{"id":5133,"date":"2022-10-03T10:50:33","date_gmt":"2022-10-03T08:50:33","guid":{"rendered":"http:\/\/select-assur.com\/?page_id=5133"},"modified":"2022-10-26T17:23:43","modified_gmt":"2022-10-26T15:23:43","slug":"formulaire-assurances-auto-2-roues","status":"publish","type":"page","link":"https:\/\/select-assur.com\/formulaire-assurances-auto-2-roues\/","title":{"rendered":"Formulaire Assurances Auto &#038; 2 Roues"},"content":{"rendered":"\t\t<div data-custom_css-type=\"wp-page\" data-custom_css-id=\"5133\" class=\"custom_css custom_css-5133\">\n\t\t\t\t\t\t\t        <section class=\"custom_css-section custom_css-top-section custom_css-element custom_css-element-c8356a6 custom_css-section-boxed custom_css-section-height-default custom_css-section-height-default ct-header-fixed-none ct-row-max-none\" data-id=\"c8356a6\" data-element_type=\"section\">\n            \n                        <div class=\"custom_css-container custom_css-column-gap-default \">\n                    <div class=\"custom_css-column custom_css-col-100 custom_css-top-column custom_css-element custom_css-element-1769643\" data-id=\"1769643\" data-element_type=\"column\">\n            <div class=\"custom_css-widget-wrap custom_css-element-populated\">\n                        \t\t<div class=\"custom_css-element custom_css-element-59836d6 custom_css-widget custom_css-widget-shortcode\" data-id=\"59836d6\" data-element_type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"custom_css-widget-container\">\n\t\t\t\t\t<div class=\"custom_css-shortcode\"><div class='fluentform fluentform_wrapper_9'><form data-form_id=\"9\" id=\"fluentform_9\" class=\"frm-fluent-form fluent_form_9 ff-el-form-top ff_form_instance_9_1 ff-form-loading ff-form-has-steps ff_has_v3_recptcha\" data-form_instance=\"ff_form_instance_9_1\" method=\"POST\" data-recptcha_key=\"6Lc4KhIsAAAAAG0v28JTBkOOnC5YJJ-iu5pLEL-_\" ><fieldset style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;\n                                 box-shadow: none!important;outline: none!important;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;\">Assurances Auto & 2 Roues<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='5133' \/><input type=\"hidden\" id=\"_fluentform_9_fluentformnonce\" name=\"_fluentform_9_fluentformnonce\" value=\"88afb416cc\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/php_api\/wp\/v2\/pages\/5133\" \/><div class='ff-step-container' class=\"Assurances Auto &amp; 2 Roues\" data-name=\"step_start-9_2\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"no\" data-enable_step_page_resume=\"no\" ><div class='ff-step-header'><div class='ff-el-progress-status'><\/div>\n            <div class='ff-el-progress'>\n                <div class='ff-el-progress-bar'><span><\/span><\/div>\n            <\/div>\n            <ul style='display: none' class='ff-el-progress-title'>\n                <li>Conducteur<\/li><li>V\u00e9hicule<\/li>\n            <\/ul><\/div><span class='ff_step_start'><\/span><div class='ff-step-body'><div class=\"Assurances Auto &amp; 2 Roues fluentform-step active\" data-name=\"step_start-9_2\" data-disable_auto_focus=\"no\" data-enable_auto_slider=\"no\" data-enable_step_data_persistency=\"no\" data-enable_step_page_resume=\"no\" ><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_dropdown_3' aria-label=\"R\u00e9siliation Loi Hamon\">R\u00e9siliation Loi Hamon<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown_3\" id=\"ff_9_dropdown_3\" class=\"ff-el-form-control\" data-name=\"dropdown_3\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"Oui\"  >Oui<\/option><option value=\"Non\"  >Non<\/option><\/select><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_input_text_6' aria-label=\"Nom de l&#039;assureur\">Nom de l'assureur<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_6\" class=\"ff-el-form-control\" data-name=\"input_text_6\" id=\"ff_9_input_text_6\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_input_text_7' aria-label=\"Num\u00e9ro de contrat\">Num\u00e9ro de contrat<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_7\" class=\"ff-el-form-control\" data-name=\"input_text_7\" id=\"ff_9_input_text_7\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_input_text_8' aria-label=\"Adresse de l&#039;assureur\">Adresse de l'assureur<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_8\" class=\"ff-el-form-control\" data-name=\"input_text_8\" id=\"ff_9_input_text_8\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_9_input_text_9' aria-label=\"Compl\u00e9ment d&#039;adresse\">Compl\u00e9ment d'adresse<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_9\" class=\"ff-el-form-control\" data-name=\"input_text_9\" id=\"ff_9_input_text_9\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_input_text_10' aria-label=\"Code postal\">Code postal<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_10\" class=\"ff-el-form-control\" data-name=\"input_text_10\" id=\"ff_9_input_text_10\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_input_text_11' aria-label=\"Ville\">Ville<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_11\" class=\"ff-el-form-control\" data-name=\"input_text_11\" id=\"ff_9_input_text_11\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group  ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Civilit\u00e9\">Civilit\u00e9<\/label> <\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_2b5324e5036000768871800ca6bb0017><input type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Monsieur\"  id='input_radio_2b5324e5036000768871800ca6bb0017' aria-label='Monsieur' aria-invalid='false' aria-required=true> <span>Monsieur<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_56e6b4be16d945fcace18bfb8e1b668d><input type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Madame\"  id='input_radio_56e6b4be16d945fcace18bfb8e1b668d' aria-label='Madame' aria-invalid='false' aria-required=true> <span>Madame<\/span><\/label><\/div><\/div><\/div><div data-type=\"name-element\" data-name=\"names_1\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_names_1_first_name_' aria-label=\"Nom\">Nom<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_1[first_name]\" id=\"ff_9_names_1_first_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell '><div class='ff-el-group  ff-el-form-top'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_names_1_last_name_' aria-label=\"Pr\u00e9nom\">Pr\u00e9nom<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names_1[last_name]\" id=\"ff_9_names_1_last_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><div class=\"ff-name-address-wrapper fluent-address\" data-type=\"address-element\" data-name=\"address_1\" ><div class='ff-el-input--content'><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_address_1_address_line_1_' aria-label=\"Adresse\">Adresse<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[address_line_1]\" id=\"ff_9_address_1_address_line_1_\" class=\"ff-el-form-control\" placeholder=\"Adresse\" data-key_name=\"address_line_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_address_1_zip_' aria-label=\"Code postal\">Code postal<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[zip]\" id=\"ff_9_address_1_zip_\" class=\"ff-el-form-control\" placeholder=\"Code Postal\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div class='ff-t-container'><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_address_1_city_' aria-label=\"Ville\">Ville<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[city]\" id=\"ff_9_address_1_city_\" class=\"ff-el-form-control\" placeholder=\"Ville\" data-key_name=\"city\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_address_1_country_' aria-label=\"Pays\">Pays<\/label> <\/div><div class='ff-el-input--content'><select name=\"address_1[country]\" id=\"ff_9_address_1_country_\" class=\"ff-el-form-control\" placeholder=\"S\u00e9lectionnez un pays\" data-key_name=\"country\" aria-invalid='false' aria-required=true><option value=''>S\u00e9lectionnez un pays<\/option><option value='AF' >Afghanistan<\/option><option value='ZA' >Afrique du Sud<\/option><option value='AL' >Albanie<\/option><option value='DZ' >Alg\u00e9rie<\/option><option value='DE' >Allemagne<\/option><option value='AS' >American Samoa<\/option><option value='AD' >Andorre<\/option><option value='AO' >Angola<\/option><option value='AI' >Anguilla<\/option><option value='AQ' >Antarctique<\/option><option value='AG' >Antigua-et-Barbuda<\/option><option value='SA' >Arabie Saoudite<\/option><option value='AR' >Argentine<\/option><option