{"id":5178,"date":"2022-10-03T11:26:11","date_gmt":"2022-10-03T09:26:11","guid":{"rendered":"http:\/\/select-assur.com\/?page_id=5178"},"modified":"2022-10-31T00:17:59","modified_gmt":"2022-10-30T23:17:59","slug":"formulaire-assurance-sante","status":"publish","type":"page","link":"https:\/\/select-assur.com\/formulaire-assurance-sante\/","title":{"rendered":"Formulaire Assurance Sant\u00e9"},"content":{"rendered":"\t\t<div data-custom_css-type=\"wp-page\" data-custom_css-id=\"5178\" class=\"custom_css custom_css-5178\">\n\t\t\t\t\t\t\t        <section class=\"custom_css-section custom_css-top-section custom_css-element custom_css-element-4267265 custom_css-section-boxed custom_css-section-height-default custom_css-section-height-default ct-header-fixed-none ct-row-max-none\" data-id=\"4267265\" 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-0bf39f9\" data-id=\"0bf39f9\" 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-cc5d0c3 custom_css-widget custom_css-widget-shortcode\" data-id=\"cc5d0c3\" 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_8'><form data-form_id=\"8\" id=\"fluentform_8\" class=\"frm-fluent-form fluent_form_8 ff-el-form-top ff_form_instance_8_1 ff-form-loading ff-form-has-steps ff_has_v3_recptcha\" data-form_instance=\"ff_form_instance_8_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;\">Assurance Sant\u00e9<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='5178' \/><input type=\"hidden\" id=\"_fluentform_8_fluentformnonce\" name=\"_fluentform_8_fluentformnonce\" value=\"63fa3fff2c\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/php_api\/wp\/v2\/pages\/5178\" \/><div class='ff-step-container' class=\"Formulaire Assurance Sant\u00e9 Pr\u00e9voyance\" data-name=\"step_start-8_7\" 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>Besoin<\/li><li>Vous<\/li>\n            <\/ul><\/div><span class='ff_step_start'><\/span><div class='ff-step-body'><div class=\"Formulaire Assurance Sant\u00e9 Pr\u00e9voyance fluentform-step active\" data-name=\"step_start-8_7\" 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  ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Etes-vous actuellement couvert par une assurance compl\u00e9mentaire sant\u00e9 ?\">Etes-vous actuellement couvert par une assurance compl\u00e9mentaire sant\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_3_e8aab07c8007a77c2f162456fdb662fe><input type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Oui\"  id='input_radio_3_e8aab07c8007a77c2f162456fdb662fe' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_3_016ad8efefe47722bd65df17af371944><input type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Non\"  id='input_radio_3_016ad8efefe47722bd65df17af371944' aria-label='Non' aria-invalid='false' aria-required=true> <span>Non<\/span><\/label><\/div><\/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=\"Souhaitez-vous donner mandat \u00e0 Select Assur de se charger de la r\u00e9siliation de votre contrat sant\u00e9 ?\">Souhaitez-vous donner mandat \u00e0 Select Assur de se charger de la r\u00e9siliation de votre contrat sant\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_4_18f1cb8e87aec8adf2ede97da7b5e079><input type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Oui\"  id='input_radio_4_18f1cb8e87aec8adf2ede97da7b5e079' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_4_08470874a58e5baee8ed7aca8e1d1d42><input type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Non\"  id='input_radio_4_08470874a58e5baee8ed7aca8e1d1d42' aria-label='Non' aria-invalid='false' aria-required=true> <span>Non<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_8_input_text' aria-label=\"Date d&#039;effet\">Date d'effet<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" value=\"17\/04\/2026\" class=\"ff-el-form-control\" maxlength=\"10\" data-name=\"input_text\" id=\"ff_8_input_text\"  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_12_0fc5aba6eb8e74ace678a809570afe99><input type=\"radio\" name=\"input_radio_12\" data-name=\"input_radio_12\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Madame\"  id='input_radio_12_0fc5aba6eb8e74ace678a809570afe99' aria-label='Madame' aria-invalid='false' aria-required=true> <span>Madame<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_12_7132b0d034c24151294c8dc5cf142dd6><input type=\"radio\" name=\"input_radio_12\" data-name=\"input_radio_12\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Monsieur\"  id='input_radio_12_7132b0d034c24151294c8dc5cf142dd6' aria-label='Monsieur' aria-invalid='false' aria-required=true> <span>Monsieur<\/span><\/label><\/div><\/div><\/div><div data-type=\"name-element\" data-name=\"names\" 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_8_names_first_name_' aria-label=\"Nom\">Nom<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_8_names_first_name_\" class=\"ff-el-form-control\" placeholder=\"Nom\" 