouvet\" data-country-code=\"BV\" >\u00cele Bouvet<\/option><option value=\"Br\u00e9sil\" data-country-code=\"BR\" >Br\u00e9sil<\/option><option value=\"Territoire britannique de l\u2019oc\u00e9an Indien\" data-country-code=\"IO\" >Territoire britannique de l\u2019oc\u00e9an Indien<\/option><option value=\"Brunei\" data-country-code=\"BN\" >Brunei<\/option><option value=\"Bulgarie\" data-country-code=\"BG\" >Bulgarie<\/option><option value=\"Burkina Faso\" data-country-code=\"BF\" >Burkina Faso<\/option><option value=\"Burundi\" data-country-code=\"BI\" >Burundi<\/option><option value=\"Cambodge\" data-country-code=\"KH\" >Cambodge<\/option><option value=\"Cameroun\" data-country-code=\"CM\" >Cameroun<\/option><option value=\"Canada\" data-country-code=\"CA\" >Canada<\/option><option value=\"Cap Vert\" data-country-code=\"CV\" >Cap Vert<\/option><option value=\"\u00celes Ca\u00efmans\" data-country-code=\"KY\" >\u00celes Ca\u00efmans<\/option><option value=\"R\u00e9publique Centrafricaine\" data-country-code=\"CF\" >R\u00e9publique Centrafricaine<\/option><option value=\"Tchad\" data-country-code=\"TD\" >Tchad<\/option><option value=\"Chili\" data-country-code=\"CL\" >Chili<\/option><option value=\"Chine, R\u00e9publique populaire de\" data-country-code=\"CN\" >Chine, R\u00e9publique populaire de<\/option><option value=\"\u00cele Christmas\" data-country-code=\"CX\" >\u00cele Christmas<\/option><option value=\"\u00celes Cocos\" data-country-code=\"CC\" >\u00celes Cocos<\/option><option value=\"Colombie\" data-country-code=\"CO\" >Colombie<\/option><option value=\"Comores\" data-country-code=\"KM\" >Comores<\/option><option value=\"Congo, R\u00e9publique d\u00e9mocratique du\" data-country-code=\"CD\" >Congo, R\u00e9publique d\u00e9mocratique du<\/option><option value=\"Congo, R\u00e9publique du\" data-country-code=\"CG\" >Congo, R\u00e9publique du<\/option><option value=\"\u00celes Cook\" data-country-code=\"CK\" >\u00celes Cook<\/option><option value=\"Costa Rica\" data-country-code=\"CR\" >Costa Rica<\/option><option value=\"C\u00f4te d\u2019Ivoire\" data-country-code=\"CI\" >C\u00f4te d\u2019Ivoire<\/option><option value=\"Croatie\" data-country-code=\"HR\" >Croatie<\/option><option value=\"Cuba\" data-country-code=\"CU\" >Cuba<\/option><option value=\"Cura\u00e7ao\" data-country-code=\"CW\" >Cura\u00e7ao<\/option><option value=\"Chypre\" data-country-code=\"CY\" >Chypre<\/option><option value=\"R\u00e9publique Tch\u00e8que\" data-country-code=\"CZ\" >R\u00e9publique Tch\u00e8que<\/option><option value=\"Danemark\" data-country-code=\"DK\" >Danemark<\/option><option value=\"Djibouti\" data-country-code=\"DJ\" >Djibouti<\/option><option value=\"Dominique\" data-country-code=\"DM\" >Dominique<\/option><option value=\"R\u00e9publique Dominicaine\" data-country-code=\"DO\" >R\u00e9publique Dominicaine<\/option><option value=\"Timor-Oriental\" data-country-code=\"TL\" >Timor-Oriental<\/option><option value=\"\u00c9quateur\" data-country-code=\"EC\" >\u00c9quateur<\/option><option value=\"\u00c9gypte\" data-country-code=\"EG\" >\u00c9gypte<\/option><option value=\"R\u00e9publique du Salvador\" data-country-code=\"SV\" >R\u00e9publique du Salvador<\/option><option value=\"Guin\u00e9e \u00c9quatoriale\" data-country-code=\"GQ\" >Guin\u00e9e \u00c9quatoriale<\/option><option value=\"\u00c9rythr\u00e9e\" data-country-code=\"ER\" >\u00c9rythr\u00e9e<\/option><option value=\"Estonie\" data-country-code=\"EE\" >Estonie<\/option><option value=\"\u00c9thiopie\" data-country-code=\"ET\" >\u00c9thiopie<\/option><option value=\"\u00celes Falkland\" data-country-code=\"FK\" >\u00celes Falkland<\/option><option value=\"\u00celes F\u00e9ro\u00e9\" data-country-code=\"FO\" >\u00celes F\u00e9ro\u00e9<\/option><option value=\"Fidji\" data-country-code=\"FJ\" >Fidji<\/option><option value=\"Finlande\" data-country-code=\"FI\" >Finlande<\/option><option value=\"France\" data-country-code=\"FR\" selected=\"selected\">France<\/option><option value=\"France, M\u00e9tropolitaine\" data-country-code=\"FX\" >France, M\u00e9tropolitaine<\/option><option value=\"Guyane fran\u00e7aise\" data-country-code=\"GF\" >Guyane fran\u00e7aise<\/option><option value=\"Polyn\u00e9sie Fran\u00e7aise\" data-country-code=\"PF\" >Polyn\u00e9sie Fran\u00e7aise<\/option><option value=\"Terres australes et antarctiques fran\u00e7aises\" data-country-code=\"TF\" >Terres australes et antarctiques fran\u00e7aises<\/option><option value=\"Gabon\" data-country-code=\"GA\" >Gabon<\/option><option value=\"Gambie\" data-country-code=\"GM\" >Gambie<\/option><option value=\"G\u00e9orgie\" data-country-code=\"GE\" >G\u00e9orgie<\/option><option value=\"Allemagne\" data-country-code=\"DE\" >Allemagne<\/option><option value=\"Guernesey\" data-country-code=\"GG\" >Guernesey<\/option><option value=\"Ghana\" data-country-code=\"GH\" >Ghana<\/option><option value=\"Gibraltar\" data-country-code=\"GI\" >Gibraltar<\/option><option value=\"Gr\u00e8ce\" data-country-code=\"GR\" >Gr\u00e8ce<\/option><option value=\"Groenland\" data-country-code=\"GL\" >Groenland<\/option><option value=\"Grenade\" data-country-code=\"GD\" >Grenade<\/option><option value=\"Guadeloupe\" data-country-code=\"GP\" >Guadeloupe<\/option><option value=\"Guam\" data-country-code=\"GU\" >Guam<\/option><option value=\"Guat\u00e9mala\" data-country-code=\"GT\" >Guat\u00e9mala<\/option><option value=\"Guin\u00e9e\" data-country-code=\"GN\" >Guin\u00e9e<\/option><option value=\"Guin\u00e9e-Bissau\" data-country-code=\"GW\" >Guin\u00e9e-Bissau<\/option><option value=\"Guyane\" data-country-code=\"GY\" >Guyane<\/option><option value=\"Ha\u00efti\" data-country-code=\"HT\" >Ha\u00efti<\/option><option value=\"\u00cele Heard et \u00eele Mcdonald\" data-country-code=\"HM\" >\u00cele Heard et \u00eele Mcdonald<\/option><option value=\"Honduras\" data-country-code=\"HN\" >Honduras<\/option><option value=\"Hong Kong\" data-country-code=\"HK\" >Hong Kong<\/option><option value=\"Hongrie\" data-country-code=\"HU\" >Hongrie<\/option><option value=\"Islande\" data-country-code=\"IS\" >Islande<\/option><option value=\"Inde\" data-country-code=\"IN\" >Inde<\/option><option value=\"Indon\u00e9sie\" data-country-code=\"ID\" >Indon\u00e9sie<\/option><option value=\"Iran\" data-country-code=\"IR\" >Iran<\/option><option value=\"Iraq\" data-country-code=\"IQ\" >Iraq<\/option><option value=\"Ireland\" data-country-code=\"IE\" >Ireland<\/option><option value=\"Israel\" data-country-code=\"IL\" >Israel<\/option><option value=\"Italie\" data-country-code=\"IT\" >Italie<\/option><option value=\"Jama\u00efque\" data-country-code=\"JM\" >Jama\u00efque<\/option><option value=\"Japon\" data-country-code=\"JP\" >Japon<\/option><option value=\"Jersey\" data-country-code=\"JE\" >Jersey<\/option><option value=\"\u00cele Johnston\" data-country-code=\"JT\" >\u00cele Johnston<\/option><option value=\"Jordanie\" data-country-code=\"JO\" >Jordanie<\/option><option value=\"Kazakhstan\" data-country-code=\"KZ\" >Kazakhstan<\/option><option value=\"Kenya\" data-country-code=\"KE\" >Kenya<\/option><option value=\"Kiribati\" data-country-code=\"KI\" >Kiribati<\/option><option value=\"Cor\u00e9e, R\u00e9publique d\u00e9mocratique populaire de\" data-country-code=\"KP\" >Cor\u00e9e, R\u00e9publique d\u00e9mocratique populaire de<\/option><option value=\"Cor\u00e9e, R\u00e9publique de\" data-country-code=\"KR\" >Cor\u00e9e, R\u00e9publique de<\/option><option value=\"Kosovo\" data-country-code=\"XK\" >Kosovo<\/option><option value=\"Kowe\u00eft\" data-country-code=\"KW\" >Kowe\u00eft<\/option><option value=\"Kirghizistan\" data-country-code=\"KG\" >Kirghizistan<\/option><option value=\"R\u00e9publique d\u00e9mocratique populaire du Laos\" data-country-code=\"LA\" >R\u00e9publique d\u00e9mocratique populaire du Laos<\/option><option value=\"Lettonie\" data-country-code=\"LV\" >Lettonie<\/option><option value=\"Liban\" data-country-code=\"LB\" >Liban<\/option><option value=\"Lesotho\" data-country-code=\"LS\" >Lesotho<\/option><option value=\"Lib\u00e9ria\" data-country-code=\"LR\" >Lib\u00e9ria<\/option><option value=\"Libye\" data-country-code=\"LY\" >Libye<\/option><option value=\"Liechtenstein\" data-country-code=\"LI\" >Liechtenstein<\/option><option value=\"Lithuanie\" data-country-code=\"LT\" >Lithuanie<\/option><option value=\"Luxembourg\" data-country-code=\"LU\" >Luxembourg<\/option><option value=\"Macao\" data-country-code=\"MO\" >Macao<\/option><option value=\"Mac\u00e9doine du Nord\" data-country-code=\"MK\" >Mac\u00e9doine du Nord<\/option><option value=\"Madagascar\" data-country-code=\"MG\" >Madagascar<\/option><option value=\"Malawi\" data-country-code=\"MW\" >Malawi<\/option><option value=\"Malaisie\" data-country-code=\"MY\" >Malaisie<\/option><option value=\"Maldives\" data-country-code=\"MV\" >Maldives<\/option><option value=\"Mali\" data-country-code=\"ML\" >Mali<\/option><option value=\"Malte\" data-country-code=\"MT\" >Malte<\/option><option value=\"\u00celes Marshall\" data-country-code=\"MH\" >\u00celes Marshall<\/option><option value=\"Martinique\" data-country-code=\"MQ\" >Martinique<\/option><option value=\"Mauritanie\" data-country-code=\"MR\" >Mauritanie<\/option><option value=\"\u00cele Maurice\" data-country-code=\"MU\" >\u00cele Maurice<\/option><option value=\"Mayotte\" data-country-code=\"YT\" >Mayotte<\/option><option value=\"Mexique\" data-country-code=\"MX\" >Mexique<\/option><option value=\"Micron\u00e9sie\" data-country-code=\"FM\" >Micron\u00e9sie<\/option><option value=\"Moldavie\" data-country-code=\"MD\" >Moldavie<\/option><option value=\"Monaco\" data-country-code=\"MC\" >Monaco<\/option><option value=\"Mongolie\" data-country-code=\"MN\" >Mongolie<\/option><option value=\"Montserrat\" data-country-code=\"MS\" >Montserrat<\/option><option value=\"Mont\u00e9n\u00e9gro\" data-country-code=\"ME\" >Mont\u00e9n\u00e9gro<\/option><option value=\"Maroc\" data-country-code=\"MA\" >Maroc<\/option><option value=\"Mozambique\" data-country-code=\"MZ\" >Mozambique<\/option><option value=\"Myanmar\" data-country-code=\"MM\" >Myanmar<\/option><option value=\"Namibie\" data-country-code=\"NA\" >Namibie<\/option><option value=\"Nauru\" data-country-code=\"NR\" >Nauru<\/option><option value=\"N\u00e9pal\" data-country-code=\"NP\" >N\u00e9pal<\/option><option value=\"Pays-Bas\" data-country-code=\"NL\" >Pays-Bas<\/option><option value=\"Antilles N\u00e9erlandaises\" data-country-code=\"AN\" >Antilles