value='AM' >Arm\u00e9nie<\/option><option value='AW' >Aruba<\/option><option value='AU' >Australie<\/option><option value='AT' >Autriche<\/option><option value='AZ' >Azerbaijan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahrain<\/option><option value='BD' >Bangladesh<\/option><option value='BB' >Barbades<\/option><option value='PW' >Belau<\/option><option value='BE' >Belgique<\/option><option value='BZ' >Belize<\/option><option value='BJ' >Benin<\/option><option value='BM' >Bermudes<\/option><option value='BT' >Bhutan<\/option><option value='BY' >Bi\u00e9lorussie<\/option><option value='BO' >Bolivie<\/option><option value='BA' >Bosnie-Herz\u00e9govine<\/option><option value='BW' >Botswana<\/option><option value='BN' >Brunei<\/option><option value='BR' >Br\u00e9sil<\/option><option value='BG' >Bulgarie<\/option><option value='BF' >Burkina Faso<\/option><option value='BI' >Burundi<\/option><option value='KH' >Cambodge<\/option><option value='CM' >Cameroun<\/option><option value='CA' >Canada<\/option><option value='CV' >Cap Vert<\/option><option value='CL' >Chili<\/option><option value='CN' >Chine<\/option><option value='CX' >Christmas Island<\/option><option value='CY' >Chypre<\/option><option value='CO' >Colombie<\/option><option value='KM' >Comores<\/option><option value='CG' >Congo (Brazzaville)<\/option><option value='CD' >Congo (Kinshasa)<\/option><option value='KP' >Cor\u00e9e du Nord<\/option><option value='KR' >Cor\u00e9e du Sud<\/option><option value='CR' >Costa Rica<\/option><option value='HR' >Croatie<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='CI' >C\u00f4te-d\u2019Ivoire<\/option><option value='DK' >Danemark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominique<\/option><option value='ER' >Erythr\u00e9e<\/option><option value='ES' >Espagne<\/option><option value='EE' >Estonie<\/option><option value='US' >Etats-Unis (USA)<\/option><option value='FJ' >Fidji<\/option><option value='FI' >Finlande<\/option><option value='FR' selected>France<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambie<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GD' >Grenade<\/option><option value='GL' >Groenland<\/option><option value='GR' >Gr\u00e8ce<\/option><option value='GP' >Guadeloupe<\/option><option value='GU' >Guam<\/option><option value='GT' >Guatemala<\/option><option value='GG' >Guernesey<\/option><option value='GN' >Guin\u00e9e<\/option><option value='GQ' >Guin\u00e9e \u00e9quatoriale<\/option><option value='GW' >Guin\u00e9e-Bissau<\/option><option value='GY' >Guyane<\/option><option value='GF' >Guyane Fran\u00e7aise<\/option><option value='GE' >G\u00e9orgie<\/option><option value='GS' >G\u00e9orgie du Sud \/ \u00eeles Sandwich<\/option><option value='HT' >Ha\u00efti<\/option><option value='HN' >Honduras<\/option><option value='HK' >Hong Kong<\/option><option value='HU' >Hongrie<\/option><option value='IN' >Inde<\/option><option value='ID' >Indon\u00e9sie<\/option><option value='IR' >Iran<\/option><option value='IQ' >Iraq<\/option><option value='IE' >Irlande<\/option><option value='IS' >Islande<\/option><option value='IL' >Isra\u00ebl<\/option><option value='IT' >Italie<\/option><option value='JM' >Jama\u00efque<\/option><option value='JP' >Japon<\/option><option value='JE' >Jersey<\/option><option value='JO' >Jordanie<\/option><option value='KZ' >Kazakhstan<\/option><option value='KE' >Kenya<\/option><option value='KI' >Kiribati<\/option><option value='XK' >Kosovo<\/option><option value='KW' >Kowe\u00eft<\/option><option value='KG' >Kyrgyzstan<\/option><option value='RE' >La R\u00e9union<\/option><option value='LA' >Laos<\/option><option value='LS' >Lesotho<\/option><option value='LV' >Lettonie<\/option><option value='LB' >Liban<\/option><option value='LR' >Liberia<\/option><option value='LY' >Libye<\/option><option value='LI' >Liechtenstein<\/option><option value='LT' >Lituanie<\/option><option value='LU' >Luxembourg<\/option><option value='MO' >Macao S.A.R., Chine<\/option><option value='MK' >Mac\u00e9doine<\/option><option value='MG' >Madagascar<\/option><option value='MY' >Malaisie<\/option><option value='MW' >Malawi<\/option><option value='MV' >Maldives<\/option><option value='ML' >Mali<\/option><option value='MT' >Malte<\/option><option value='MA' >Maroc<\/option><option value='MQ' >Martinique<\/option><option value='MU' >Maurice<\/option><option value='MR' >Mauritanie<\/option><option value='YT' >Mayotte<\/option><option value='MX' >Mexique<\/option><option value='FM' >Micron\u00e9sie<\/option><option value='MD' >Moldavie<\/option><option value='MC' >Monaco<\/option><option value='MN' >Mongolie<\/option><option value='ME' >Montenegro<\/option><option value='MS' >Montserrat<\/option><option value='MZ' >Mozambique<\/option><option value='MM' >Myanmar<\/option><option value='NA' >Namibie<\/option><option value='NR' >Nauru<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nigeria<\/option><option value='NU' >Niue<\/option><option value='MP' >Northern Mariana Islands<\/option><option value='NO' >Norv\u00e8ge<\/option><option value='NC' >Nouvelle-Cal\u00e9donie<\/option><option value='NZ' >Nouvelle-Z\u00e9lande<\/option><option value='NP' >N\u00e9pal<\/option><option value='OM' >Oman<\/option><option value='PK' >Pakistan<\/option><option value='PA' >Panama<\/option><option value='PG' >Papouasie-Nouvelle-Guin\u00e9e<\/option><option value='PY' >Paraguay<\/option><option value='NL' >Pays-Bas<\/option><option value='PH' >Philippines<\/option><option value='PN' >Pitcairn<\/option><option value='PL' >Pologne<\/option><option value='PF' >Polyn\u00e9sie Fran\u00e7aise<\/option><option value='PT' >Portugal<\/option><option value='PR' >Puerto Rico<\/option><option value='PE' >P\u00e9rou<\/option><option value='QA' >Qatar<\/option><option value='RO' >Roumanie<\/option><option value='GB' >Royaume-Uni (UK)<\/option><option value='RU' >Russie<\/option><option value='RW' >Rwanda<\/option><option value='CF' >R\u00e9publique Centrafricaine<\/option><option value='DO' >R\u00e9publique Dominicaine<\/option><option value='CZ' >R\u00e9publique Tch\u00e8que<\/option><option value='BQ' >Saba, Saint-Eustache et Bonaire<\/option><option value='EH' >Sahara occidental<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='PM' >Saint Pierre et Miquelon<\/option><option value='KN' >Saint-Kitts-et-Nevis<\/option><option value='MF' >Saint-Martin (partie fran\u00e7aise)<\/option><option value='SX' >Saint-Martin (partie n\u00e9erlandaise)<\/option><option value='VC' >Saint-Vincent-et-les-Grenadines<\/option><option value='SH' >Sainte-H\u00e9l\u00e8ne<\/option><option value='LC' >Sainte-Lucie<\/option><option value='SV' >Salvador<\/option><option value='WS' >Samoa<\/option><option value='SM' >San Marino<\/option><option value='ST' >Sao Tom\u00e9-et-Principe<\/option><option value='RS' >Serbie<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapour<\/option><option value='SK' >Slovaquie<\/option><option value='SI' >Slov\u00e9nie<\/option><option value='SO' >Somalie<\/option><option value='SD' >Soudan<\/option><option value='SS' >Soudan du Sud<\/option><option value='LK' >Sri Lanka<\/option><option value='CH' >Suisse<\/option><option value='SR' >Suriname<\/option><option value='SE' >Su\u00e8de<\/option><option value='SJ' >Svalbard et Jan Mayen<\/option><option value='SZ' >Swaziland<\/option><option value='SY' >Syrie<\/option><option value='SN' >S\u00e9n\u00e9gal<\/option><option value='TW' >Taiwan<\/option><option value='TJ' >Tajikistan<\/option><option value='TZ' >Tanzanie<\/option><option value='TD' >Tchad<\/option><option value='TF' >Terres Australes Fran\u00e7aises<\/option><option value='PS' >Territoire Palestinien<\/option><option value='IO' >Territoire britannique de l&rsquo;oc\u00e9an Indien<\/option><option value='TH' >Thailande<\/option><option value='TL' >Timor-Leste<\/option><option value='TG' >Togo<\/option><option value='TK' >Tokelau<\/option><option value='TO' >Tonga<\/option><option value='TT' >Trinit\u00e9-et-Tobago<\/option><option value='TN' >Tunisie<\/option><option value='TM' >Turkm\u00e9nistan<\/option><option value='TR' >Turquie<\/option><option value='TV' >Tuvalu<\/option><option value='UG' >Uganda<\/option><option value='UA' >Ukraine<\/option><option value='UY' >Uruguay<\/option><option value='UZ' >Uzbekistan<\/option><option value='VU' >Vanuatu<\/option><option value='VA' >Vatican<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis et Futuna<\/option><option value='YE' >Yemen<\/option><option value='ZM' >Zambie<\/option><option value='ZW' >Zimbabwe<\/option><option