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_8_names_last_name_' aria-label=\"Pr\u00e9nom\">Pr\u00e9nom<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[last_name]\" id=\"ff_8_names_last_name_\" class=\"ff-el-form-control\" placeholder=\"Pr\u00e9nom\" aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_8_input_text_1' aria-label=\"Date de naissance\">Date de naissance<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" value=\"17\/04\/2026\" class=\"ff-el-form-control\" maxlength=\"10\" data-name=\"input_text_1\" id=\"ff_8_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_8_dropdown' aria-label=\"R\u00e9gime\">R\u00e9gime<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown\" id=\"ff_8_dropdown\" class=\"ff-el-form-control\" data-name=\"dropdown\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"Assur\u00e9 social\"  >Assur\u00e9 social<\/option><option value=\"TNS\"  >TNS<\/option><option value=\"TNS en cours d&#039;immat.\"  >TNS en cours d'immat.<\/option><option value=\"Profession lib\u00e9rale\"  >Profession lib\u00e9rale<\/option><option value=\"MSA exploitant agricole\"  >MSA exploitant agricole<\/option><option value=\"MSA salari\u00e9 agricole\"  >MSA salari\u00e9 agricole<\/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=\"R\u00e9gime SS Alsace-Moselle\">R\u00e9gime SS Alsace-Moselle<\/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_bc96a210c175e8badb3970550ed63156><input type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Oui\"  id='input_radio_bc96a210c175e8badb3970550ed63156' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_b4ab17ccbc02682e68a7afc6200c4c8f><input type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Non\"  id='input_radio_b4ab17ccbc02682e68a7afc6200c4c8f' aria-label='Non' aria-invalid='false' aria-required=true> <span>Non<\/span><\/label><\/div><\/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=\"Voulez-vous assurer votre conjoint ?\">Voulez-vous assurer votre conjoint ?<\/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_5_f71f6a1263b46c4d8be7d7c5c768a1c2><input type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Oui\"  id='input_radio_5_f71f6a1263b46c4d8be7d7c5c768a1c2' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_5_48179233e0bac4d0064b0fe8deb572f8><input type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Non\"  id='input_radio_5_48179233e0bac4d0064b0fe8deb572f8' aria-label='Non' aria-invalid='false' aria-required=true> <span>Non<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_8_input_text_2' aria-label=\"Date de naissance\">Date de naissance<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" value=\"17\/04\/2026\" class=\"ff-el-form-control\" maxlength=\"10\" data-name=\"input_text_2\" id=\"ff_8_input_text_2\"  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_8_dropdown_4' aria-label=\"R\u00e9gime\">R\u00e9gime<\/label> <\/div><div class='ff-el-input--content'><select name=\"dropdown_4\" id=\"ff_8_dropdown_4\" class=\"ff-el-form-control\" data-name=\"dropdown_4\" data-calc_value=\"0\"  aria-invalid=\"false\" aria-required=true><option value=\"\"><\/option><option value=\"Assur\u00e9 social\"  >Assur\u00e9 social<\/option><option value=\"TNS\"  >TNS<\/option><option value=\"TNS en cours d&#039;immat.\"  >TNS en cours d'immat.<\/option><option value=\"Profession lib\u00e9rale\"  >Profession lib\u00e9rale<\/option><option value=\"MSA exploitant agricole\"  >MSA exploitant agricole<\/option><option value=\"MSA salari\u00e9 agricole\"  >MSA salari\u00e9 agricole<\/option><\/select><\/div><\/div><div class='ff-el-group has-conditions  ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"R\u00e9gime SS Alsace-Moselle\">R\u00e9gime SS Alsace-Moselle<\/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_6_c4555c76e9eef219f3fc4f71cfd6cfec><input type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Oui\"  id='input_radio_6_c4555c76e9eef219f3fc4f71cfd6cfec' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_6_910e44c52bc671928afc01072403c43c><input type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Non\"  id='input_radio_6_910e44c52bc671928afc01072403c43c' aria-label='Non' aria-invalid='false' aria-required=true> <span>Non<\/span><\/label><\/div><\/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=\"Autres b\u00e9n\u00e9ficiaires ?\">Autres b\u00e9n\u00e9ficiaires ?