N\u00e9erlandaises<\/option><option value=\"Nouvelle-Cal\u00e9donie\" data-country-code=\"NC\" >Nouvelle-Cal\u00e9donie<\/option><option value=\"Nouvelle Zelande\" data-country-code=\"NZ\" >Nouvelle Zelande<\/option><option value=\"Nicaragua\" data-country-code=\"NI\" >Nicaragua<\/option><option value=\"Niger\" data-country-code=\"NE\" >Niger<\/option><option value=\"Nigeria\" data-country-code=\"NG\" >Nigeria<\/option><option value=\"Niu\u00e9\" data-country-code=\"NU\" >Niu\u00e9<\/option><option value=\"\u00cele Norfolk\" data-country-code=\"NF\" >\u00cele Norfolk<\/option><option value=\"\u00celes Mariannes du Nord\" data-country-code=\"MP\" >\u00celes Mariannes du Nord<\/option><option value=\"Norv\u00e8ge\" data-country-code=\"NO\" >Norv\u00e8ge<\/option><option value=\"Oman\" data-country-code=\"OM\" >Oman<\/option><option value=\"Pakistan\" data-country-code=\"PK\" >Pakistan<\/option><option value=\"Palau\" data-country-code=\"PW\" >Palau<\/option><option value=\"Palestine, \u00c9tat de\" data-country-code=\"PS\" >Palestine, \u00c9tat de<\/option><option value=\"Panama\" data-country-code=\"PA\" >Panama<\/option><option value=\"Papouasie-Nouvelle-Guin\u00e9e\" data-country-code=\"PG\" >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value=\"Paraguay\" data-country-code=\"PY\" >Paraguay<\/option><option value=\"P\u00e9rou\" data-country-code=\"PE\" >P\u00e9rou<\/option><option value=\"Philippines\" data-country-code=\"PH\" >Philippines<\/option><option value=\"\u00celes Pitcairn\" data-country-code=\"PN\" >\u00celes Pitcairn<\/option><option value=\"Pologne\" data-country-code=\"PL\" >Pologne<\/option><option value=\"Portugal\" data-country-code=\"PT\" >Portugal<\/option><option value=\"Porto Rico\" data-country-code=\"PR\" >Porto Rico<\/option><option value=\"Qatar\" data-country-code=\"QA\" >Qatar<\/option><option value=\"\u00cele de la R\u00e9union\" data-country-code=\"RE\" >\u00cele de la R\u00e9union<\/option><option value=\"Roumanie\" data-country-code=\"RO\" >Roumanie<\/option><option value=\"Russie\" data-country-code=\"RU\" >Russie<\/option><option value=\"Rwanda\" data-country-code=\"RW\" >Rwanda<\/option><option value=\"Saint-Kitts-et-Nevis\" data-country-code=\"KN\" >Saint-Kitts-et-Nevis<\/option><option value=\"Sainte Lucie\" data-country-code=\"LC\" >Sainte Lucie<\/option><option value=\"Saint-Vincent-et-les-Grenadines\" data-country-code=\"VC\" >Saint-Vincent-et-les-Grenadines<\/option><option value=\"Samoa\" data-country-code=\"WS\" >Samoa<\/option><option value=\"Sainte-H\u00e9l\u00e8ne\" data-country-code=\"SH\" >Sainte-H\u00e9l\u00e8ne<\/option><option value=\"Saint Pierre et Miquelon\" data-country-code=\"PM\" >Saint Pierre et Miquelon<\/option><option value=\"Saint-Marin\" data-country-code=\"SM\" >Saint-Marin<\/option><option value=\"Sao Tom\u00e9-et-Principe\" data-country-code=\"ST\" >Sao Tom\u00e9-et-Principe<\/option><option value=\"Arabie Saoudite\" data-country-code=\"SA\" >Arabie Saoudite<\/option><option value=\"S\u00e9n\u00e9gal\" data-country-code=\"SN\" >S\u00e9n\u00e9gal<\/option><option value=\"Serbie\" data-country-code=\"RS\" >Serbie<\/option><option value=\"Seychelles\" data-country-code=\"SC\" >Seychelles<\/option><option value=\"Sierra Leone\" data-country-code=\"SL\" >Sierra Leone<\/option><option value=\"Singapour\" data-country-code=\"SG\" >Singapour<\/option><option value=\"Saint-Martin (Royaume des Pays-Bas)\" data-country-code=\"MF\" >Saint-Martin (Royaume des Pays-Bas)<\/option><option value=\"Slovaquie\" data-country-code=\"SK\" >Slovaquie<\/option><option value=\"Slov\u00e9nie\" data-country-code=\"SI\" >Slov\u00e9nie<\/option><option value=\"\u00celes Salomon\" data-country-code=\"SB\" >\u00celes Salomon<\/option><option value=\"Somalie\" data-country-code=\"SO\" >Somalie<\/option><option value=\"Afrique du Sud\" data-country-code=\"ZA\" >Afrique du Sud<\/option><option value=\"G\u00e9orgie du Sud et Sandwich du Sud\" data-country-code=\"GS\" >G\u00e9orgie du Sud et Sandwich du Sud<\/option><option value=\"Espagne\" data-country-code=\"ES\" >Espagne<\/option><option value=\"Sri Lanka\" data-country-code=\"LK\" >Sri Lanka<\/option><option value=\"Apatrides\" data-country-code=\"XX\" >Apatrides<\/option><option value=\"Soudan\" data-country-code=\"SD\" >Soudan<\/option><option value=\"Soudan, Sud\" data-country-code=\"SS\" >Soudan, Sud<\/option><option value=\"Suriname\" data-country-code=\"SR\" >Suriname<\/option><option value=\"Svalbard et Jan Mayen\" data-country-code=\"SJ\" >Svalbard et Jan Mayen<\/option><option value=\"Swaziland\" data-country-code=\"SZ\" >Swaziland<\/option><option value=\"Su\u00e8de\" data-country-code=\"SE\" >Su\u00e8de<\/option><option value=\"Suisse\" data-country-code=\"CH\" >Suisse<\/option><option value=\"Syrie\" data-country-code=\"SY\" >Syrie<\/option><option value=\"Taiwan, R\u00e9publique de Chine\" data-country-code=\"TW\" >Taiwan, R\u00e9publique de Chine<\/option><option value=\"Tadjikistan\" data-country-code=\"TJ\" >Tadjikistan<\/option><option value=\"Tanzanie\" data-country-code=\"TZ\" >Tanzanie<\/option><option value=\"Tha\u00eflande\" data-country-code=\"TH\" >Tha\u00eflande<\/option><option value=\"Togo\" data-country-code=\"TG\" >Togo<\/option><option value=\"Tokelau\" data-country-code=\"TK\" >Tokelau<\/option><option value=\"Tonga\" data-country-code=\"TO\" >Tonga<\/option><option value=\"Trinit\u00e9 et Tobago\" data-country-code=\"TT\" >Trinit\u00e9 et Tobago<\/option><option value=\"Tunisie\" data-country-code=\"TN\" >Tunisie<\/option><option value=\"Turquie\" data-country-code=\"TR\" >Turquie<\/option><option value=\"Turkm\u00e9nistan\" data-country-code=\"TM\" >Turkm\u00e9nistan<\/option><option value=\"\u00celes Turques-et-Ca\u00efques\" data-country-code=\"TC\" >\u00celes Turques-et-Ca\u00efques<\/option><option value=\"Tuvalu\" data-country-code=\"TV\" >Tuvalu<\/option><option value=\"Ouganda\" data-country-code=\"UG\" >Ouganda<\/option><option value=\"Ukraine\" data-country-code=\"UA\" >Ukraine<\/option><option value=\"\u00c9mirats Arabes Unis\" data-country-code=\"AE\" >\u00c9mirats Arabes Unis<\/option><option value=\"Royaume-Uni\" data-country-code=\"GB\" >Royaume-Uni<\/option><option value=\"\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis\" data-country-code=\"UM\" >\u00celes mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><option value=\"\u00c9tats-Unis d\u2019Am\u00e9rique (USA)\" data-country-code=\"US\" >\u00c9tats-Unis d\u2019Am\u00e9rique (USA)<\/option><option value=\"Uruguay\" data-country-code=\"UY\" >Uruguay<\/option><option value=\"Ouzb\u00e9kistan\" data-country-code=\"UZ\" >Ouzb\u00e9kistan<\/option><option value=\"Vanuatu\" data-country-code=\"VU\" >Vanuatu<\/option><option value=\"Cit\u00e9 du Vatican\" data-country-code=\"VA\" >Cit\u00e9 du Vatican<\/option><option value=\"V\u00e9n\u00e9zu\u00e9la\" data-country-code=\"VE\" >V\u00e9n\u00e9zu\u00e9la<\/option><option value=\"Vietnam\" data-country-code=\"VN\" >Vietnam<\/option><option value=\"\u00celes Vierges britanniques\" data-country-code=\"VG\" >\u00celes Vierges britanniques<\/option><option value=\"\u00celes Vierges am\u00e9ricaines\" data-country-code=\"VI\" >\u00celes Vierges am\u00e9ricaines<\/option><option value=\"\u00celes Wallis et Futuna\" data-country-code=\"WF\" >\u00celes Wallis et Futuna<\/option><option value=\"Sahara occidental\" data-country-code=\"EH\" >Sahara occidental<\/option><option value=\"R\u00e9p. Arabe du Y\u00e9men\" data-country-code=\"YE\" >R\u00e9p. Arabe du Y\u00e9men<\/option><option value=\"Y\u00e9men d\u00e9mocratique\" data-country-code=\"YD\" >Y\u00e9men d\u00e9mocratique<\/option><option value=\"Zambie\" data-country-code=\"ZM\" >Zambie<\/option><option value=\"Zimbabwe\" data-country-code=\"ZW\" >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-phone-1_69fb3cc5c2334-label\">T\u00e9l\u00e9phone  <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"\" id=\"forminator-field-phone-1_69fb3cc5c2334\" class=\"forminator-input forminator-field--phone\" data-required=\"1\" aria-required=\"true\" autocomplete=\"off\" data-national_mode=\"enabled\" data-country=\"FR\" data-validation=\"standard\" aria-describedby=\"forminator-field-phone-1_69fb3cc5c2334-description\" \/><span id=\"forminator-field-phone-1_69fb3cc5c2334-description\" class=\"forminator-description\" id=\"forminator-field-phone-1_69fb3cc5c2334-description\">Merci d'indiquer votre num\u00e9ro de t\u00e9l\u00e9phone<\/span><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-email-1_69fb3cc5c2334-label\">Adresse e-mail <span class=\"forminator-required\">*<\/span><\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"\" id=\"forminator-field-email-1_69fb3cc5c2334\" class=\"forminator-input forminator-email--field\" data-required=\"1\" aria-required=\"true\" \/><\/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-477__field--select-3_69fb3cc5c2334\" id=\"forminator-form-477__field--select-3_69fb3cc5c2334-label\" class=\"forminator-label\">Statut familial<\/label><select id=\"forminator-form-477__field--select-3_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-3\" data-default-value=\"Merci de pr\u00e9ciser votre statut familial\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-3_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-3_69fb3cc5c2334-description\"><option value=\"C\u00e9libataire\"  data-calculation=\"0\">C\u00e9libataire<\/option><option value=\"C\u00e9libataire\"  data-calculation=\"0\">C\u00e9libataire<\/option><option value=\"Pasc\u00e9\"  data-calculation=\"0\">Pasc\u00e9<\/option><option value=\"concubinage\"  data-calculation=\"0\">Concubinage<\/option><option value=\"Divorc\u00e9 \/ s\u00e9par\u00e9\"  data-calculation=\"0\">Divorc\u00e9 \/ s\u00e9par\u00e9<\/option><option value=\"veufveuve\"  data-calculation=\"0\">Veuf\/Veuve<\/option><option value=\"Merci de pr\u00e9ciser votre statut familial\" selected=\"selected\" data-calculation=\"0\">Merci de pr\u00e9ciser votre statut familial<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-4\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-4_69fb3cc5c2334\" id=\"forminator-form-477__field--select-4_69fb3cc5c2334-label\" class=\"forminator-label\">Avez-vous des enfants \u00e0 charge ?