value='EG' >\u00c9gypte<\/option><option value='AE' >\u00c9mirats Arabes Unis<\/option><option value='EC' >\u00c9quateur<\/option><option value='ET' >\u00c9thiopie<\/option><option value='BV' >\u00cele Bouvet<\/option><option value='NF' >\u00cele Norfolk<\/option><option value='IM' >\u00cele de Man<\/option><option value='AX' >\u00celes Aland<\/option><option value='KY' >\u00celes Ca\u00efmans<\/option><option value='CC' >\u00celes Cocos<\/option><option value='CK' >\u00celes Cook<\/option><option value='FK' >\u00celes Falkland<\/option><option value='FO' >\u00celes F\u00e9ro\u00e9<\/option><option value='HM' >\u00celes Heard-et-MacDonald<\/option><option value='MH' >\u00celes Marshall<\/option><option value='UM' >\u00celes Mineures \u00e9loign\u00e9es des \u00c9tats-Unis<\/option><option value='SB' >\u00celes Salomon<\/option><option value='TC' >\u00celes Turques et Ca\u00efques<\/option><option value='VI' >\u00celes Vierges am\u00e9ricaines (US)<\/option><option value='VG' >\u00celes Vierges britanniques<\/option><\/select><\/div><\/div><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_1\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_email_1' aria-label=\"E-mail\">E-mail<\/label> <\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email_1\" id=\"ff_9_email_1\" class=\"ff-el-form-control\" data-name=\"email_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_phone_2' aria-label=\"T\u00e9l\u00e9phone\">T\u00e9l\u00e9phone<\/label> <\/div><div class='ff-el-input--content'><input name=\"phone_2\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" data-name=\"phone_2\" id=\"ff_9_phone_2\" inputmode=\"tel\" ><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_2\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_input_text_15' aria-label=\"Date de naissance\">Date de naissance<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_15\" value=\"09\/04\/2026\" class=\"ff-el-form-control\" maxlength=\"10\" data-name=\"input_text_15\" id=\"ff_9_input_text_15\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_input_text_16' aria-label=\"Date d&#039;obtention du permis\">Date d'obtention du permis<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_16\" value=\"09\/04\/2026\" class=\"ff-el-form-control\" maxlength=\"10\" data-name=\"input_text_16\" id=\"ff_9_input_text_16\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_3\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_dropdown' aria-label=\"Type de permis\">Type de permis<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown\" id=\"ff_9_dropdown\" class=\"ff-el-form-control\" data-name=\"dropdown\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"Permis B\"  >Permis B<\/option><option value=\"Permis B avec conduite accompagn\u00e9e\"  >Permis B avec conduite accompagn\u00e9e<\/option><option value=\"Permis \u00e9tranger UE\"  >Permis \u00e9tranger UE<\/option><option value=\"Permis \u00e9tranger hors UE\"  >Permis \u00e9tranger hors UE<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_input_text' aria-label=\"N\u00b0 de permis de conduire\">N\u00b0 de permis de conduire<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_9_input_text\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_4\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_dropdown_12' aria-label=\"Situation familiale\">Situation familiale<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown_12\" id=\"ff_9_dropdown_12\" class=\"ff-el-form-control\" data-name=\"dropdown_12\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"C\u00e9libataire\"  >C\u00e9libataire<\/option><option value=\"Mari\u00e9\"  >Mari\u00e9<\/option><option value=\"Concubinage\"  >Concubinage<\/option><option value=\"Pacs\u00e9\"  >Pacs\u00e9<\/option><option value=\"S\u00e9par\u00e9\"  >S\u00e9par\u00e9<\/option><option value=\"Divorc\u00e9\"  >Divorc\u00e9<\/option><option value=\"Veuf\"  >Veuf<\/option><\/select><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_dropdown_13' aria-label=\"Profession\">Profession<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown_13\" id=\"ff_9_dropdown_13\" class=\"ff-el-form-control\" data-name=\"dropdown_13\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"Salari\u00e9 non cadre\"  >Salari\u00e9 non cadre<\/option><option value=\"Salari\u00e9 cadre\"  >Salari\u00e9 cadre<\/option><option value=\"Etudiant\"  >Etudiant<\/option><option value=\"Fonctionnaire\t\"  >Fonctionnaire<\/option><option value=\"Recherche d&#039;emploi\"  >Recherche d'emploi<\/option><option value=\"Retrait\u00e9\"  >Retrait\u00e9<\/option><option value=\"Sans profession\"  >Sans profession<\/option><option value=\"Chef d&#039;entreprise\"  >Chef d'entreprise<\/option><option value=\"Profession lib\u00e9rale\"  >Profession lib\u00e9rale<\/option><option value=\"Artisan\"  >Artisan<\/option><option value=\"Enseignant\"  >Enseignant<\/option><option value=\"Commer\u00e7ant\"  >Commer\u00e7ant<\/option><option value=\"Agriculteur\"  >Agriculteur<\/option><option value=\"Soci\u00e9t\u00e9\"  >Soci\u00e9t\u00e9<\/option><option value=\"Autre\"  >Autre<\/option><\/select><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_numeric-field_2' aria-label=\"Nombre d&#039;enfants\">Nombre d'enfants<\/label> <\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_2\" id=\"ff_9_numeric-field_2\" class=\"ff-el-form-control\" data-name=\"numeric-field_2\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_dropdown_14' aria-label=\"Suspension ou annulation de permis\">Suspension ou annulation de permis<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown_14\" id=\"ff_9_dropdown_14\" class=\"ff-el-form-control\" data-name=\"dropdown_14\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"Non\"  >Non<\/option><option value=\"Suspendu\"  >Suspendu<\/option><option value=\"Annul\u00e9\"  >Annul\u00e9<\/option><\/select><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_dropdown_15' aria-label=\"La sanction a eu lieu\">La sanction a eu lieu<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown_15\" id=\"ff_9_dropdown_15\" class=\"ff-el-form-control\" data-name=\"dropdown_15\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"Moins de 5 ans\"  >Moins de 5 ans<\/option><option value=\"Plus de 5 ans\"  >Plus de 5 ans<\/option><\/select><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_dropdown_16' aria-label=\"Raison de la sanction\">Raison de la sanction<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown_16\" id=\"ff_9_dropdown_16\" class=\"ff-el-form-control\" data-name=\"dropdown_16\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"Non\"  >Non<\/option><option value=\"Alcool\u00e9mie\"  >Alcool\u00e9mie<\/option><option value=\"Alcool\u00e9mie et grand exc\u00e8s de vitesse\"  >Alcool\u00e9mie et grand exc\u00e8s de vitesse<\/option><option value=\"Alcool\u00e9mie et petit exc\u00e8s de vitesse\"  >Alcool\u00e9mie et petit exc\u00e8s de vitesse<\/option><option value=\"Alcool\u00e9mie et sinistre\"  >Alcool\u00e9mie et sinistre<\/option><option value=\"Alcool\u00e9mie et sinistre et exc\u00e8s de vitesse\"  >Alcool\u00e9mie et sinistre et exc\u00e8s de vitesse<\/option><option value=\"Autre\"  >Autre<\/option><option value=\"D\u00e9faut d&#039;assurance\"  >D\u00e9faut d'assurance<\/option><option value=\"D\u00e9lit de fuite\"  >D\u00e9lit de fuite<\/option><option value=\"Stup\u00e9fiant\"  >Stup\u00e9fiant<\/option><option value=\"Stup\u00e9fiant et grand exc\u00e8s de vitesse\"  >Stup\u00e9fiant et grand exc\u00e8s de vitesse<\/option><option value=\"Stup\u00e9fiant et petit exc\u00e8s de vitesse\"  >Stup\u00e9fiant et petit exc\u00e8s de vitesse<\/option><option value=\"Stup\u00e9fiant et sinistre\"  >Stup\u00e9fiant et sinistre<\/option><option value=\"Stup\u00e9fiant et sinistre et exc\u00e8s de vitesse\"  >Stup\u00e9fiant et sinistre et exc\u00e8s de vitesse<\/option><option value=\"R\u00e9sistance \u00e0 l&#039;ordre public\"  >R\u00e9sistance \u00e0 l'ordre public<\/option><option value=\"Refus d&#039;obtemp\u00e9rer\"  >Refus d'obtemp\u00e9rer<\/option><option value=\"Retrait total de points de permis\"  >Retrait total de points de permis<\/option><option value=\"Petit exc\u00e8s de vitesse\"  >Petit exc\u00e8s de vitesse<\/option><option value=\"Grand exc\u00e8s de vitesse\"  >Grand exc\u00e8s de vitesse<\/option><\/select><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_dropdown_17' aria-label=\"Dur\u00e9e de la suspension\">Dur\u00e9e de la