<\/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_7_16674ec6f2a7396f089e18b0721148ae><input type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Oui\"  id='input_radio_7_16674ec6f2a7396f089e18b0721148ae' aria-label='Oui' aria-invalid='false' aria-required=true> <span>Oui<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_7_f1ffd1f3227c7d39e82ff35f9a12d544><input type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Non\"  id='input_radio_7_f1ffd1f3227c7d39e82ff35f9a12d544' aria-label='Non' aria-invalid='false' aria-required=true> <span>Non<\/span><\/label><\/div><\/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 de naissance' for=''>Date de naissance<\/label><\/div><\/th>\n                                                    <th><div class='ff-el-input--label ff-el-is-required asterisk-right'><label aria-label='R\u00e9gime' for=''>R\u00e9gime<\/label><\/div><\/th>\n                                                    <th><div class='ff-el-input--label ff-el-is-required asterisk-right'><label aria-label='R\u00e9gime SS Alsace-Moselle' for=''>R\u00e9gime SS Alsace-Moselle<\/label><\/div><\/th>\n                                                <th><\/th>\n                    <\/tr>\n                    <\/thead>\n                    <tbody>\n                    <tr>\n                                                    <td data-label=\"Date de naissance\">\n                                                                <div class='ff-el-group'><div class='ff-el-input--content'><input type=\"text\" value=\"17\/04\/2026\" name=\"repeater_field[0][]\" id=\"ff_8_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=\"R\u00e9gime\">\n                                                                <div class='ff-el-group'><div class='ff-el-input--content'><select type=\"select\" name=\"repeater_field[0][]\" id=\"ff_8_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=\"Assur\u00e9 social\"  >Assur\u00e9 social<\/option><option value=\"TNS\"  >TNS<\/option><option value=\"TNS en cours d&#039;immat.\"  >TNS en cours d'immat.<\/option><option value=\"Profession lib\u00e9rale\"  >Profession lib\u00e9rale<\/option><option value=\"MSA exploitant agricole\"  >MSA exploitant agricole<\/option><option value=\"MSA salari\u00e9 agricole\"  >MSA salari\u00e9 agricole<\/option><\/select><\/div><\/div>                            <\/td>\n                                                    <td data-label=\"R\u00e9gime SS Alsace-Moselle\">\n                                                                <div class='ff-el-group'><div class='ff-el-input--content'><select type=\"select\" name=\"repeater_field[0][]\" id=\"ff_8_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=\"Oui\"  >Oui<\/option><option value=\"Non\"  >Non<\/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='ff-el-group  ff_list_buttons'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"S\u00e9lectionner un niveau de garantie\">S\u00e9lectionner un niveau de garantie<\/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_11_cab1837aaba98d9ef523aae6dd564dc2><input type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Niveau 1\"  id='input_radio_11_cab1837aaba98d9ef523aae6dd564dc2' aria-label='Niveau 1' aria-invalid='false' aria-required=true> <span>Niveau 1<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_11_66ace35413c498b476980d20464a04d7><input type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Niveau 2\"  id='input_radio_11_66ace35413c498b476980d20464a04d7' aria-label='Niveau 2' aria-invalid='false' aria-required=true> <span>Niveau 2<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_11_019598906e08a2c2d0854b3314d647a8><input type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Niveau 3\"  id='input_radio_11_019598906e08a2c2d0854b3314d647a8' aria-label='Niveau 3' aria-invalid='false' aria-required=true> <span>Niveau 3<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_11_3cd43221f2d2ced2c12ccaf1d19a0b52><input type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Niveau 4\"  id='input_radio_11_3cd43221f2d2ced2c12ccaf1d19a0b52' aria-label='Niveau 4' aria-invalid='false' aria-required=true> <span>Niveau 4<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_11_90bcf2c2a0e3a16eeb9a77c035f9bbce><input type=\"radio\" name=\"input_radio_11\" data-name=\"input_radio_11\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Niveau 5\"  id='input_radio_11_90bcf2c2a0e3a16eeb9a77c035f9bbce' aria-label='Niveau 5' aria-invalid='false' aria-required=true> <span>Niveau 5<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-8_1\" ><p><img decoding=\"async\" class=\"alignnone wp-image-5582 size-full\" src=\"http:\/\/select-assur.com\/php_media\/2022\/10\/Tableau-des-garanties-SA66.png\" alt=\"\" width=\"1091\" height=\"570\" srcset=\"https:\/\/select-assur.com\/php_media\/2022\/10\/Tableau-des-garanties-SA66.png 1091w, https:\/\/select-assur.com\/php_media\/2022\/10\/Tableau-des-garanties-SA66-300x157.png 300w, https:\/\/select-assur.com\/php_media\/2022\/10\/Tableau-des-garanties-SA66-1024x535.png 1024w, https:\/\/select-assur.com\/php_media\/2022\/10\/Tableau-des-garanties-SA66-768x401.png 768w\" sizes=\"(max-width: 1091px) 100vw, 1091px\" \/><\/p><\/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: 25.92%;'><div