</noscript> <!-- End Google Tag Manager (noscript) --> <div id="motopress-main" class="main-holder"> <!--Begin #motopress-main--> <header class="motopress-wrapper header"> <div class="container"> <div class="row"> <div class="span12" data-motopress-wrapper-file="wrapper/wrapper-header.php" data-motopress-wrapper-type="header" data-motopress-id="67579cc5a4f07"> <div class="row"> <div class="span3" data-motopress-type="static" data-motopress-static-file="static/static-logo.php"> <!-- BEGIN LOGO --> <div class="logo pull-left"> <h2 class="logo_h logo_h__txt"><a href="https://reseaucourtage.com/" title="Réseau de conseillers en ligne" class="logo_link">Réseau Courtage</a></h2> <p class="logo_tagline">Réseau de conseillers en ligne</p><!-- Site Tagline --> </div> <!-- END LOGO --> </div> <div class="span7" data-motopress-type="static" data-motopress-static-file="static/static-nav.php"> <!-- BEGIN MAIN NAVIGATION --> <nav class="nav nav__primary clearfix"> <ul id="topnav" class="sf-menu"><li id="menu-item-2912" class="menu-item menu-item-type-post_type menu-item-object-page menu-item-home"><a href="https://reseaucourtage.com/">Accueil</a></li> <li id="menu-item-2214" class="menu-item menu-item-type-custom menu-item-object-custom current-menu-ancestor current-menu-parent menu-item-has-children"><a href="#">Services</a> <ul class="sub-menu"> <li id="menu-item-3006" class="menu-item menu-item-type-post_type menu-item-object-page"><a href="https://reseaucourtage.com/soumission-habitationauto/">Assurance Habitation & Auto</a></li> <li id="menu-item-3008" class="menu-item menu-item-type-post_type menu-item-object-page"><a href="https://reseaucourtage.com/soumission/">Assurance Vie</a></li> <li id="menu-item-3173" class="menu-item menu-item-type-post_type menu-item-object-page"><a href="https://reseaucourtage.com/soumission-hypothecaire/">Prêt Hypothécaire</a></li> <li id="menu-item-3049" class="menu-item menu-item-type-post_type menu-item-object-page current-menu-item page_item page-item-3041 current_page_item"><a href="https://reseaucourtage.com/assurance-accident-maladie/">Assurance Accident Maladie</a></li> <li id="menu-item-3165" class="menu-item menu-item-type-custom menu-item-object-custom"><a href="https://www.securiglobe.com/fr/produits-assurance-voyage/assurance-maladie-voyage/?aff=WEB182%20target=_blank">Assurance Voyage</a></li> </ul> </li> <li id="menu-item-2271" class="menu-item menu-item-type-post_type menu-item-object-page"><a href="https://reseaucourtage.com/faq/">FAQ</a></li> <li id="menu-item-2083" class="menu-item menu-item-type-post_type menu-item-object-page"><a href="https://reseaucourtage.com/contactez-nous/">Contactez-Nous</a></li> </ul></nav><!-- END MAIN NAVIGATION --> </div> <div class="span2" data-motopress-type="static" data-motopress-static-file="static/static-login-out.php"> <div id="loginout" class="clearfix"> </div> </div> </div> </div> </div> </div> </header> <div class="motopress-wrapper content-holder clearfix"> <div class="container"> <div class="row"> <div class="span12" data-motopress-wrapper-file="page-fullwidth.php" data-motopress-wrapper-type="content"> <div class="row"> <div class="span12" data-motopress-type="static" data-motopress-static-file="static/static-title.php"> <section class="title-section"> <h1 class="title-header"> Assurance Accident Maladie </h1> </section><!-- .title-section --> </div> </div> <div id="content" class="row"> <div class="span12" data-motopress-type="loop" data-motopress-loop-file="loop/loop-page.php"> <div id="post-3041" class="page post-3041 type-page status-publish hentry"> <div class="frm_forms with_frm_style frm_center_submit frm_style_style-formidable" id="frm_form_29_container" > <form enctype="multipart/form-data" method="post" class="frm-show-form frm_js_validate frm_pro_form frm_ajax_submit " id="form_wsde0" > <div class="frm_form_fields form-group"> <fieldset> <legend class="frm_hidden">Assurance Accident Maladie</legend> <div class="frm_fields_container"> <input type="hidden" name="frm_action" value="create" /> <input type="hidden" name="form_id" value="29" /> <input type="hidden" name="frm_hide_fields_29" id="frm_hide_fields_29" value="" /> <input type="hidden" name="form_key" value="wsde0" /> <input type="hidden" name="item_meta[0]" value="" /> <input type="hidden" id="frm_submit_entry_29" name="frm_submit_entry_29" value="82183b8bfc" /><input type="hidden" name="_wp_http_referer" value="/assurance-accident-maladie/" /><label for="frm_verify_29" class="frm_screen_reader frm_hidden">If you are human, leave this field blank.