<\/label><select id=\"forminator-form-477__field--select-4_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-4\" data-default-value=\"non\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-4_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-4_69fb3cc5c2334-description\"><option value=\"oui\"  data-calculation=\"0\">OUI<\/option><option value=\"non\" selected=\"selected\" data-calculation=\"0\">NON<\/option><\/select><\/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_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-number-1_69fb3cc5c2334-label\">Combien ? <span class=\"forminator-required\">*<\/span><\/label><input name=\"number-1\" value=\"\" placeholder=\"\" id=\"forminator-field-number-1_69fb3cc5c2334\" 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=\"1\" max=\"15\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-name-2_69fb3cc5c2334-label\">Nom et Pr\u00e9nom <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"\" id=\"forminator-field-name-2_69fb3cc5c2334\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-6 \"><label for=\"forminator-field-date-2\" class=\"forminator-label\">Date de naissance 1er enfant <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_69fb3cc5c2334\" class=\"forminator-label\">Jour <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-2-day\" value=\"\" placeholder=\"\" id=\"forminator-field-date-2-day_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"day\" data-format=\"dd\/mm\/yy\" data-parent=\"date-2\" aria-describedby=\"forminator-field-date-2_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-2-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-month_69fb3cc5c2334\" class=\"forminator-label\">Mois <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-2-month\" value=\"\" placeholder=\"\" id=\"forminator-field-date-2-month_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"month\" data-format=\"dd\/mm\/yy\" data-parent=\"date-2\" aria-describedby=\"forminator-field-date-2_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-2-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-year_69fb3cc5c2334\" class=\"forminator-label\">Ann\u00e9e <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" name=\"date-2-year\" placeholder=\"\" id=\"forminator-field-date-2-year_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"dd\/mm\/yy\" data-parent=\"date-2\" aria-describedby=\"forminator-field-date-2_69fb3cc5c2334-description\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-name-3_69fb3cc5c2334-label\">Nom et Pr\u00e9nom <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"\" id=\"forminator-field-name-3_69fb3cc5c2334\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/div><\/div><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 2\u00e8me enfant <span class=\"forminator-required\">*<\/span><\/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_69fb3cc5c2334\" class=\"forminator-label\">Jour <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-3-day\" value=\"\" placeholder=\"\" id=\"forminator-field-date-3-day_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"day\" data-format=\"dd\/mm\/yy\" data-parent=\"date-3\" aria-describedby=\"forminator-field-date-3_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-3-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-month_69fb3cc5c2334\" class=\"forminator-label\">Mois <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-3-month\" value=\"\" placeholder=\"\" id=\"forminator-field-date-3-month_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"month\" data-format=\"dd\/mm\/yy\" data-parent=\"date-3\" aria-describedby=\"forminator-field-date-3_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-3-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-year_69fb3cc5c2334\" class=\"forminator-label\">Ann\u00e9e <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" name=\"date-3-year\" placeholder=\"\" id=\"forminator-field-date-3-year_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"dd\/mm\/yy\" data-parent=\"date-3\" aria-describedby=\"forminator-field-date-3_69fb3cc5c2334-description\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-4\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-4_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-name-4_69fb3cc5c2334-label\">Nom et Pr\u00e9nom <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-4\" value=\"\" placeholder=\"\" id=\"forminator-field-name-4_69fb3cc5c2334\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/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 de naissance 3\u00e8me enfant <span class=\"forminator-required\">*<\/span><\/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_69fb3cc5c2334\" class=\"forminator-label\">Jour <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-4-day\" value=\"\" placeholder=\"\" id=\"forminator-field-date-4-day_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"day\" data-format=\"dd\/mm\/yy\" data-parent=\"date-4\" aria-describedby=\"forminator-field-date-4_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-4-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-month_69fb3cc5c2334\" class=\"forminator-label\">Mois <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-4-month\" value=\"\" placeholder=\"\" id=\"forminator-field-date-4-month_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"month\" data-format=\"dd\/mm\/yy\" data-parent=\"date-4\" aria-describedby=\"forminator-field-date-4_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-4-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-year_69fb3cc5c2334\" class=\"forminator-label\">Ann\u00e9e <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" name=\"date-4-year\" placeholder=\"\" id=\"forminator-field-date-4-year_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"dd\/mm\/yy\" data-parent=\"date-4\" aria-describedby=\"forminator-field-date-4_69fb3cc5c2334-description\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-5\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-5_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-name-5_69fb3cc5c2334-label\">Nom et Pr\u00e9nom <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-5\" value=\"\" placeholder=\"\" id=\"forminator-field-name-5_69fb3cc5c2334\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/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 de naissance 4\u00e8me enfant <span class=\"forminator-required\">*<\/span><\/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_69fb3cc5c2334\" class=\"forminator-label\">Jour <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-5-day\" value=\"\" placeholder=\"\" id=\"forminator-field-date-5-day_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"day\" data-format=\"dd\/mm\/yy\" data-parent=\"date-5\" aria-describedby=\"forminator-field-date-5_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-5-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-5-month_69fb3cc5c2334\" class=\"forminator-label\">Mois <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-5-month\" value=\"\" placeholder=\"\" id=\"forminator-field-date-5-month_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"month\" data-format=\"dd\/mm\/yy\" data-parent=\"date-5\" aria-describedby=\"forminator-field-date-5_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-5-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-5-year_69fb3cc5c2334\" class=\"forminator-label\">Ann\u00e9e <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" name=\"date-5-year\" placeholder=\"\" id=\"forminator-field-date-5-year_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"dd\/mm\/yy\" data-parent=\"date-5\" aria-describedby=\"forminator-field-date-5_69fb3cc5c2334-description\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-6\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-6_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-name-6_69fb3cc5c2334-label\">Nom et Pr\u00e9nom <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-6\" value=\"\" placeholder=\"\" id=\"forminator-field-name-6_69fb3cc5c2334\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/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 de naissance 5\u00e8me enfant <span class=\"forminator-required\">*<\/span><\/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_69fb3cc5c2334\" class=\"forminator-label\">Jour <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-7-day\" value=\"\" placeholder=\"\" id=\"forminator-field-date-7-day_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"day\" data-format=\"dd\/mm\/yy\" data-parent=\"date-7\" aria-describedby=\"forminator-field-date-7_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-7-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-7-month_69fb3cc5c2334\" class=\"forminator-label\">Mois <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-7-month\" value=\"\" placeholder=\"\" id=\"forminator-field-date-7-month_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"month\" data-format=\"dd\/mm\/yy\" data-parent=\"date-7\" aria-describedby=\"forminator-field-date-7_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-7-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-7-year_69fb3cc5c2334\" class=\"forminator-label\">Ann\u00e9e <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" name=\"date-7-year\" placeholder=\"\" id=\"forminator-field-date-7-year_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"dd\/mm\/yy\" data-parent=\"date-7\" aria-describedby=\"forminator-field-date-7_69fb3cc5c2334-description\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-7\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-7_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-name-7_69fb3cc5c2334-label\">Nom et Pr\u00e9nom <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"name-7\" value=\"\" placeholder=\"\" id=\"forminator-field-name-7_69fb3cc5c2334\" class=\"forminator-input forminator-name--field\" aria-required=\"true\" \/><\/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 de naissance 6\u00e8me enfant <span class=\"forminator-required\">*<\/span><\/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_69fb3cc5c2334\" class=\"forminator-label\">Jour <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-6-day\" value=\"\" placeholder=\"\" id=\"forminator-field-date-6-day_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"day\" data-format=\"dd\/mm\/yy\" data-parent=\"date-6\" aria-describedby=\"forminator-field-date-6_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-6-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-6-month_69fb3cc5c2334\" class=\"forminator-label\">Mois <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-6-month\" value=\"\" placeholder=\"\" id=\"forminator-field-date-6-month_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"month\" data-format=\"dd\/mm\/yy\" data-parent=\"date-6\" aria-describedby=\"forminator-field-date-6_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-6-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-6-year_69fb3cc5c2334\" class=\"forminator-label\">Ann\u00e9e <span class=\"forminator-required\">*<\/span><\/label><input type=\"number\" min=\"1\" name=\"date-6-year\" placeholder=\"\" id=\"forminator-field-date-6-year_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"dd\/mm\/yy\" data-parent=\"date-6\" aria-describedby=\"forminator-field-date-6_69fb3cc5c2334-description\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-5\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-5_69fb3cc5c2334\" id=\"forminator-form-477__field--select-5_69fb3cc5c2334-label\" class=\"forminator-label\">Avez vous des animaux ?