suspension<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown_17\" id=\"ff_9_dropdown_17\" class=\"ff-el-form-control\" data-name=\"dropdown_17\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"Aucune\"  >Aucune<\/option><option value=\"De 1 \u00e0 3 mois\"  >De 1 \u00e0 3 mois<\/option><option value=\"De 4 \u00e0 6 mois\"  >De 4 \u00e0 6 mois<\/option><option value=\"De 7 \u00e0 12 mois\"  >De 7 \u00e0 12 mois<\/option><option value=\"De 13 \u00e0 24 mois\"  >De 13 \u00e0 24 mois<\/option><option value=\"Plus de 24 mois\"  >Plus de 24 mois<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_dropdown_18' aria-label=\"Avez-vous eu des sinistres au cours des 60 derniers mois\">Avez-vous eu des sinistres au cours des 60 derniers mois<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown_18\" id=\"ff_9_dropdown_18\" class=\"ff-el-form-control\" data-name=\"dropdown_18\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"Oui \"  >Oui<\/option><option value=\"Non\"  >Non<\/option><\/select><\/div><\/div>        <div data-type=\"repeater_field\" data-name=\"repeater_field\" class=\"ff-el-group ff-el-repeater js-repeater has-conditions\" data-root_name=\"repeater_field\"  >\n            <div class='ff-el-input--label asterisk-right'><label aria-label='Pr\u00e9cisez :' for=''>Pr\u00e9cisez :<\/label><\/div>            <div class='ff-el-input--content'>\n                <table data-max_repeat=\"\" data-root_name=\"repeater_field\" class=\"ff_repeater_table ff_flexible_table\">\n                    <thead>\n                    <tr>\n                                                    <th><div class='ff-el-input--label ff-el-is-required asterisk-right'><label aria-label='Date du sinistre' for=''>Date du sinistre<\/label><\/div><\/th>\n                                                    <th><div class='ff-el-input--label ff-el-is-required asterisk-right'><label aria-label='Type du sinistre' for=''>Type du sinistre<\/label><\/div><\/th>\n                                                    <th><div class='ff-el-input--label ff-el-is-required asterisk-right'><label aria-label='Nature du sinistre' for=''>Nature du sinistre<\/label><\/div><\/th>\n                                                    <th><div class='ff-el-input--label ff-el-is-required asterisk-right'><label aria-label='Responsabilit\u00e9 du sinistre' for=''>Responsabilit\u00e9 du sinistre<\/label><\/div><\/th>\n                                                <th><\/th>\n                    <\/tr>\n                    <\/thead>\n                    <tbody>\n                    <tr>\n                                                    <td data-label=\"Date du sinistre\">\n                                                                <div class='ff-el-group'><div class='ff-el-input--content'><input type=\"text\" value=\"09\/04\/2026\" name=\"repeater_field[0][]\" id=\"ff_9_repeater_field_0\" data-repeater_index=\"0\" data-type=\"repeater_item\" data-name=\"repeater_field_0_0\" data-error_index=\"repeater_field[0]\" class=\"ff-el-form-control\"  aria-invalid=\"false\" aria-required=true><\/div><\/div>                            <\/td>\n                                                    <td data-label=\"Type du sinistre\">\n                                                                <div class='ff-el-group'><div class='ff-el-input--content'><select type=\"select\" name=\"repeater_field[0][]\" id=\"ff_9_repeater_field_1\" data-repeater_index=\"1\" data-type=\"repeater_item\" data-name=\"repeater_field_1_0\" data-error_index=\"repeater_field[1]\" data-calc_value=\"0\" class=\"ff-el-form-control\"  aria-invalid=\"false\" aria-required=true><option value=\"Collision\"  >Collision<\/option><option value=\"Bris de glace\"  >Bris de glace<\/option><option value=\"Vol\"  >Vol<\/option><option value=\"Stationnement\"  >Stationnement<\/option><option value=\"Incendie\"  >Incendie<\/option><option value=\"Vandalisme\"  >Vandalisme<\/option><option value=\"Ev\u00e9nements naturels\"  >Ev\u00e9nements naturels<\/option><\/select><\/div><\/div>                            <\/td>\n                                                    <td data-label=\"Nature du sinistre\">\n                                                                <div class='ff-el-group'><div class='ff-el-input--content'><select type=\"select\" name=\"repeater_field[0][]\" id=\"ff_9_repeater_field_2\" data-repeater_index=\"2\" data-type=\"repeater_item\" data-name=\"repeater_field_2_0\" data-error_index=\"repeater_field[2]\" data-calc_value=\"0\" class=\"ff-el-form-control\"  aria-invalid=\"false\" aria-required=true><option value=\"Mat\u00e9riel\"  >Mat\u00e9riel<\/option><option value=\"Corporel\"  >Corporel<\/option><\/select><\/div><\/div>                            <\/td>\n                                                    <td data-label=\"Responsabilit\u00e9 du sinistre\">\n                                                                <div class='ff-el-group'><div class='ff-el-input--content'><select type=\"select\" name=\"repeater_field[0][]\" id=\"ff_9_repeater_field_3\" data-repeater_index=\"3\" data-type=\"repeater_item\" data-name=\"repeater_field_3_0\" data-error_index=\"repeater_field[3]\" data-calc_value=\"0\" class=\"ff-el-form-control\"  aria-invalid=\"false\" aria-required=true><option value=\"Non responsable\"  >Non responsable<\/option><option value=\"Partiellement responsable\"  >Partiellement responsable<\/option><option value=\"Responsable\"  >Responsable<\/option><\/select><\/div><\/div>                            <\/td>\n                                                <td class=\"repeat_btn\"><div class=\"ff-el-repeat-buttons-list js-repeat-buttons\"><span class=\"repeat-plus\"><svg width=\"20\" height=\"20\" viewBox=\"0 0 512 512\"><path d=\"m256 48c-115 0-208 93-208 208 0 115 93 208 208 208 115 0 208-93 208-208 0-115-93-208-208-208z m107 229l-86 0 0 86-42 0 0-86-86 0 0-42 86 0 0-86 42 0 0 86 86 0z\"><\/path><\/svg><\/span><span class=\"repeat-minus\"><svg width=\"20\" height=\"20\" viewBox=\"0 0 512 512\"><path d=\"m256 48c-115 0-208 93-208 208 0 115 93 208 208 208 115 0 208-93 208-208 0-115-93-208-208-208z m107 229l-214 0 0-42 214 0z\"\"><\/path><\/svg><\/span><\/div><\/td>\n                    <\/tr>\n                    <\/tbody>\n                <\/table>\n            <\/div>\n        <\/div>\n        <div class='step-nav ff_step_nav_last'><button  type='button' data-action='prev' class='ff-btn ff-btn-prev ff-btn-secondary'>Pr\u00e9c\u00e9dent<\/button><button  type='button' data-action='next' class='ff-float-right ff-btn ff-btn-next ff-btn-secondary'>Suivant<\/button><\/div><\/div><div class=\" fluentform-step\" data-name=\"form_step-9_1\" ><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_input_text_1' aria-label=\"Plaque d&#039;immatriculation du v\u00e9hicule\">Plaque d'immatriculation du v\u00e9hicule<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_9_input_text_1\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_input_text_17' aria-label=\"Date d&#039;achat du v\u00e9hicule\">Date d'achat du v\u00e9hicule<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_17\" value=\"09\/04\/2026\" class=\"ff-el-form-control\" maxlength=\"10\" data-name=\"input_text_17\" id=\"ff_9_input_text_17\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_input_text_14' aria-label=\"Marque du v\u00e9hicule\">Marque du v\u00e9hicule<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_14\" class=\"ff-el-form-control\" data-name=\"input_text_14\" id=\"ff_9_input_text_14\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_input_text_18' aria-label=\"Mod\u00e8le du v\u00e9hicule\">Mod\u00e8le du v\u00e9hicule<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_18\" class=\"ff-el-form-control\" data-name=\"input_text_18\" id=\"ff_9_input_text_18\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_dropdown_6' aria-label=\"Titulaire de la carte grise ?\">Titulaire de la carte grise ?<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown_6\" id=\"ff_9_dropdown_6\" class=\"ff-el-form-control\" data-name=\"dropdown_6\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"Conducteur principal\"  >Conducteur principal<\/option><option value=\"Conjoint ou concubin\"  >Conjoint ou concubin<\/option><option value=\"Conducteur principal ET conjoint ou concubin\"  >Conducteur principal ET conjoint ou concubin<\/option><option value=\"Parents\"  >Parents<\/option><option value=\"Parents du conjoint ou concubin\"  >Parents du conjoint ou concubin<\/option><option value=\"Soci\u00e9t\u00e9\"  >Soci\u00e9t\u00e9<\/option><option value=\"Soci\u00e9t\u00e9 de leasing\"  >Soci\u00e9t\u00e9 de leasing<\/option><option value=\"Enfant\"  >Enfant<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_dropdown_7' aria-label=\"Information sur l&#039;utilisation de votre v\u00e9hicule ?