class='ff-el-group  ff_list_buttons'><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_febddeced2fffe4f15a86ee5a5c76e42><input type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Pack Hospitalisation &amp; Honoraire\"  id='checkbox_febddeced2fffe4f15a86ee5a5c76e42' aria-label='Pack Hospitalisation &amp; Honoraire' aria-invalid='false' aria-required=false> <span>Pack Hospitalisation & Honoraire<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 74.08%;'><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-8_2\" ><p style=\"text-align: center\">D\u00e9passement Honoraires Chirurgie\/Soins de ville : +50% - Chambre Particuli\u00e8re : +20\u20ac - Forfait Hospitalisation \u00e0 la journ\u00e9e : +30\u20ac<\/p><\/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: 25.92%;'><div class='ff-el-group  ff_list_buttons'><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_1_e9fa7036625affc2c20fd72e54be1e9c><input type=\"checkbox\" name=\"checkbox_1[]\" data-name=\"checkbox_1\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Pack Bien-\u00eatre et Pr\u00e9vention 1\"  id='checkbox_1_e9fa7036625affc2c20fd72e54be1e9c' aria-label='Pack Bien-\u00eatre et Pr\u00e9vention 1' aria-invalid='false' aria-required=false> <span>Pack Bien-\u00eatre et Pr\u00e9vention 1<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 74.08%;'><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-8_3\" ><p style=\"text-align: center\">Allocation Naissance : 350\u20ac - M\u00e9decines Douces : + 20\u20ac - Contraception : 100\u20ac - Abonnement sportif : 50\u20ac<\/p><\/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: 25.92%;'><div class='ff-el-group  ff_list_buttons'><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_2_cac1fd68345d137af535972c4013c739><input type=\"checkbox\" name=\"checkbox_2[]\" data-name=\"checkbox_2\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Pack Bien-\u00eatre et Pr\u00e9vention 2\"  id='checkbox_2_cac1fd68345d137af535972c4013c739' aria-label='Pack Bien-\u00eatre et Pr\u00e9vention 2' aria-invalid='false' aria-required=false> <span>Pack Bien-\u00eatre et Pr\u00e9vention 2<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 74.08%;'><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-8_4\" ><p style=\"text-align: center\">Cures Thermales : + 200\u20ac - M\u00e9decines Douces : + 20\u20ac - Pharmacie non rembours\u00e9e : 50\u20ac - Abonnement sportif : 50\u20ac<\/p><\/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: 25.92%;'><div class='ff-el-group  ff_list_buttons'><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_3_a5aeaad1e0c46cb72711a40c6382b5cc><input type=\"checkbox\" name=\"checkbox_3[]\" data-name=\"checkbox_3\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Pack Optique - Dentaire - Audio\"  id='checkbox_3_a5aeaad1e0c46cb72711a40c6382b5cc' aria-label='Pack Optique - Dentaire - Audio' aria-invalid='false' aria-required=false> <span>Pack Optique - Dentaire - Audio<\/span><\/label><\/div><\/div><\/div><\/div><div class='ff-t-cell ff-t-column-2' style='flex-basis: 74.08%;'><div class='ff-el-group  ff-custom_html' data-name=\"custom_html-8_5\" ><p style=\"text-align: center\">Lentilles rembours\u00e9es ou non : + 200\u20ac - proth\u00e8ses dentaires et Orthodontie rembours\u00e9es : + 100% - Proth\u00e8ses Audio : +100\u20ac<\/p><\/div><\/div><\/div><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-8_6\" ><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_8_phone_1' aria-label=\"T\u00e9l\u00e9phone portable\">T\u00e9l\u00e9phone portable<\/label> <\/div><div class='ff-el-input--content'><input name=\"phone_1\" class=\"ff-el-form-control ff-el-phone\" type=\"tel\" data-name=\"phone_1\" id=\"ff_8_phone_1\" inputmode=\"tel\" ><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_8_email' aria-label=\"E-mail\">E-mail<\/label> <\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_8_email\" class=\"ff-el-form-control\" data-name=\"email\"  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id=\"ff_8_address_1_address_line_2_\" class=\"ff-el-form-control\" data-key_name=\"address_line_2\"  aria-invalid=\"false\" aria-required=false><\/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 asterisk-right\"><label for='ff_8_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_8_address_1_zip_\" class=\"ff-el-form-control\" placeholder=\"Code Postal\" data-key_name=\"zip\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><\/div><div class='ff-t-cell'><div class='ff-el-group'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_8_address_1_city_' aria-label=\"Ville\">Ville<\/label> <\/div><div class='ff-el-input--content'><input type=\"text\" name=\"address_1[city]\" id=\"ff_8_address_1_city_\" class=\"ff-el-form-control\" placeholder=\"Ville\" data-key_name=\"city\"  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