<\/label><select id=\"forminator-form-477__field--select-5_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-5\" data-default-value=\"non\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-5_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-5_69fb3cc5c2334-description\"><option value=\"oui\"  data-calculation=\"0\">OUI<\/option><option value=\"non\" selected=\"selected\" data-calculation=\"0\">NON<\/option><\/select><\/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_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-text-2_69fb3cc5c2334-label\">Quelle esp\u00e8ce d&#039;animaux ? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"merci de pr\u00e9ciser l&#039;esp\u00e8ce et le nombre\" id=\"forminator-field-text-2_69fb3cc5c2334\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/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\">ACTIVITE DANS VOTRE HABITATION<\/h2><\/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_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-text-4_69fb3cc5c2334-label\">Quelle est votre profession ?<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"\" id=\"forminator-field-text-4_69fb3cc5c2334\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69fb3cc5c2334-label\" aria-describedby=\"forminator-radiogroup-69fb3cc5c2334-description\"><span id=\"forminator-radiogroup-69fb3cc5c2334-label\" class=\"forminator-label\">Travaillez vous \u00e0 votre domicile ?<\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-69fb3cc5c2334\" class=\"forminator-radio\" title=\"Oui\"><input type=\"radio\" name=\"radio-2\" value=\"oui\" id=\"forminator-field-radio-2-1-69fb3cc5c2334\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   aria-describedby=\"forminator-field-radio-2-69fb3cc5c2334-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Oui<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-69fb3cc5c2334\" class=\"forminator-radio\" title=\"Non\"><input type=\"radio\" name=\"radio-2\" value=\"non\" id=\"forminator-field-radio-2-2-69fb3cc5c2334\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\" checked=\"checked\"  aria-describedby=\"forminator-field-radio-2-69fb3cc5c2334-description\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Non<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-1\" class=\"forminator-field-select forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-1_69fb3cc5c2334\" id=\"forminator-form-477__field--select-1_69fb3cc5c2334-label\" class=\"forminator-label\">Avez vous des biens professionnels \u00e0 votre domicile ?<\/label><select id=\"forminator-form-477__field--select-1_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-1\" data-default-value=\"non\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-1_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-1_69fb3cc5c2334-description\"><option value=\"oui\"  data-calculation=\"0\">OUI<\/option><option value=\"non\" selected=\"selected\" data-calculation=\"0\">NON<\/option><\/select><\/div><\/div><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-text-1_69fb3cc5c2334-label\">Si oui quels types de bien ? <span class=\"forminator-required\">*<\/span><\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69fb3cc5c2334\" class=\"forminator-input forminator-name--field\" data-required=\"1\" \/><\/div><\/div><div id=\"currency-1\" class=\"forminator-field-currency forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-currency-1_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-currency-1_69fb3cc5c2334-label\">Quelle valeur ? <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-suffix\"><input name=\"currency-1\" value=\"\" placeholder=\"\" id=\"forminator-field-currency-1_69fb3cc5c2334\" class=\"forminator-input forminator-currency\" data-required=\"1\" aria-required=\"1\" data-decimals=\"0\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" type=\"number\" step=\"any\" \/><span class=\"forminator-suffix\">EUR<\/span><\/div><\/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\">COMPOSITION DE VOTRE HABITATION<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-2\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-2_69fb3cc5c2334\" id=\"forminator-form-477__field--select-2_69fb3cc5c2334-label\" class=\"forminator-label\">L&#039;immeuble \u00e0 garantir est il situ\u00e9 \u00e0 une autre adresse  que celle-indiqu\u00e9e ci-dessus ? <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-477__field--select-2_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-2\" data-default-value=\"non\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-2_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-2_69fb3cc5c2334-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 id=\"address-2\" class=\"forminator-field-address forminator-col forminator-col-6 \"><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_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-address-2-street_address_69fb3cc5c2334-label\">Rue<\/label><input type=\"text\" name=\"address-2-street_address\" placeholder=\"Merci de pr\u00e9ciser l&#039;adresse de votre habitation \u00e0 garantir\" id=\"forminator-field-address-2-street_address_69fb3cc5c2334\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" 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_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-address-2-address_line_69fb3cc5c2334-label\">Appartement, suite, etc.<\/label><input type=\"text\" name=\"address-2-address_line\" placeholder=\"\" id=\"forminator-field-address-2-address_line_69fb3cc5c2334\" 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_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-address-2-city_69fb3cc5c2334-label\">Ville<\/label><input type=\"text\" name=\"address-2-city\" placeholder=\"\" id=\"forminator-field-address-2-city_69fb3cc5c2334\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" 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_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-address-2-zip_69fb3cc5c2334-label\">Code postal<\/label><input type=\"text\" name=\"address-2-zip\" placeholder=\"\" id=\"forminator-field-address-2-zip_69fb3cc5c2334\" class=\"forminator-input\" value=\"\" \/><\/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-477__field--select-9_69fb3cc5c2334\" id=\"forminator-form-477__field--select-9_69fb3cc5c2334-label\" class=\"forminator-label\">Il s&#039;agit de votre r\u00e9sidence:<\/label><select id=\"forminator-form-477__field--select-9_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-9\" data-default-value=\"principale\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-9_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-9_69fb3cc5c2334-description\"><option value=\"principale\" selected=\"selected\" data-calculation=\"0\">Principale<\/option><option value=\"secondaire\"  data-calculation=\"0\">Secondaire<\/option><\/select><\/div><\/div><div id=\"select-10\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-10_69fb3cc5c2334\" id=\"forminator-form-477__field--select-10_69fb3cc5c2334-label\" class=\"forminator-label\">Etes vous:<\/label><select id=\"forminator-form-477__field--select-10_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-10\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-10_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-10_69fb3cc5c2334-description\"><option value=\"locataire\"  data-calculation=\"0\">Locataire<\/option><option value=\"Propri\u00e9taire \"  data-calculation=\"0\">Propri\u00e9taire <\/option><option value=\"colocation\"  data-calculation=\"0\">Colocation<\/option><option value=\"copropritaire\"  data-calculation=\"0\">Copropri\u00e9taire<\/option><option value=\"propri\u00e9taire ou copropri\u00e9taire non occupant\"  data-calculation=\"0\">propri\u00e9taire ou copropri\u00e9taire non occupant<\/option><option value=\"usufruitier\"  data-calculation=\"0\">Usufruitier<\/option><\/select><\/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-477__field--select-13_69fb3cc5c2334\" id=\"forminator-form-477__field--select-13_69fb3cc5c2334-label\" class=\"forminator-label\">P\u00e9riode de construction de votre logement:<\/label><select id=\"forminator-form-477__field--select-13_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-13\" data-default-value=\"merci-de-prciser-la-priode\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-13_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-13_69fb3cc5c2334-description\"><option value=\"neuf\"  data-calculation=\"0\">Neuf<\/option><option value=\"moins-de-10-ans\"  data-calculation=\"0\">Moins de 10 ans<\/option><option value=\"moins-d-15-ans\"  data-calculation=\"0\">Moins d 15 ans<\/option><option value=\"moins-de-30-ans\"  data-calculation=\"0\">Moins de 30 ans<\/option><option value=\"plus-de-30-ans\"  data-calculation=\"0\">Plus de 30 ans<\/option><option value=\"plus-de-50-ans\"  data-calculation=\"0\">Plus de 50 ans<\/option><option value=\"plus-de-100-ans\"  data-calculation=\"0\">Plus de 100 ans<\/option><option value=\"ne-sait-pas\"  data-calculation=\"0\">Ne sait pas<\/option><option value=\"merci-de-prciser-la-priode\" selected=\"selected\" data-calculation=\"0\">Merci de pr\u00e9ciser la p\u00e9riode<\/option><\/select><\/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-477__field--select-11_69fb3cc5c2334\" id=\"forminator-form-477__field--select-11_69fb3cc5c2334-label\" class=\"forminator-label\">Quelle cat\u00e9gorie de logement habitez-vous ? <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-477__field--select-11_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-11\" data-default-value=\"appartement\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-11_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-11_69fb3cc5c2334-description\"><option value=\"\">Merci de choisir une option<\/option><option value=\"maison\"  data-calculation=\"0\">Maison<\/option><option value=\"appartement\" selected=\"selected\" data-calculation=\"0\">Appartement<\/option><option value=\"manoir\"  data-calculation=\"0\">Manoir<\/option><option value=\"Gentihommi\u00e8re\"  data-calculation=\"0\">Gentihommi\u00e8re<\/option><option value=\"Long\u00e8re\"  data-calculation=\"0\">Long\u00e8re<\/option><option value=\"Ch\u00e2teau\"  data-calculation=\"0\">Ch\u00e2teau<\/option><\/select><\/div><\/div><div id=\"select-14\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-14_69fb3cc5c2334\" id=\"forminator-form-477__field--select-14_69fb3cc5c2334-label\" class=\"forminator-label\">Le b\u00e2timent est il class\u00e9 aux monuments historique ou inscrit \u00e0 l&#039;inventaire?  <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-477__field--select-14_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-14\" data-default-value=\"non\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-14_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-14_69fb3cc5c2334-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=\"number-2\" class=\"forminator-field-number forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-2_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-number-2_69fb3cc5c2334-label\">Nombre d&#039;\u00e9tages y compris le rez de chauss\u00e9e<\/label><input name=\"number-2\" value=\"\" placeholder=\"Par exemple\u00a0: 2\" id=\"forminator-field-number-2_69fb3cc5c2334\" 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=\"150\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-3\" class=\"forminator-field-number forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-3_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-number-3_69fb3cc5c2334-label\">Nombre de pi\u00e8ces de votre habitation <span class=\"forminator-required\">*<\/span><\/label><input name=\"number-3\" value=\"\" placeholder=\"y compris v\u00e9randa\" id=\"forminator-field-number-3_69fb3cc5c2334\" 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=\"1\" max=\"150\" \/><\/div><\/div><div id=\"number-4\" class=\"forminator-field-number forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-4_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-number-4_69fb3cc5c2334-label\">Quelle est la superficie de votre logement ?<\/label><input name=\"number-4\" value=\"\" placeholder=\"\" id=\"forminator-field-number-4_69fb3cc5c2334\" 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=\"150\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-12\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-12_69fb3cc5c2334\" id=\"forminator-form-477__field--select-12_69fb3cc5c2334-label\" class=\"forminator-label\">Une pi\u00e8ce d\u00e9passe-t-elle une surface de 30 M\u00b2 ?<\/label><select id=\"forminator-form-477__field--select-12_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-12\" data-default-value=\"non\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-12_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-12_69fb3cc5c2334-description\"><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=\"number-5\" class=\"forminator-field-number forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-5_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-number-5_69fb3cc5c2334-label\">Quelle est la surface de cette pi\u00e8ce ?<\/label><input name=\"number-5\" value=\"\" placeholder=\"Par exemple\u00a0:  15 m\u00b2\" id=\"forminator-field-number-5_69fb3cc5c2334\" 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=\"150\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-69fb3cc5c2334-label\"><h4 id=\"forminator-checkbox-group-69fb3cc5c2334-label\" class=\"forminator-label\">Poss\u00e9dez vous ?<\/h4><label id=\"forminator-field-checkbox-1-1-69fb3cc5c2334-label\" for=\"forminator-field-checkbox-1-1-69fb3cc5c2334\" class=\"forminator-checkbox\" title=\"Une v\u00e9randa \"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"une-vranda\" id=\"forminator-field-checkbox-1-1-69fb3cc5c2334\" aria-labelledby=\"forminator-field-checkbox-1-1-69fb3cc5c2334-label\" data-calculation=\"0\"   aria-describedby=\"forminator-field-checkbox-1-69fb3cc5c2334-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Une v\u00e9randa <\/span><\/label><label id=\"forminator-field-checkbox-1-2-69fb3cc5c2334-label\" for=\"forminator-field-checkbox-1-2-69fb3cc5c2334\" class=\"forminator-checkbox\" title=\"Une mezzanine \"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"une-mezzanine\" id=\"forminator-field-checkbox-1-2-69fb3cc5c2334\" aria-labelledby=\"forminator-field-checkbox-1-2-69fb3cc5c2334-label\" data-calculation=\"0\"   aria-describedby=\"forminator-field-checkbox-1-69fb3cc5c2334-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Une mezzanine <\/span><\/label><label id=\"forminator-field-checkbox-1-3-69fb3cc5c2334-label\" for=\"forminator-field-checkbox-1-3-69fb3cc5c2334\" class=\"forminator-checkbox\" title=\"Un garage \"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"un-garage\" id=\"forminator-field-checkbox-1-3-69fb3cc5c2334\" aria-labelledby=\"forminator-field-checkbox-1-3-69fb3cc5c2334-label\" data-calculation=\"0\"   aria-describedby=\"forminator-field-checkbox-1-69fb3cc5c2334-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Un garage <\/span><\/label><label id=\"forminator-field-checkbox-1-4-69fb3cc5c2334-label\" for=\"forminator-field-checkbox-1-4-69fb3cc5c2334\" class=\"forminator-checkbox\" title=\"Un grenier  \"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"un-grenier\" id=\"forminator-field-checkbox-1-4-69fb3cc5c2334\" aria-labelledby=\"forminator-field-checkbox-1-4-69fb3cc5c2334-label\" data-calculation=\"0\"   aria-describedby=\"forminator-field-checkbox-1-69fb3cc5c2334-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Un grenier  <\/span><\/label><label id=\"forminator-field-checkbox-1-5-69fb3cc5c2334-label\" for=\"forminator-field-checkbox-1-5-69fb3cc5c2334\" class=\"forminator-checkbox\" title=\"Des d\u00e9pendances \"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"des-dpendances\" id=\"forminator-field-checkbox-1-5-69fb3cc5c2334\" aria-labelledby=\"forminator-field-checkbox-1-5-69fb3cc5c2334-label\" data-calculation=\"0\"   aria-describedby=\"forminator-field-checkbox-1-69fb3cc5c2334-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Des d\u00e9pendances <\/span><\/label><label id=\"forminator-field-checkbox-1-6-69fb3cc5c2334-label\" for=\"forminator-field-checkbox-1-6-69fb3cc5c2334\" class=\"forminator-checkbox\" title=\"Une cave \"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"une-cave\" id=\"forminator-field-checkbox-1-6-69fb3cc5c2334\" aria-labelledby=\"forminator-field-checkbox-1-6-69fb3cc5c2334-label\" data-calculation=\"0\"   aria-describedby=\"forminator-field-checkbox-1-69fb3cc5c2334-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Une cave <\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-15\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-15_69fb3cc5c2334\" id=\"forminator-form-477__field--select-15_69fb3cc5c2334-label\" class=\"forminator-label\">Type de couverture de votre immeuble<\/label><select id=\"forminator-form-477__field--select-15_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-15\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-15_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-15_69fb3cc5c2334-description\"><option value=\"traditionnelle-ardoises-tuiles\"  data-calculation=\"0\">Traditionnelle (ardoises, tuiles...)<\/option><option value=\"terrasse\"  data-calculation=\"0\">Terrasse <\/option><option value=\"chaume\"  data-calculation=\"0\">Chaume<\/option><option value=\"bitume\"  data-calculation=\"0\">Bitum\u00e9e<\/option><option value=\"autre\"  data-calculation=\"0\">Autre<\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-16\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-16_69fb3cc5c2334\" id=\"forminator-form-477__field--select-16_69fb3cc5c2334-label\" class=\"forminator-label\">Mode de chauffage<\/label><select id=\"forminator-form-477__field--select-16_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-16\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-16_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-16_69fb3cc5c2334-description\"><option value=\"electrique\"  data-calculation=\"0\">Electrique<\/option><option value=\"chauffage-central-gaz-ou-fuel\"  data-calculation=\"0\">Chauffage central gaz ou fuel<\/option><option value=\"chemine-ouverte\"  data-calculation=\"0\">Chemin\u00e9e ouverte<\/option><option value=\"Foyer ferm\u00e9, po\u00eale \"  data-calculation=\"0\">Foyer ferm\u00e9, po\u00eale <\/option><option value=\"climatisation\"  data-calculation=\"0\">Climatisation<\/option><option value=\"chauffage-solaire\"  data-calculation=\"0\">Chauffage solaire<\/option><\/select><\/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-477__field--select-20_69fb3cc5c2334\" id=\"forminator-form-477__field--select-20_69fb3cc5c2334-label\" class=\"forminator-label\">ACTIVITES PROFESSIONNELLES DANS L&#039; IMMEUBLE<\/label><select id=\"forminator-form-477__field--select-20_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-20\" data-default-value=\"non\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-20_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-20_69fb3cc5c2334-description\"><option value=\"oui\"  data-calculation=\"0\">OUI<\/option><option value=\"non\" selected=\"selected\" data-calculation=\"0\">NON<\/option><\/select><\/div><\/div><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-text-5_69fb3cc5c2334-label\">QUELLE ACTIVITES ?<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"ex: boulangerie,  plombier etc...