\">Information sur l'utilisation de votre v\u00e9hicule ?<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown_7\" id=\"ff_9_dropdown_7\" class=\"ff-el-form-control\" data-name=\"dropdown_7\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"Priv\u00e9 et trajet travail\"  >Priv\u00e9 et trajet travail<\/option><option value=\"Priv\u00e9\"  >Priv\u00e9<\/option><option value=\"Priv\u00e9 et professionnel\"  >Priv\u00e9 et professionnel<\/option><option value=\"Tous d\u00e9placements\"  >Tous d\u00e9placements<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_dropdown_8' aria-label=\"Stationnement du v\u00e9hicule ?\">Stationnement du v\u00e9hicule ?<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown_8\" id=\"ff_9_dropdown_8\" class=\"ff-el-form-control\" data-name=\"dropdown_8\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"Garage ferm\u00e9\"  >Garage ferm\u00e9<\/option><option value=\"Parking collectif plein air\"  >Parking collectif plein air<\/option><option value=\"Voie publique\"  >Voie publique<\/option><option value=\"Jardin clos priv\u00e9\"  >Jardin clos priv\u00e9<\/option><option value=\"Parking ferm\u00e9 collectif\"  >Parking ferm\u00e9 collectif<\/option><option value=\"Garage public surveill\u00e9\"  >Garage public surveill\u00e9<\/option><\/select><\/div><\/div><div data-name=\"ff_cn_id_5\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_numeric-field' aria-label=\"Code postal\">Code postal<\/label> <\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field\" id=\"ff_9_numeric-field\" class=\"ff-el-form-control\" data-name=\"numeric-field\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_9_input_text_12' aria-label=\"Commune de stationnement la nuit\">Commune de stationnement la nuit<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_12\" class=\"ff-el-form-control\" data-name=\"input_text_12\" id=\"ff_9_input_text_12\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div data-name=\"ff_cn_id_6\"  class='ff-t-container ff-column-container ff_columns_total_2  '><div class='ff-t-cell ff-t-column-1' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_numeric-field_1' aria-label=\"Code postal\">Code postal<\/label> <\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric-field_1\" id=\"ff_9_numeric-field_1\" class=\"ff-el-form-control\" data-name=\"numeric-field_1\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 50%;'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_9_input_text_13' aria-label=\"Commune de votre lieu de travail\">Commune de votre lieu de travail<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_13\" class=\"ff-el-form-control\" data-name=\"input_text_13\" id=\"ff_9_input_text_13\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_dropdown_9' aria-label=\"Financement du v\u00e9hicule ?\">Financement du v\u00e9hicule ?<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown_9\" id=\"ff_9_dropdown_9\" class=\"ff-el-form-control\" data-name=\"dropdown_9\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"Comptant\"  >Comptant<\/option><option value=\"Cr\u00e9dit\"  >Cr\u00e9dit<\/option><option value=\"Leasing\"  >Leasing<\/option><option value=\"Donation\"  >Donation<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_dropdown_10' aria-label=\"Kilom\u00e9trage effectu\u00e9 par an ?\">Kilom\u00e9trage effectu\u00e9 par an ?<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown_10\" id=\"ff_9_dropdown_10\" class=\"ff-el-form-control\" data-name=\"dropdown_10\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"De 0 \u00e0 4999 km\"  >De 0 \u00e0 4999 km<\/option><option value=\"De 5000 \u00e0 7999 km\t\"  >De 5000 \u00e0 7999 km<\/option><option value=\"De 8000 \u00e0 11999 km\"  >De 8000 \u00e0 11999 km<\/option><option value=\"De 12000 \u00e0 15999 km\"  >De 12000 \u00e0 15999 km<\/option><option value=\"De 16000 \u00e0 24999 km\"  >De 16000 \u00e0 24999 km<\/option><option value=\"De 25000 \u00e0 34999 km\"  >De 25000 \u00e0 34999 km<\/option><option value=\"Plus de 35000 km\"  >Plus de 35000 km<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_dropdown_11' aria-label=\"Ce v\u00e9hicule est-il actuellement assur\u00e9 ?\">Ce v\u00e9hicule est-il actuellement assur\u00e9 ?<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown_11\" id=\"ff_9_dropdown_11\" class=\"ff-el-form-control\" data-name=\"dropdown_11\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"Oui\"  >Oui<\/option><option value=\"Non, depuis moins de 8 jours\"  >Non, depuis moins de 8 jours<\/option><option value=\"Non, depuis plus de 8 jours\"  >Non, depuis plus de 8 jours<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_dropdown_19' aria-label=\"Nombre d&#039;ann\u00e9es pendant lesquelles vous avez \u00e9t\u00e9 assur\u00e9\">Nombre d'ann\u00e9es pendant lesquelles vous avez \u00e9t\u00e9 assur\u00e9<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown_19\" id=\"ff_9_dropdown_19\" class=\"ff-el-form-control\" data-name=\"dropdown_19\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"Moins d&#039;un an\"  >Moins d'un an<\/option><option value=\"1 an\"  >1 an<\/option><option value=\"2 ans\"  >2 ans<\/option><option value=\"3 ans\"  >3 ans<\/option><option value=\"4 ans\"  >4 ans<\/option><option value=\"5 ans\"  >5 ans<\/option><option value=\"6 ans\"  >6 ans<\/option><option value=\"7 ans\"  >7 ans<\/option><option value=\"8 ans\"  >8 ans<\/option><option value=\"9 ans\"  >9 ans<\/option><option value=\"10 ans\"  >10 ans<\/option><option value=\"11 ans\"  >11 ans<\/option><option value=\"12 ans\"  >12 ans<\/option><option value=\"13 ans\"  >13 ans<\/option><option value=\"14 ans\"  >14 ans<\/option><option value=\"15 ans\"  >15 ans<\/option><option value=\"16 ans\"  >16 ans<\/option><option value=\"17 ans\"  >17 ans<\/option><option value=\"18 ans\"  >18 ans<\/option><option value=\"19 ans\"  >19 ans<\/option><option value=\"20 ans\"  >20 ans<\/option><option value=\"21 ans\"  >21 ans<\/option><option value=\"22 ans\"  >22 ans<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_dropdown_20' aria-label=\"Bonus\/Malus\">Bonus\/Malus<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown_20\" id=\"ff_9_dropdown_20\" class=\"ff-el-form-control\" data-name=\"dropdown_20\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"50 % bonus \/ coef 0.5\r\"  >50 % bonus \/ coef 0.5<\/option><option value=\"49 % bonus \/ coef 0.51\r\"  >49 % bonus \/ coef 0.51<\/option><option value=\"48 % bonus \/ coef 0.52\r\"  >48 % bonus \/ coef 0.52<\/option><option value=\"47 % bonus \/ coef 0.53\r\"  >47 % bonus \/ coef 0.53<\/option><option value=\"46 % bonus \/ coef 0.54\r\"  >46 % bonus \/ coef 0.54<\/option><option value=\"45 % bonus \/ coef 0.55\r\"  >45 % bonus \/ coef 0.55<\/option><option value=\"44 % bonus \/ coef 0.56\r\"  >44 % bonus \/ coef 0.56<\/option><option value=\"43 % bonus \/ coef 0.57\r\"  >43 % bonus \/ coef 0.57<\/option><option value=\"42 % bonus \/ coef 0.58\r\"  >42 % bonus \/ coef 0.58<\/option><option value=\"41 % bonus \/ coef 0.59\r\"  >41 % bonus \/ coef 0.59<\/option><option value=\"40 % bonus \/ coef 0.6\r\"  >40 % bonus \/ coef 0.6<\/option><option value=\"39 % bonus \/ coef 0.61\r\"  >39 % bonus \/ coef 0.61<\/option><option value=\"38 % bonus \/ coef 0.62\r\"  >38 % bonus \/ coef 0.62<\/option><option value=\"37 % bonus \/ coef 0.63\r\"  >37 % bonus \/ coef 0.63<\/option><option value=\"36 % bonus \/ coef 0.64\r\"  >36 % bonus \/ coef 0.64<\/option><option value=\"35 % bonus \/ coef 0.65\r\"  >35 % bonus \/ coef 0.65<\/option><option value=\"34 % bonus \/ coef 0.66\r\"  >34 % bonus \/ coef 0.66<\/option><option value=\"33 % bonus \/ coef 0.67\r\"  >33 % bonus \/ coef 0.67<\/option><option value=\"32 % bonus \/ coef 0.68\r\"  >32 % bonus \/ coef 0.68<\/option><option value=\"31 % bonus \/ coef 0.69\r\"  >31 % bonus \/ coef 0.69<\/option><option value=\"30 % bonus \/ coef 0.7\r\"  >30 % bonus \/ coef 0.7<\/option><option value=\"29 % bonus \/ coef 0.71\r\"  >29 % bonus \/ coef 0.71<\/option><option value=\"28 % bonus \/ coef 0.72\r\"  >28 % bonus \/ coef 0.72<\/option><option value=\"27 % bonus \/ coef 0.73\r\"  >27 % bonus \/ coef 0.73<\/option><option value=\"26 % bonus \/ coef 0.74\r\"  >26 % bonus \/ coef 0.74<\/option><option value=\"25 % bonus \/ coef 0.75\r\"  >25 % bonus \/ coef 0.75<\/option><option value=\"24 % bonus \/ coef 0.76\r\"  >24 % bonus \/ coef 0.76<\/option><option value=\"23 % bonus \/ coef 0.77\r\"  >23 % bonus \/ coef 0.77<\/option><option value=\"22 % bonus \/ coef 0.78\r\"  >22 % bonus \/ coef 0.78<\/option><option value=\"21 % bonus \/ coef 0.79\r\"  >21 % bonus \/ coef 0.79<\/option><option value=\"20 % bonus \/ coef 0.8\r\"  >20 % bonus \/ coef 0.8<\/option><option value=\"19 % bonus \/ coef 0.81\r\"  >19 % bonus \/ coef 0.81<\/option><option value=\"18 % bonus \/ coef 0.82\r\"  >18 % bonus \/ coef 0.82<\/option><option value=\"17 % bonus \/ coef 0.83\r\"  >17 % bonus \/ coef 0.83<\/option><option value=\"16 % bonus \/ coef 0.84\r\"  >16 % bonus \/ coef 0.84<\/option><option value=\"15 % bonus \/ coef 0.85\r\"  >15 % bonus \/ coef 0.85<\/option><option value=\"14 % bonus \/ coef 0.86\r\"  >14 % bonus \/ coef 0.86<\/option><option value=\"13 % bonus \/ coef 0.87\r\"  >13 % bonus \/ coef 0.87<\/option><option value=\"12 % bonus \/ coef 0.88\r\"  >12 % bonus \/ coef 0.88<\/option><option value=\"11 % bonus \/ coef 0.89\r\"  >11 % bonus \/ coef 0.89<\/option><option value=\"10 % bonus \/ coef 0.9\r\"  >10 % bonus \/ coef 0.9<\/option><option value=\"9 % bonus \/ coef 0.91\r\"  >9 % bonus \/ coef 0.91<\/option><option value=\"8 % bonus \/ coef 0.92\r\"  >8 % bonus \/ coef 0.92<\/option><option value=\"7 % bonus \/ coef 0.93\r\"  >7 % bonus \/ coef 0.93<\/option><option value=\"6 % bonus \/ coef 0.94\r\"  >6 % bonus \/ coef 0.94<\/option><option value=\"5 % bonus \/ coef 0.95\r\"  >5 % bonus \/ coef 0.95<\/option><option value=\"4 % bonus \/ coef 0.96\r\"  >4 % bonus \/ coef 0.96<\/option><option value=\"3 % bonus \/ coef 0.97\r\"  >3 % bonus \/ coef 0.97<\/option><option value=\"2 % bonus \/ coef 0.98\r\"  >2 % bonus \/ coef 0.98<\/option><option value=\"1 % bonus \/ coef 0.99\r\"  >1 % bonus \/ coef 0.99<\/option><option value=\"0 % bonus \/ coef 1\r\"  >0 % bonus \/ coef 1<\/option><option value=\"1 % malus \/ coef 1.01\r\"  >1 % malus \/ coef 1.01<\/option><option value=\"2 % malus \/ coef 1.02\r\"  >2 % malus \/ coef 1.02<\/option><option value=\"3 % malus \/ coef 1.03\r\"  >3 % malus \/ coef 1.03<\/option><option value=\"4 % malus \/ coef 1.04\r\"  >4 % malus \/ coef 1.04<\/option><option value=\"5 % malus \/ coef 1.05\r\"  >5 % malus \/ coef 1.05<\/option><option value=\"6 % malus \/ coef 1.06\r\"  >6 % malus \/ coef 1.06<\/option><option value=\"7 % malus \/ coef 1.07\r\"  >7 % malus \/ coef 1.07<\/option><option value=\"8 % malus \/ coef 1.08\r\"  >8 % malus \/ coef 1.08<\/option><option value=\"9 % malus \/ coef 1.09\r\"  >9 % malus \/ coef 1.09<\/option><option value=\"10 % malus \/ coef 1.1\r\"  >10 % malus \/ coef 1.1<\/option><option value=\"11 % malus \/ coef 1.11\r\"  >11 % malus \/ coef 1.11<\/option><option value=\"12 % malus \/ coef 1.12\r\"  >12 % malus \/ coef 1.12<\/option><option value=\"13 % malus \/ coef 1.13\r\"  >13 % malus \/ coef 1.13<\/option><option value=\"14 % malus \/ coef 1.14\r\"  >14 % malus \/ coef 1.14<\/option><option value=\"15 % malus \/ coef 1.15\r\"  >15 % malus \/ coef 1.15<\/option><option value=\"16 % malus \/ coef 1.16\r\"  >16 % malus \/ coef 1.16<\/option><option value=\"17 % malus \/ coef 1.17\r\"  >17 % malus \/ coef 1.17<\/option><option value=\"18 % malus \/ coef 1.18\r\"  >18 % malus \/ coef 1.18<\/option><option value=\"19 % malus \/ coef 1.19\r\"  >19 % malus \/ coef 1.19<\/option><option value=\"20 % malus \/ coef 1.2\r\"  >20 % malus \/ coef 1.2<\/option><option value=\"21 % malus \/ coef 1.21\r\"  >21 % malus \/ coef 1.21<\/option><option value=\"22 % malus \/ coef 1.22\r\"  >22 % malus \/ coef 1.22<\/option><option value=\"23 % malus \/ coef 1.23\r\"  >23 % malus \/ coef 1.23<\/option><option value=\"24 % malus \/ coef 1.24\r\"  >24 % malus \/ coef 1.24<\/option><option value=\"25 % malus \/ coef 1.25\r\"  >25 % malus \/ coef 1.25<\/option><option value=\"26 % malus \/ coef 1.26\r\"  >26 % malus \/ coef 1.26<\/option><option value=\"27 % malus \/ coef 1.27\r\"  >27 % malus \/ coef 1.27<\/option><option value=\"28 % malus \/ coef 1.28\r\"  >28 % malus \/ coef 1.28<\/option><option value=\"29 % malus \/ coef 1.29\r\"  >29 % malus \/ coef 1.29<\/option><option value=\"30 % malus \/ coef 1.3\r\"  >30 % malus \/ coef 1.3<\/option><option value=\"31 % malus \/ coef 1.31\r\"  >31 % malus \/ coef 1.31<\/option><option value=\"32 % malus \/ coef 1.32\r\"  >32 % malus \/ coef 1.32<\/option><option value=\"33 % malus \/ coef 1.33\r\"  >33 % malus \/ coef 1.33<\/option><option value=\"34 % malus \/ coef 1.34\r\"  >34 % malus \/ coef 1.34<\/option><option value=\"35 % malus \/ coef 1.35\r\"  >35 % malus \/ coef 1.35<\/option><option value=\"36 % malus \/ coef 1.36\r\"  >36 % malus \/ coef 1.36<\/option><option value=\"37 % malus \/ coef 1.37\r\"  >37 % malus \/ coef 1.37<\/option><option value=\"38 % malus \/ coef 1.38\r\"  >38 % malus \/ coef 1.38<\/option><option value=\"39 % malus \/ coef 1.39\r\"  >39 % malus \/ coef 1.39<\/option><option value=\"40 % malus \/ coef 1.4\r\"  >40 % malus \/ coef 1.4<\/option><option value=\"41 % malus \/ coef 1.41\r\"  >41 % malus \/ coef 1.41<\/option><option value=\"42 % malus \/ coef 1.42\r\"  >42 % malus \/ coef 1.42<\/option><option value=\"43 % malus \/ coef 1.43\r\"  >43 % malus \/ coef 1.43<\/option><option value=\"44 % malus \/ coef 1.44\r\"  >44 % malus \/ coef 1.44<\/option><option value=\"45 % malus \/ coef 1.45\r\"  >45 % malus \/ coef 1.45<\/option><option value=\"46 % malus \/ coef 1.46\r\"  >46 % malus \/ coef 1.46<\/option><option value=\"47 % malus \/ coef 1.47\r\"  >47 % malus \/ coef 1.47<\/option><option value=\"48 % malus \/ coef 1.48\r\"  >48 % malus \/ coef 1.48<\/option><option value=\"49 % malus \/ coef 1.49\r\"  >49 % malus \/ coef 1.49<\/option><option value=\"50 % malus \/ coef 1.5\r\"  >50 % malus \/ coef 1.5<\/option><option value=\"51 % malus \/ coef 1.51\r\"  >51 % malus \/ coef 1.51<\/option><option value=\"52 % malus \/ coef 1.52\r\"  >52 % malus \/ coef 1.52<\/option><option value=\"53 % malus \/ coef 1.53\r\"  >53 % malus \/ coef 1.53<\/option><option value=\"54 % malus \/ coef 1.54\r\"  >54 % malus \/ coef 1.54<\/option><option value=\"55 % malus \/ coef 1.55\r\"  >55 % malus \/ coef 1.55<\/option><option value=\"56 % malus \/ coef 1.56\r\"  >56 % malus \/ coef 1.56<\/option><option value=\"57 % malus \/ coef 1.57\r\"  >57 % malus \/ coef 1.57<\/option><option value=\"58 % malus \/ coef 1.58\r\"  >58 % malus \/ coef 1.58<\/option><option value=\"59 % malus \/ coef 1.59\r\"  >59 % malus \/ coef 1.59<\/option><option value=\"60 % malus \/ coef 1.6\r\"  >60 % malus \/ coef 1.6<\/option><option value=\"61 % malus \/ coef 1.61\r\"  >61 % malus \/ coef 1.61<\/option><option value=\"62 % malus \/ coef 1.62\r\"  >62 % malus \/ coef 1.62<\/option><option value=\"63 % malus \/ coef 1.63\r\"  >63 % malus \/ coef 1.63<\/option><option value=\"64 % malus \/ coef 1.64\r\"  >64 % malus \/ coef 1.64<\/option><option value=\"65 % malus \/ coef 1.65\r\"  >65 % malus \/ coef 1.65<\/option><option value=\"66 % malus \/ coef 1.66\r\"  >66 % malus \/ coef 1.66<\/option><option value=\"67 % malus \/ coef 1.67\r\"  >67 % malus \/ coef 1.67<\/option><option value=\"68 % malus \/ coef 1.68\r\"  >68 % malus \/ coef 1.68<\/option><option value=\"69 % malus \/ coef 1.69\r\"  >69 % malus \/ coef 1.69<\/option><option value=\"70 % malus \/ coef 1.7\r\"  >70 % malus \/ coef 1.7<\/option><option value=\"71 % malus \/ coef 1.71\r\"  >71 % malus \/ coef 1.71<\/option><option value=\"72 % malus \/ coef 1.72\r\"  >72 % malus \/ coef 1.72<\/option><option value=\"73 % malus \/ coef 1.73\r\"  >73 % malus \/ coef 1.73<\/option><option value=\"74 % malus \/ coef 1.74\r\"  >74 % malus \/ coef 1.74<\/option><option value=\"75 % malus \/ coef 1.75\r\"  >75 % malus \/ coef 1.75<\/option><option value=\"76 % malus \/ coef 1.76\r\"  >76 % malus \/ coef 1.76<\/option><option value=\"77 % malus \/ coef 1.77\r\"  >77 % malus \/ coef 1.77<\/option><option value=\"78 % malus \/ coef 1.78\r\"  >78 % malus \/ coef 1.78<\/option><option value=\"79 % malus \/ coef 1.79\r\"  >79 % malus \/ coef 1.79<\/option><option value=\"80 % malus \/ coef 1.8\r\"  >80 % malus \/ coef 1.8<\/option><option value=\"81 % malus \/ coef 1.81\r\"  >81 % malus \/ coef 1.81<\/option><option value=\"82 % malus \/ coef 1.82\r\"  >82 % malus \/ coef 1.82<\/option><option value=\"83 % malus \/ coef 1.83\r\"  >83 % malus \/ coef 1.83<\/option><option value=\"84 % malus \/ coef 