\" id=\"forminator-field-text-5_69fb3cc5c2334\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/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\">VOTRE MOBILIER<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-17\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-17_69fb3cc5c2334\" id=\"forminator-form-477__field--select-17_69fb3cc5c2334-label\" class=\"forminator-label\">Valeur du mobilier et du contenu du logement <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-477__field--select-17_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-17\" data-default-value=\"\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-17_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-17_69fb3cc5c2334-description\"><option value=\"\">Merci de choisir une option<\/option><option value=\"5-000\"  data-calculation=\"0\">5 000 \u20ac<\/option><option value=\"10-000\"  data-calculation=\"0\">10 000 \u20ac<\/option><option value=\"20-000 \"  data-calculation=\"0\">20 000 \u20ac<\/option><option value=\"30-000\"  data-calculation=\"0\">30 000 \u20ac<\/option><option value=\"40-000\"  data-calculation=\"0\">40 000 \u20ac<\/option><option value=\"50-000\"  data-calculation=\"0\">50 000 \u20ac<\/option><option value=\"70-000\"  data-calculation=\"0\">70 000 \u20ac<\/option><option value=\"80-000\"  data-calculation=\"0\">80 000 \u20ac<\/option><option value=\"90-000\"  data-calculation=\"0\">90 000 \u20ac<\/option><option value=\"100-000\"  data-calculation=\"0\">100 000  \u20ac<\/option><option value=\"120-00\"  data-calculation=\"0\">120 00 \u20ac<\/option><option value=\"130-000\"  data-calculation=\"0\">130 000 \u20ac<\/option><option value=\"150-000\"  data-calculation=\"0\">150 000 \u20ac<\/option><option value=\"autre\"  data-calculation=\"0\">AUTRE<\/option><\/select><\/div><\/div><div id=\"currency-2\" class=\"forminator-field-currency forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-currency-2_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-currency-2_69fb3cc5c2334-label\">Montant du capital \u00e0 garantir <span class=\"forminator-required\">*<\/span><\/label><div class=\"forminator-input-with-suffix\"><input name=\"currency-2\" value=\"\" placeholder=\"\" id=\"forminator-field-currency-2_69fb3cc5c2334\" class=\"forminator-input forminator-currency\" data-required=\"1\" aria-required=\"1\" data-decimals=\"0\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" type=\"number\" step=\"any\" \/><span class=\"forminator-suffix\">EUR<\/span><\/div><\/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-477__field--select-18_69fb3cc5c2334\" id=\"forminator-form-477__field--select-18_69fb3cc5c2334-label\" class=\"forminator-label\">Poss\u00e9dez vous des objets pr\u00e9cieux ? <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-477__field--select-18_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-18\" data-default-value=\"\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-18_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-18_69fb3cc5c2334-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><\/select><span id=\"forminator-form-477__field--select-18_69fb3cc5c2334-description\" class=\"forminator-description\">(bijoux, tapis, fourrure, tableaux, collections...)<\/span><\/div><\/div><div id=\"select-19\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-19_69fb3cc5c2334\" id=\"forminator-form-477__field--select-19_69fb3cc5c2334-label\" class=\"forminator-label\">Quel est le pourcentage de la valeur de vos objets pr\u00e9cieux dans le mobilier ?<\/label><select id=\"forminator-form-477__field--select-19_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-19\" data-default-value=\"5\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-19_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-19_69fb3cc5c2334-description\"><option value=\"5\" selected=\"selected\" data-calculation=\"0\">5%<\/option><option value=\"10\"  data-calculation=\"0\">10%<\/option><option value=\"15\"  data-calculation=\"0\">15%<\/option><option value=\"20\"  data-calculation=\"0\">20%<\/option><option value=\"25\"  data-calculation=\"0\">25%<\/option><option value=\"30\"  data-calculation=\"0\">30%<\/option><option value=\"35\"  data-calculation=\"0\">35%<\/option><option value=\"40\"  data-calculation=\"0\">40%<\/option><option value=\"45%\"  data-calculation=\"0\">45%<\/option><option value=\"50\"  data-calculation=\"0\">50%<\/option><option value=\"aucune-valeur-a-garantir\"  data-calculation=\"0\">AUCUNE VALEUR A GARANTIR<\/option><\/select><span id=\"forminator-form-477__field--select-19_69fb3cc5c2334-description\" class=\"forminator-description\">exemple 5% du capital mobilier choisi<\/span><\/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-477__field--select-6_69fb3cc5c2334\" id=\"forminator-form-477__field--select-6_69fb3cc5c2334-label\" class=\"forminator-label\">Avez vous un ou plusieurs aquariums dans votre habitation<\/label><select id=\"forminator-form-477__field--select-6_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-6\" data-default-value=\"non\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-6_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-6_69fb3cc5c2334-description\"><option value=\"oui\"  data-calculation=\"0\">OUI<\/option><option value=\"non\" selected=\"selected\" data-calculation=\"0\">NON<\/option><\/select><\/div><\/div><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-text-3_69fb3cc5c2334-label\">Si oui, quelle contenance ?<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"Exemple: 150 litres \" id=\"forminator-field-text-3_69fb3cc5c2334\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-8\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-8_69fb3cc5c2334\" id=\"forminator-form-477__field--select-8_69fb3cc5c2334-label\" class=\"forminator-label\">Pratiquez vous la chasse ?<\/label><select id=\"forminator-form-477__field--select-8_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-8\" data-default-value=\"non\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-8_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-8_69fb3cc5c2334-description\"><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=\"select-7\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-7_69fb3cc5c2334\" id=\"forminator-form-477__field--select-7_69fb3cc5c2334-label\" class=\"forminator-label\">Une personne ext\u00e9rieure vit-elle avec vous dans cette habitation ? (hors conjoint et enfant)<\/label><select id=\"forminator-form-477__field--select-7_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-7\" data-default-value=\"non\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-7_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-7_69fb3cc5c2334-description\"><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=\"section-4\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">PREVENTION<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-21\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-21_69fb3cc5c2334\" id=\"forminator-form-477__field--select-21_69fb3cc5c2334-label\" class=\"forminator-label\">MODE DE FERMETURE<\/label><select id=\"forminator-form-477__field--select-21_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-21\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-21_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-21_69fb3cc5c2334-description\"><option value=\"serrure-simple\"  data-calculation=\"0\">Serrure simple<\/option><option value=\"serrure-3-points\"  data-calculation=\"0\">Serrure 3 points<\/option><option value=\"serrure-simple-verrous\"  data-calculation=\"0\">Serrure simple + verrous<\/option><option value=\"autre\"  data-calculation=\"0\">Autre<\/option><\/select><\/div><\/div><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-text-6_69fb3cc5c2334-label\">Merci de pr\u00e9ciser<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_69fb3cc5c2334\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/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-477__field--select-22_69fb3cc5c2334\" id=\"forminator-form-477__field--select-22_69fb3cc5c2334-label\" class=\"forminator-label\">Disposez vous d&#039;un syst\u00e8me de t\u00e9l\u00e9surveillance ?<\/label><select id=\"forminator-form-477__field--select-22_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-22\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-22_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-22_69fb3cc5c2334-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=\"select-23\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-23_69fb3cc5c2334\" id=\"forminator-form-477__field--select-23_69fb3cc5c2334-label\" class=\"forminator-label\">Disposez vous d&#039;un d\u00e9tecteur de fum\u00e9e ? (obligatoire)<\/label><select id=\"forminator-form-477__field--select-23_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-23\" data-default-value=\"oui\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-23_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-23_69fb3cc5c2334-description\"><option value=\"oui\" selected=\"selected\" data-calculation=\"0\">OUI<\/option><option value=\"non\"  data-calculation=\"0\">NON<\/option><\/select><\/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-477__field--select-24_69fb3cc5c2334\" id=\"forminator-form-477__field--select-24_69fb3cc5c2334-label\" class=\"forminator-label\">Disposez vous d&#039;extincteurs ?<\/label><select id=\"forminator-form-477__field--select-24_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-24\" data-default-value=\"non\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-24_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-24_69fb3cc5c2334-description\"><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=\"select-25\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-25_69fb3cc5c2334\" id=\"forminator-form-477__field--select-25_69fb3cc5c2334-label\" class=\"forminator-label\">Disposez vous d&#039;un jardin ?<\/label><select id=\"forminator-form-477__field--select-25_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-25\" data-default-value=\"non\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-25_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-25_69fb3cc5c2334-description\"><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=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-text-7_69fb3cc5c2334-label\">Quelle surface ?