1.84\r\"  >84 % malus \/ coef 1.84<\/option><option value=\"85 % malus \/ coef 1.85\r\"  >85 % malus \/ coef 1.85<\/option><option value=\"86 % malus \/ coef 1.86\r\"  >86 % malus \/ coef 1.86<\/option><option value=\"87 % malus \/ coef 1.87\r\"  >87 % malus \/ coef 1.87<\/option><option value=\"88 % malus \/ coef 1.88\r\"  >88 % malus \/ coef 1.88<\/option><option value=\"89 % malus \/ coef 1.89\r\"  >89 % malus \/ coef 1.89<\/option><option value=\"90 % malus \/ coef 1.9\r\"  >90 % malus \/ coef 1.9<\/option><option value=\"91 % malus \/ coef 1.91\r\"  >91 % malus \/ coef 1.91<\/option><option value=\"92 % malus \/ coef 1.92\r\"  >92 % malus \/ coef 1.92<\/option><option value=\"93 % malus \/ coef 1.93\r\"  >93 % malus \/ coef 1.93<\/option><option value=\"94 % malus \/ coef 1.94\r\"  >94 % malus \/ coef 1.94<\/option><option value=\"95 % malus \/ coef 1.95\r\"  >95 % malus \/ coef 1.95<\/option><option value=\"96 % malus \/ coef 1.96\r\"  >96 % malus \/ coef 1.96<\/option><option value=\"97 % malus \/ coef 1.97\r\"  >97 % malus \/ coef 1.97<\/option><option value=\"98 % malus \/ coef 1.98\r\"  >98 % malus \/ coef 1.98<\/option><option value=\"99 % malus \/ coef 1.99\r\"  >99 % malus \/ coef 1.99<\/option><option value=\"100 % malus \/ coef 2\r\"  >100 % malus \/ coef 2<\/option><option value=\"101 % malus \/ coef 2.01\r\"  >101 % malus \/ coef 2.01<\/option><option value=\"102 % malus \/ coef 2.02\r\"  >102 % malus \/ coef 2.02<\/option><option value=\"103 % malus \/ coef 2.03\r\"  >103 % malus \/ coef 2.03<\/option><option value=\"104 % malus \/ coef 2.04\r\"  >104 % malus \/ coef 2.04<\/option><option value=\"105 % malus \/ coef 2.05\r\"  >105 % malus \/ coef 2.05<\/option><option value=\"106 % malus \/ coef 2.06\r\"  >106 % malus \/ coef 2.06<\/option><option value=\"107 % malus \/ coef 2.07\r\"  >107 % malus \/ coef 2.07<\/option><option value=\"108 % malus \/ coef 2.08\r\"  >108 % malus \/ coef 2.08<\/option><option value=\"109 % malus \/ coef 2.09\r\"  >109 % malus \/ coef 2.09<\/option><option value=\"110 % malus \/ coef 2.1\r\"  >110 % malus \/ coef 2.1<\/option><option value=\"111 % malus \/ coef 2.11\r\"  >111 % malus \/ coef 2.11<\/option><option value=\"112 % malus \/ coef 2.12\r\"  >112 % malus \/ coef 2.12<\/option><option value=\"113 % malus \/ coef 2.13\r\"  >113 % malus \/ coef 2.13<\/option><option value=\"114 % malus \/ coef 2.14\r\"  >114 % malus \/ coef 2.14<\/option><option value=\"115 % malus \/ coef 2.15\r\"  >115 % malus \/ coef 2.15<\/option><option value=\"116 % malus \/ coef 2.16\r\"  >116 % malus \/ coef 2.16<\/option><option value=\"117 % malus \/ coef 2.17\r\"  >117 % malus \/ coef 2.17<\/option><option value=\"118 % malus \/ coef 2.18\r\"  >118 % malus \/ coef 2.18<\/option><option value=\"119 % malus \/ coef 2.19\r\"  >119 % malus \/ coef 2.19<\/option><option value=\"120 % malus \/ coef 2.2\r\"  >120 % malus \/ coef 2.2<\/option><option value=\"121 % malus \/ coef 2.21\r\"  >121 % malus \/ coef 2.21<\/option><option value=\"122 % malus \/ coef 2.22\r\"  >122 % malus \/ coef 2.22<\/option><option value=\"123 % malus \/ coef 2.23\r\"  >123 % malus \/ coef 2.23<\/option><option value=\"124 % malus \/ coef 2.24\r\"  >124 % malus \/ coef 2.24<\/option><option value=\"125 % malus \/ coef 2.25\r\"  >125 % malus \/ coef 2.25<\/option><option value=\"126 % malus \/ coef 2.26\r\"  >126 % malus \/ coef 2.26<\/option><option value=\"127 % malus \/ coef 2.27\r\"  >127 % malus \/ coef 2.27<\/option><option value=\"128 % malus \/ coef 2.28\r\"  >128 % malus \/ coef 2.28<\/option><option value=\"129 % malus \/ coef 2.29\r\"  >129 % malus \/ coef 2.29<\/option><option value=\"130 % malus \/ coef 2.3\r\"  >130 % malus \/ coef 2.3<\/option><option value=\"131 % malus \/ coef 2.31\r\"  >131 % malus \/ coef 2.31<\/option><option value=\"132 % malus \/ coef 2.32\r\"  >132 % malus \/ coef 2.32<\/option><option value=\"133 % malus \/ coef 2.33\r\"  >133 % malus \/ coef 2.33<\/option><option value=\"134 % malus \/ coef 2.34\r\"  >134 % malus \/ coef 2.34<\/option><option value=\"135 % malus \/ coef 2.35\r\"  >135 % malus \/ coef 2.35<\/option><option value=\"136 % malus \/ coef 2.36\r\"  >136 % malus \/ coef 2.36<\/option><option value=\"137 % malus \/ coef 2.37\r\"  >137 % malus \/ coef 2.37<\/option><option value=\"138 % malus \/ coef 2.38\r\"  >138 % malus \/ coef 2.38<\/option><option value=\"139 % malus \/ coef 2.39\r\"  >139 % malus \/ coef 2.39<\/option><option value=\"140 % malus \/ coef 2.4\r\"  >140 % malus \/ coef 2.4<\/option><option value=\"141 % malus \/ coef 2.41\r\"  >141 % malus \/ coef 2.41<\/option><option value=\"142 % malus \/ coef 2.42\r\"  >142 % malus \/ coef 2.42<\/option><option value=\"143 % malus \/ coef 2.43\r\"  >143 % malus \/ coef 2.43<\/option><option value=\"144 % malus \/ coef 2.44\r\"  >144 % malus \/ coef 2.44<\/option><option value=\"145 % malus \/ coef 2.45\r\"  >145 % malus \/ coef 2.45<\/option><option value=\"146 % malus \/ coef 2.46\r\"  >146 % malus \/ coef 2.46<\/option><option value=\"147 % malus \/ coef 2.47\r\"  >147 % malus \/ coef 2.47<\/option><option value=\"148 % malus \/ coef 2.48\r\"  >148 % malus \/ coef 2.48<\/option><option value=\"149 % malus \/ coef 2.49\r\"  >149 % malus \/ coef 2.49<\/option><option value=\"150 % malus \/ coef 2.5\r\"  >150 % malus \/ coef 2.5<\/option><option value=\"151 % malus \/ coef 2.51\r\"  >151 % malus \/ coef 2.51<\/option><option value=\"152 % malus \/ coef 2.52\r\"  >152 % malus \/ coef 2.52<\/option><option value=\"153 % malus \/ coef 2.53\r\"  >153 % malus \/ coef 2.53<\/option><option value=\"154 % malus \/ coef 2.54\r\"  >154 % malus \/ coef 2.54<\/option><option value=\"155 % malus \/ coef 2.55\r\"  >155 % malus \/ coef 2.55<\/option><option value=\"156 % malus \/ coef 2.56\r\"  >156 % malus \/ coef 2.56<\/option><option value=\"157 % malus \/ coef 2.57\r\"  >157 % malus \/ coef 2.57<\/option><option value=\"158 % malus \/ coef 2.58\r\"  >158 % malus \/ coef 2.58<\/option><option value=\"159 % malus \/ coef 2.59\r\"  >159 % malus \/ coef 2.59<\/option><option value=\"160 % malus \/ coef 2.6\r\"  >160 % malus \/ coef 2.6<\/option><option value=\"161 % malus \/ coef 2.61\r\"  >161 % malus \/ coef 2.61<\/option><option value=\"162 % malus \/ coef 2.62\r\"  >162 % malus \/ coef 2.62<\/option><option value=\"163 % malus \/ coef 2.63\r\"  >163 % malus \/ coef 2.63<\/option><option value=\"164 % malus \/ coef 2.64\r\"  >164 % malus \/ coef 2.64<\/option><option value=\"165 % malus \/ coef 2.65\r\"  >165 % malus \/ coef 2.65<\/option><option value=\"166 % malus \/ coef 2.66\r\"  >166 % malus \/ coef 2.66<\/option><option value=\"167 % malus \/ coef 2.67\r\"  >167 % malus \/ coef 2.67<\/option><option value=\"168 % malus \/ coef 2.68\r\"  >168 % malus \/ coef 2.68<\/option><option value=\"169 % malus \/ coef 2.69\r\"  >169 % malus \/ coef 2.69<\/option><option value=\"170 % malus \/ coef 2.7\r\"  >170 % malus \/ coef 2.7<\/option><option value=\"171 % malus \/ coef 2.71\r\"  >171 % malus \/ coef 2.71<\/option><option value=\"172 % malus \/ coef 2.72\r\"  >172 % malus \/ coef 2.72<\/option><option value=\"173 % malus \/ coef 2.73\r\"  >173 % malus \/ coef 2.73<\/option><option value=\"174 % malus \/ coef 2.74\r\"  >174 % malus \/ coef 2.74<\/option><option value=\"175 % malus \/ coef 2.75\r\"  >175 % malus \/ coef 2.75<\/option><option value=\"176 % malus \/ coef 2.76\r\"  >176 % malus \/ coef 2.76<\/option><option value=\"177 % malus \/ coef 2.77\r\"  >177 % malus \/ coef 2.77<\/option><option value=\"178 % malus \/ coef 2.78\r\"  >178 % malus \/ coef 2.78<\/option><option value=\"179 % malus \/ coef 2.79\r\"  >179 % malus \/ coef 2.79<\/option><option value=\"180 % malus \/ coef 2.8\r\"  >180 % malus \/ coef 2.8<\/option><option value=\"181 % malus \/ coef 2.81\r\"  >181 % malus \/ coef 2.81<\/option><option value=\"182 % malus \/ coef 2.82\r\"  >182 % malus \/ coef 2.82<\/option><option value=\"183 % malus \/ coef 2.83\r\"  >183 % malus \/ coef 2.83<\/option><option value=\"184 % malus \/ coef 2.84\r\"  >184 % malus \/ coef 2.84<\/option><option value=\"185 % malus \/ coef 2.85\r\"  >185 % malus \/ coef 2.85<\/option><option value=\"186 % malus \/ coef 2.86\r\"  >186 % malus \/ coef 2.86<\/option><option value=\"187 % malus \/ coef 2.87\r\"  >187 % malus \/ coef 2.87<\/option><option value=\"188 % malus \/ coef 2.88\r\"  >188 % malus \/ coef 2.88<\/option><option value=\"189 % malus \/ coef 2.89\r\"  >189 % malus \/ coef 2.89<\/option><option value=\"190 % malus \/ coef 2.9\r\"  >190 % malus \/ coef 2.9<\/option><option value=\"191 % malus \/ coef 2.91\r\"  >191 % malus \/ coef 2.91<\/option><option value=\"192 % malus \/ coef 2.92\r\"  >192 % malus \/ coef 2.92<\/option><option value=\"193 % malus \/ coef 2.93\r\"  >193 % malus \/ coef 2.93<\/option><option value=\"194 % malus \/ coef 2.94\r\"  >194 % malus \/ coef 2.94<\/option><option value=\"195 % malus \/ coef 2.95\r\"  >195 % malus \/ coef 2.95<\/option><option value=\"196 % malus \/ coef 2.96\r\"  >196 % malus \/ coef 2.96<\/option><option value=\"197 % malus \/ coef 2.97\r\"  >197 % malus \/ coef 2.97<\/option><option value=\"198 % malus \/ coef 2.98\r\"  >198 % malus \/ coef 2.98<\/option><option value=\"199 % malus \/ coef 2.99\r\"  >199 % malus \/ coef 2.99<\/option><option value=\"200 % malus \/ coef 3\r\"  >200 % malus \/ coef 3<\/option><option value=\"201 % malus \/ coef 3.01\r\"  >201 % malus \/ coef 3.01<\/option><option value=\"202 % malus \/ coef 3.02\r\"  >202 % malus \/ coef 3.02<\/option><option value=\"203 % malus \/ coef 3.03\r\"  >203 % malus \/ coef 3.03<\/option><option value=\"204 % malus \/ coef 3.04\r\"  >204 % malus \/ coef 3.04<\/option><option value=\"205 % malus \/ coef 3.05\r\"  >205 % malus \/ coef 3.05<\/option><option value=\"206 % malus \/ coef 3.06\r\"  >206 % malus \/ coef 3.06<\/option><option value=\"207 % malus \/ coef 3.07\r\"  >207 % malus \/ coef 3.07<\/option><option value=\"208 % malus \/ coef 3.08\r\"  >208 % malus \/ coef 3.08<\/option><option value=\"209 % malus \/ coef 3.09\r\"  >209 % malus \/ coef 3.09<\/option><option value=\"210 % malus \/ coef 3.1\r\"  >210 % malus \/ coef 3.1<\/option><option value=\"211 % malus \/ coef 3.11\r\"  >211 % malus \/ coef 3.11<\/option><option value=\"212 % malus \/ coef 3.12\r\"  >212 % malus \/ coef 3.12<\/option><option value=\"213 % malus \/ coef 3.13\r\"  >213 % malus \/ coef 3.13<\/option><option value=\"214 % malus \/ coef 3.14\r\"  >214 % malus \/ coef 3.14<\/option><option value=\"215 % malus \/ coef 3.15\r\"  >215 % malus \/ coef 3.15<\/option><option value=\"216 % malus \/ coef 3.16\r\"  >216 % malus \/ coef 3.16<\/option><option value=\"217 % malus \/ coef 3.17\r\"  >217 % malus \/ coef 3.17<\/option><option value=\"218 % malus \/ coef 3.18\r\"  >218 % malus \/ coef 3.18<\/option><option value=\"219 % malus \/ coef 3.19\r\"  >219 % malus \/ coef 3.19<\/option><option value=\"220 % malus \/ coef 3.2\r\"  >220 % malus \/ coef 3.2<\/option><option value=\"221 % malus \/ coef 3.21\r\"  >221 % malus \/ coef 3.21<\/option><option value=\"222 % malus \/ coef 3.22\r\"  >222 % malus \/ coef 3.22<\/option><option value=\"223 % malus \/ coef 3.23\r\"  >223 % malus \/ coef 3.23<\/option><option value=\"224 % malus \/ coef 3.24\r\"  >224 % malus \/ coef 3.24<\/option><option value=\"225 % malus \/ coef 3.25\r\"  >225 % malus \/ coef 3.25<\/option><option value=\"226 % malus \/ coef 3.26\r\"  >226 % malus \/ coef 3.26<\/option><option value=\"227 % malus \/ coef 3.27\r\"  >227 % malus \/ coef 3.27<\/option><option value=\"228 % malus \/ coef 3.28\r\"  >228 % malus \/ coef 3.28<\/option><option value=\"229 % malus \/ coef 3.29\r\"  >229 % malus \/ coef 3.29<\/option><option value=\"230 % malus \/ coef 3.3\r\"  >230 % malus \/ coef 3.3<\/option><option value=\"231 % malus \/ coef 3.31\r\"  >231 % malus \/ coef 3.31<\/option><option value=\"232 % malus \/ coef 3.32\r\"  >232 % malus \/ coef 3.32<\/option><option value=\"233 % malus \/ coef 3.33\r\"  >233 % malus \/ coef 3.33<\/option><option value=\"234 % malus \/ coef 3.34\r\"  >234 % malus \/ coef 3.34<\/option><option value=\"235 % malus \/ coef 3.35\r\"  >235 % malus \/ coef 3.35<\/option><option value=\"236 % malus \/ coef 3.36\r\"  >236 % malus \/ coef 3.36<\/option><option value=\"237 % malus \/ coef 3.37\r\"  >237 % malus \/ coef 3.37<\/option><option value=\"238 % malus \/ coef 3.38\r\"  >238 % malus \/ coef 3.38<\/option><option value=\"239 % malus \/ coef 3.39\r\"  >239 % malus \/ coef 3.39<\/option><option value=\"240 % malus \/ coef 3.4\r\"  >240 % malus \/ coef 3.4<\/option><option value=\"241 % malus \/ coef 3.41\r\"  >241 % malus \/ coef 3.41<\/option><option value=\"242 % malus \/ coef 3.42\r\"  >242 % malus \/ coef 3.42<\/option><option value=\"243 % malus \/ coef 3.43\r\"  >243 % malus \/ coef 3.43<\/option><option value=\"244 % malus \/ coef 3.44\r\"  >244 % malus \/ coef 3.44<\/option><option value=\"245 % malus \/ coef 3.45\r\"  >245 % malus \/ coef 3.45<\/option><option value=\"246 % malus \/ coef 3.46\r\"  >246 % malus \/ coef 3.46<\/option><option value=\"247 % malus \/ coef 3.47\r\"  >247 % malus \/ coef 3.47<\/option><option value=\"248 % malus \/ coef 3.48\r\"  >248 % malus \/ coef 3.48<\/option><option value=\"249 % malus \/ coef 3.49\r\"  >249 % malus \/ coef 3.49<\/option><option value=\"250 % malus \/ coef 3.5\r\"  >250 % malus \/ coef 3.5<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_dropdown_21' aria-label=\"Nombre de mois d&#039;assurance sur les 36 derniers mois\">Nombre de mois d'assurance sur les 36 derniers mois<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown_21\" id=\"ff_9_dropdown_21\" class=\"ff-el-form-control\" data-name=\"dropdown_21\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"Pas d&#039;assurance\"  >Pas d'assurance<\/option><option value=\"De 1 \u00e0 7 mois\"  >De 1 \u00e0 7 mois<\/option><option value=\"De 8 \u00e0 11 mois\"  >De 8 \u00e0 11 mois<\/option><option value=\"De 12 \u00e0 15 mois\"  >De 12 \u00e0 15 mois<\/option><option value=\"De 16 \u00e0 23 mois\"  >De 16 \u00e0 23 mois<\/option><option value=\"De 24 \u00e0 35 mois\"  >De 24 \u00e0 35 mois<\/option><option value=\"Sup\u00e9rieur ou \u00e9gal \u00e0 36 mois\"  >Sup\u00e9rieur ou \u00e9gal \u00e0 36 mois<\/option><\/select><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_9_dropdown_22' aria-label=\"R\u00e9siliation par un pr\u00e9c\u00e9dent assureur sur les 36 derniers mois ?\">R\u00e9siliation par un pr\u00e9c\u00e9dent assureur sur les 36 derniers mois ?<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown_22\" id=\"ff_9_dropdown_22\" class=\"ff-el-form-control\" data-name=\"dropdown_22\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"Aucune\"  >Aucune<\/option><option value=\"Non paiement de prime depuis moins de 3 mois\"  >Non paiement de prime depuis moins de 3 mois<\/option><option value=\"Non paiement de prime entre 3 et 6 mois\"  >Non paiement de prime entre 3 et 6 mois<\/option><option value=\"Non paiement de prime depuis plus de 6 mois\"  >Non paiement de prime depuis plus de 6 mois<\/option><option value=\"Sinistre\"  >Sinistre<\/option><option value=\"Sinistre et Non paiement de prime depuis moins de 3 mois\"  >Sinistre et Non paiement de prime depuis moins de 3 mois<\/option><option value=\"Sinistre et Non paiement de prime entre 3 et 6 mois\"  >Sinistre et Non paiement de prime entre 3 et 6 mois<\/option><option value=\"Sinistre et Non paiement de prime depuis plus de 6 mois\"  >Sinistre et Non paiement de prime depuis plus de 6 mois<\/option><option value=\"Sinistre et conduite sous l&#039;empire d&#039;un \u00e9tat alcoolique\"  >Sinistre et conduite sous l'empire d'un \u00e9tat alcoolique<\/option><option value=\"Sinistre et conduite sous l\u2019emprise de stup\u00e9fiant\"  >Sinistre et conduite sous l\u2019emprise de stup\u00e9fiant<\/option><option value=\"Fausse d\u00e9claration\"  >Fausse d\u00e9claration<\/option><option value=\"Nullit\u00e9 de contrat\"  >Nullit\u00e9 de contrat<\/option><option value=\"Oui, pour une autre raison\"  >Oui, pour une autre raison<\/option><option value=\"D\u00e9faut de pi\u00e8ces\"  >D\u00e9faut de pi\u00e8ces<\/option><option value=\"D\u00e9lit de fuite\"  >D\u00e9lit de fuite<\/option><option value=\"Conduite sous l&#039;emprise d&#039;un \u00e9tat alcoolique\"  >Conduite sous l'emprise d'un \u00e9tat alcoolique<\/option><option value=\"Conduite sous l\u2019emprise de stup\u00e9fiant\"  >Conduite sous l\u2019emprise de stup\u00e9fiant<\/option><option value=\"Aggravation du risque\"  >Aggravation du risque<\/option><\/select><\/div><\/div><div class='ff-el-group  ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Avez-vous eu un r\u00e9sultat positif lors d&#039;un contr\u00f4le d&#039;alcool\u00e9mie au cours des 5 derni\u00e8res ann\u00e9es ?\">Avez-vous eu un r\u00e9sultat positif lors d'un contr\u00f4le d'alcool\u00e9mie au cours des 5 derni\u00e8res ann\u00e9es ?<\/label> <\/div><div class='ff-el-input--content'><div class='ff-el-form-check 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