<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"\" id=\"forminator-field-text-7_69fb3cc5c2334\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-6\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">VOS GARANTIES<\/h2><\/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\">GARANTIES ACQUISES AUTOMATIQUEMENT:<\/label><ul>\n<li>Responsabilit\u00e9 Civile vie priv\u00e9e, D\u00e9fense juridique et recours<\/li>\n<li>Vol, vandalisme<\/li>\n<li>Incendie, et \u00e9v\u00e8nements annexes<\/li>\n<li>Temp\u00eates, Gr\u00eale, Neige, Catastrophes naturelles<\/li>\n<li>Catastrophes technologiques<\/li>\n<li>Bris de glace<\/li>\n<li>Risques locatifs ou d'occupant<\/li>\n<\/ul><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-3\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-69fb3cc5c2334-label\"><h4 id=\"forminator-checkbox-group-69fb3cc5c2334-label\" class=\"forminator-label\">Vos garanties optionnelles:<\/h4><label id=\"forminator-field-checkbox-3-1-69fb3cc5c2334-label\" for=\"forminator-field-checkbox-3-1-69fb3cc5c2334\" class=\"forminator-checkbox\" title=\"Dommages \u00e9lectriques\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Dommages \u00e9lectriques\" id=\"forminator-field-checkbox-3-1-69fb3cc5c2334\" aria-labelledby=\"forminator-field-checkbox-3-1-69fb3cc5c2334-label\" data-calculation=\"0\"   aria-describedby=\"forminator-field-checkbox-3-69fb3cc5c2334-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Dommages \u00e9lectriques<\/span><\/label><label id=\"forminator-field-checkbox-3-2-69fb3cc5c2334-label\" for=\"forminator-field-checkbox-3-2-69fb3cc5c2334\" class=\"forminator-checkbox\" title=\"Perte de marchandise en cong\u00e9lateur\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Perte de marchandise en cong\u00e9lateur\" id=\"forminator-field-checkbox-3-2-69fb3cc5c2334\" aria-labelledby=\"forminator-field-checkbox-3-2-69fb3cc5c2334-label\" data-calculation=\"0\"   aria-describedby=\"forminator-field-checkbox-3-69fb3cc5c2334-description\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Perte de marchandise en cong\u00e9lateur<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_69fb3cc5c2334\" id=\"forminator-field-textarea-1_69fb3cc5c2334-label\" class=\"forminator-label\">Vous voulez apporter des pr\u00e9cisions ?<\/label><textarea name=\"textarea-1\" placeholder=\"tapez vos explications \" id=\"forminator-field-textarea-1_69fb3cc5c2334\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/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\">VOTRE SINISTRALITE <\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-26\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-26_69fb3cc5c2334\" id=\"forminator-form-477__field--select-26_69fb3cc5c2334-label\" class=\"forminator-label\">Avez vous \u00e9t\u00e9 r\u00e9sili\u00e9 par un assureur au cours des 36 derniers mois ? <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-477__field--select-26_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-26\" data-default-value=\"non\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-26_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-26_69fb3cc5c2334-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=\"select-27\" class=\"forminator-field-select forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-27_69fb3cc5c2334\" id=\"forminator-form-477__field--select-27_69fb3cc5c2334-label\" class=\"forminator-label\">Pour quelle raison ? <span class=\"forminator-required\">*<\/span><\/label><select id=\"forminator-form-477__field--select-27_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"1\" name=\"select-27\" data-default-value=\"\" data-placeholder=\"Merci de choisir une option\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-27_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-27_69fb3cc5c2334-description\"><option value=\"\">Merci de choisir une option<\/option><option value=\"rsili-pour-sinistres\"  data-calculation=\"0\">R\u00e9sili\u00e9 pour sinistres<\/option><option value=\"rsili-pour-non-paiement\"  data-calculation=\"0\">R\u00e9sili\u00e9 pour non paiement <\/option><option value=\"rsili-pour-fausse-dclaration\"  data-calculation=\"0\">R\u00e9sili\u00e9 pour fausse d\u00e9claration <\/option><option value=\"autre\"  data-calculation=\"0\">Autre <\/option><\/select><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-6\" class=\"forminator-field-number forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-6_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-number-6_69fb3cc5c2334-label\">Nombre de sinistres au cours des 36 derniers mois <span class=\"forminator-required\">*<\/span><\/label><input name=\"number-6\" value=\"\" placeholder=\"\" id=\"forminator-field-number-6_69fb3cc5c2334\" 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-28\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-28_69fb3cc5c2334\" id=\"forminator-form-477__field--select-28_69fb3cc5c2334-label\" class=\"forminator-label\">SINISTRE N\u00b01<\/label><select id=\"forminator-form-477__field--select-28_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-28\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-28_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-28_69fb3cc5c2334-description\"><option value=\"degats-des-eaux\"  data-calculation=\"0\">DEGATS DES EAUX<\/option><option value=\"bris-de-glace\"  data-calculation=\"0\">BRIS DE GLACE<\/option><option value=\"vol\"  data-calculation=\"0\">VOL<\/option><option value=\"vandalisme\"  data-calculation=\"0\">VANDALISME<\/option><option value=\"incendie\"  data-calculation=\"0\">INCENDIE<\/option><option value=\"catastrophe-naturelle-inondations\"  data-calculation=\"0\">CATASTROPHE NATURELLE \/ INONDATIONS<\/option><option value=\"catastrophe-technologique\"  data-calculation=\"0\">CATASTROPHE TECHNOLOGIQUE<\/option><\/select><\/div><\/div><div id=\"date-8\" class=\"forminator-field-date forminator-col forminator-col-6 \"><label for=\"forminator-field-date-8\" class=\"forminator-label\">Date<\/label><div class=\"forminator-date-input\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-8-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-8-month_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-date-8-month_69fb3cc5c2334-label\">Mois<\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-8-month\" value=\"\" placeholder=\"\" id=\"forminator-field-date-8-month_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"month\" data-format=\"mm\/dd\/yy\" data-parent=\"date-8\" aria-describedby=\"forminator-field-date-8_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-8-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-8-day_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-date-8-day_69fb3cc5c2334-label\">Jour<\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-8-day\" value=\"\" placeholder=\"\" id=\"forminator-field-date-8-day_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"day\" data-format=\"mm\/dd\/yy\" data-parent=\"date-8\" aria-describedby=\"forminator-field-date-8_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-8-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-8-year_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-date-8-year_69fb3cc5c2334-label\">Ann\u00e9e<\/label><input type=\"number\" min=\"1\" name=\"date-8-year\" placeholder=\"\" id=\"forminator-field-date-8-year_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"mm\/dd\/yy\" data-parent=\"date-8\" aria-describedby=\"forminator-field-date-8_69fb3cc5c2334-description\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-29\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-29_69fb3cc5c2334\" id=\"forminator-form-477__field--select-29_69fb3cc5c2334-label\" class=\"forminator-label\">SINISTRE N\u00b02<\/label><select id=\"forminator-form-477__field--select-29_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-29\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-29_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-29_69fb3cc5c2334-description\"><option value=\"degats-des-eaux\"  data-calculation=\"0\">DEGATS DES EAUX<\/option><option value=\"bris-de-glace\"  data-calculation=\"0\">BRIS DE GLACE<\/option><option value=\"vol\"  data-calculation=\"0\">VOL<\/option><option value=\"vandalisme\"  data-calculation=\"0\">VANDALISME<\/option><option value=\"incendie\"  data-calculation=\"0\">INCENDIE<\/option><option value=\"catastrophe-naturelle-inondations\"  data-calculation=\"0\">CATASTROPHE NATURELLE \/ INONDATIONS<\/option><option value=\"catastrophe-technologique\"  data-calculation=\"0\">CATASTROPHE TECHNOLOGIQUE<\/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-input\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-9-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-9-month_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-date-9-month_69fb3cc5c2334-label\">Mois<\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-9-month\" value=\"\" placeholder=\"\" id=\"forminator-field-date-9-month_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"month\" data-format=\"mm\/dd\/yy\" data-parent=\"date-9\" aria-describedby=\"forminator-field-date-9_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-9-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-9-day_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-date-9-day_69fb3cc5c2334-label\">Jour<\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-9-day\" value=\"\" placeholder=\"\" id=\"forminator-field-date-9-day_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"day\" data-format=\"mm\/dd\/yy\" data-parent=\"date-9\" aria-describedby=\"forminator-field-date-9_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-9-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-9-year_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-date-9-year_69fb3cc5c2334-label\">Ann\u00e9e<\/label><input type=\"number\" min=\"1\" name=\"date-9-year\" placeholder=\"\" id=\"forminator-field-date-9-year_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"mm\/dd\/yy\" data-parent=\"date-9\" aria-describedby=\"forminator-field-date-9_69fb3cc5c2334-description\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-30\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-30_69fb3cc5c2334\" id=\"forminator-form-477__field--select-30_69fb3cc5c2334-label\" class=\"forminator-label\">SINISTRE N\u00b03<\/label><select id=\"forminator-form-477__field--select-30_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-30\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-30_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-30_69fb3cc5c2334-description\"><option value=\"degats-des-eaux\"  data-calculation=\"0\">DEGATS DES EAUX<\/option><option value=\"bris-de-glace\"  data-calculation=\"0\">BRIS DE GLACE<\/option><option value=\"vol\"  data-calculation=\"0\">VOL<\/option><option value=\"vandalisme\"  data-calculation=\"0\">VANDALISME<\/option><option value=\"incendie\"  data-calculation=\"0\">INCENDIE<\/option><option value=\"catastrophe-naturelle-inondations\"  data-calculation=\"0\">CATASTROPHE NATURELLE \/ INONDATIONS<\/option><option value=\"catastrophe-technologique\"  data-calculation=\"0\">CATASTROPHE TECHNOLOGIQUE<\/option><\/select><\/div><\/div><div id=\"date-10\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-10-picker_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-date-10-picker_69fb3cc5c2334-label\">Date<\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-10-picker_69fb3cc5c2334\"><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_69fb3cc5c2334\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/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=\"select-31\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-31_69fb3cc5c2334\" id=\"forminator-form-477__field--select-31_69fb3cc5c2334-label\" class=\"forminator-label\">SINISTRE N\u00b04<\/label><select id=\"forminator-form-477__field--select-31_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-31\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-31_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-31_69fb3cc5c2334-description\"><option value=\"degats-des-eaux\"  data-calculation=\"0\">DEGATS DES EAUX<\/option><option value=\"bris-de-glace\"  data-calculation=\"0\">BRIS DE GLACE<\/option><option value=\"vol\"  data-calculation=\"0\">VOL<\/option><option value=\"vandalisme\"  data-calculation=\"0\">VANDALISME<\/option><option value=\"incendie\"  data-calculation=\"0\">INCENDIE<\/option><option value=\"catastrophe-naturelle-inondations\"  data-calculation=\"0\">CATASTROPHE NATURELLE \/ INONDATIONS<\/option><option value=\"catastrophe-technologique\"  data-calculation=\"0\">CATASTROPHE TECHNOLOGIQUE<\/option><\/select><\/div><\/div><div id=\"date-11\" class=\"forminator-field-date forminator-col forminator-col-6 \"><label for=\"forminator-field-date-11\" class=\"forminator-label\">Date<\/label><div class=\"forminator-date-input\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-11-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-11-month_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-date-11-month_69fb3cc5c2334-label\">Mois<\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-11-month\" value=\"\" placeholder=\"\" id=\"forminator-field-date-11-month_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"month\" data-format=\"mm\/dd\/yy\" data-parent=\"date-11\" aria-describedby=\"forminator-field-date-11_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-11-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-11-day_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-date-11-day_69fb3cc5c2334-label\">Jour<\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-11-day\" value=\"\" placeholder=\"\" id=\"forminator-field-date-11-day_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"day\" data-format=\"mm\/dd\/yy\" data-parent=\"date-11\" aria-describedby=\"forminator-field-date-11_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-11-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-11-year_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-date-11-year_69fb3cc5c2334-label\">Ann\u00e9e<\/label><input type=\"number\" min=\"1\" name=\"date-11-year\" placeholder=\"\" id=\"forminator-field-date-11-year_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"mm\/dd\/yy\" data-parent=\"date-11\" aria-describedby=\"forminator-field-date-11_69fb3cc5c2334-description\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-32\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-32_69fb3cc5c2334\" id=\"forminator-form-477__field--select-32_69fb3cc5c2334-label\" class=\"forminator-label\">SINISTRE N\u00b05<\/label><select id=\"forminator-form-477__field--select-32_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-32\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-32_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-32_69fb3cc5c2334-description\"><option value=\"degats-des-eaux\"  data-calculation=\"0\">DEGATS DES EAUX<\/option><option value=\"bris-de-glace\"  data-calculation=\"0\">BRIS DE GLACE<\/option><option value=\"vol\"  data-calculation=\"0\">VOL<\/option><option value=\"vandalisme\"  data-calculation=\"0\">VANDALISME<\/option><option value=\"incendie\"  data-calculation=\"0\">INCENDIE<\/option><option value=\"catastrophe-naturelle-inondations\"  data-calculation=\"0\">CATASTROPHE NATURELLE \/ INONDATIONS<\/option><option value=\"catastrophe-technologique\"  data-calculation=\"0\">CATASTROPHE TECHNOLOGIQUE<\/option><\/select><\/div><\/div><div id=\"date-12\" class=\"forminator-field-date forminator-col forminator-col-6 \"><label for=\"forminator-field-date-12\" class=\"forminator-label\">Date<\/label><div class=\"forminator-date-input\"><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"date-12-month\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-12-month_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-date-12-month_69fb3cc5c2334-label\">Mois<\/label><input type=\"number\" min=\"1\" max=\"12\" name=\"date-12-month\" value=\"\" placeholder=\"\" id=\"forminator-field-date-12-month_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"month\" data-format=\"mm\/dd\/yy\" data-parent=\"date-12\" aria-describedby=\"forminator-field-date-12_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-12-day\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-12-day_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-date-12-day_69fb3cc5c2334-label\">Jour<\/label><input type=\"number\" min=\"1\" max=\"31\" name=\"date-12-day\" value=\"\" placeholder=\"\" id=\"forminator-field-date-12-day_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"day\" data-format=\"mm\/dd\/yy\" data-parent=\"date-12\" aria-describedby=\"forminator-field-date-12_69fb3cc5c2334-description\" \/><\/div><\/div><div id=\"date-12-year\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-date-12-year_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-date-12-year_69fb3cc5c2334-label\">Ann\u00e9e<\/label><input type=\"number\" min=\"1\" name=\"date-12-year\" placeholder=\"\" id=\"forminator-field-date-12-year_69fb3cc5c2334\" class=\"forminator-input\" data-field=\"year\" value=\"\" data-format=\"mm\/dd\/yy\" data-parent=\"date-12\" aria-describedby=\"forminator-field-date-12_69fb3cc5c2334-description\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"select-33\" class=\"forminator-field-select forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-form-477__field--select-33_69fb3cc5c2334\" id=\"forminator-form-477__field--select-33_69fb3cc5c2334-label\" class=\"forminator-label\">SINISTRE N\u00b06<\/label><select id=\"forminator-form-477__field--select-33_69fb3cc5c2334\" class=\"forminator-select--field forminator-select2\" data-required=\"\" name=\"select-33\" data-default-value=\"\" data-placeholder=\"\" data-search=\"false\" aria-labelledby=\"forminator-form-477__field--select-33_69fb3cc5c2334-label\" aria-describedby=\"forminator-form-477__field--select-33_69fb3cc5c2334-description\"><option value=\"degats-des-eaux\"  data-calculation=\"0\">DEGATS DES EAUX<\/option><option value=\"bris-de-glace\"  data-calculation=\"0\">BRIS DE GLACE<\/option><option value=\"vol\"  data-calculation=\"0\">VOL<\/option><option value=\"vandalisme\"  data-calculation=\"0\">VANDALISME<\/option><option value=\"incendie\"  data-calculation=\"0\">INCENDIE<\/option><option value=\"catastrophe-naturelle-inondations\"  data-calculation=\"0\">CATASTROPHE NATURELLE \/ INONDATIONS<\/option><option value=\"catastrophe-technologique\"  data-calculation=\"0\">CATASTROPHE TECHNOLOGIQUE<\/option><\/select><\/div><\/div><div id=\"date-13\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-13-picker_69fb3cc5c2334\" class=\"forminator-label\" id=\"forminator-field-date-13-picker_69fb3cc5c2334-label\">Date<\/label><div class=\"forminator-input-with-icon\"><label for=\"forminator-field-date-13-picker_69fb3cc5c2334\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><\/label><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-13\" value=\"\" placeholder=\"\" id=\"forminator-field-date-13-picker_69fb3cc5c2334\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"mm\/dd\/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=\"upload-1\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-1_69fb3cc5c2334\" class=\"forminator-label\">Vous souhaitez nous transmettre un document ? T\u00e9l\u00e9chargez-le<\/label><div class=\"forminator-file-upload \" data-element=\"upload-1_69fb3cc5c2334\" aria-describedby=\"forminator-field-upload-1_69fb3cc5c2334-description\"><input type=\"file\" name=\"upload-1\" id=\"forminator-field-upload-1_69fb3cc5c2334\" 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_69fb3cc5c2334_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-1_69fb3cc5c2334\">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\">Envoyer demande de devis<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"90e139781d\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F2573\" \/><input type=\"hidden\" name=\"form_id\" value=\"477\"><input type=\"hidden\" name=\"page_id\" value=\"2573\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/aca-pl.com\/?page_id=2573\"><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 class=\"has-background\" style=\"background-color:#f1e830\"><strong>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.<\/strong><\/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\u2019objectif de ce questionnaire est d\u2019obtenir 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\u2019envoi. Des documents compl\u00e9mentaires &hellip; <a href=\"https:\/\/aca-pl.com\/?page_id=2573\" class=\"more-link\">Continuer la lecture de <span class=\"screen-reader-text\">MULTIRISQUE HABITATION<\/span>  <span class=\"meta-nav\">&rarr;<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"_themeisle_gutenberg_block_has_review":false,"footnotes":""},"class_list":["post-2573","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v24.9 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>MULTIRISQUE HABITATION -<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/aca-pl.com\/?page_id=2573\" \/>\n<meta property=\"og:locale\" content=\"fr_FR\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"MULTIRISQUE HABITATION -\" \/>\n<meta property=\"og:description\" content=\"L\u2019objectif de ce questionnaire est d\u2019obtenir 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\u2019envoi. 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