</label> <input type="text" class="frm_hidden frm_verify" id="frm_verify_29" name="frm_verify" value="" /> <div id="frm_field_378_container" class="frm_form_field frm_html_container form-field"> <h2 style="text-align: center;"><span style="color: #ffffff;"><b><u><br /> Assurance accident, maladie et salaire (employé ou propriétaire d'entreprise)</u></b></span></h2> </div> <div id="frm_field_381_container" class="frm_form_field frm_section_heading form-field frm_fourth frm_third"> <h3 class="frm_pos_top frm_section_spacing">Renseignement personnel</h3> <div id="frm_field_383_container" class="frm_form_field form-field frm_required_field form-group frm_top_container"> <label for="field_5w453" class="frm_primary_label control-label">Prénom <span class="frm_required">*</span> </label> <input type="text" id="field_5w453" name="item_meta[383]" value="" data-sectionid="381" style="width:300px" maxlength="25" data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Prénom est non valide" class="auto_width form-control" /> </div> <div id="frm_field_387_container" class="frm_form_field form-field frm_required_field form-group frm_top_container"> <label for="field_u2rq" class="frm_primary_label control-label">Nom <span class="frm_required">*</span> </label> <input type="text" id="field_u2rq" name="item_meta[387]" value="" data-sectionid="381" style="width:300px" maxlength="25" data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Nom est non valide" class="auto_width form-control" /> </div> <div id="frm_field_384_container" class="frm_form_field form-field frm_required_field form-group frm_top_container"> <label for="field_rx1aw" class="frm_primary_label control-label">Date de naissance (jj-mm-aaaa) <span class="frm_required">*</span> </label> <input type="text" id="field_rx1aw" name="item_meta[384]" value="" data-sectionid="381" data-frmmask="99-99-9999" style="width:300px" maxlength="12" data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Date de naissance (jj-mm-aaaa) est non valide" class="auto_width form-control" pattern="\d\d-\d\d-\d\d\d\d$" /> </div> <div id="frm_field_386_container" class="frm_form_field form-field frm_required_field form-group frm_top_container horizontal_radio"> <label class="frm_primary_label control-label">Sexe <span class="frm_required">*</span> </label> <div class="frm_opt_container"> <div class="frm_checkbox checkbox-inline checkbox" id="frm_checkbox_386-381-0"><label for="field_kitac-0"><input type="checkbox" name="item_meta[386][]" id="field_kitac-0" value="Femme" data-sectionid="381" data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Sexe est non valide" /> Femme</label></div> <div class="frm_checkbox checkbox-inline checkbox" id="frm_checkbox_386-381-1"><label for="field_kitac-1"><input type="checkbox" name="item_meta[386][]" id="field_kitac-1" value="Homme" data-sectionid="381" data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Sexe est non valide" /> Homme</label></div> </div> </div> <div id="frm_field_385_container" class="frm_form_field form-field frm_required_field form-group frm_top_container horizontal_radio"> <label class="frm_primary_label control-label">Fumeur <span class="frm_required">*</span> </label> <div class="frm_opt_container"> <div class="frm_checkbox checkbox-inline checkbox" id="frm_checkbox_385-381-0"><label for="field_k079r-0"><input type="checkbox" name="item_meta[385][]" id="field_k079r-0" value="Oui" data-sectionid="381" data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Fumeur est non valide" /> Oui</label></div> <div class="frm_checkbox checkbox-inline checkbox" id="frm_checkbox_385-381-1"><label for="field_k079r-1"><input type="checkbox" name="item_meta[385][]" id="field_k079r-1" value="Non" data-sectionid="381" data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Fumeur est non valide" /> Non</label></div> </div> </div> <div id="frm_field_416_container" class="frm_form_field form-field frm_required_field form-group frm_top_container"> <label for="field_2dgs4" class="frm_primary_label control-label">Meilleur pour vous contacter <span class="frm_required">*</span> </label> <select name="item_meta[416]" id="field_2dgs4" data-sectionid="381" data-frmval="Choisir ..." data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Meilleur pour vous contacter est non valide" class="form-control" > <option value="Choisir ..." selected="selected" class=""> Choisir ... </option> <option value="Matin" class=""> Matin </option> <option value="Après-midi" class=""> Après-midi </option> <option value="Soir" class=""> Soir </option> <option value="En tout temps" class=""> En tout temps </option> </select> </div> <input type="hidden" name="item_meta[388]" id="field_kg1l8" value="" data-sectionid="381" data-invmsg="Problème de santé est non valide" class="form-control" /> </div> <div id="frm_field_389_container" class="frm_form_field frm_section_heading form-field frm_third"> <h3 class="frm_pos_top frm_section_spacing">Types de protections<!--Couvert par un régime autre.--></h3> <div id="frm_field_417_container" class="frm_form_field form-field form-group frm_top_container vertical_radio"> <label class="frm_primary_label control-label"> <span class="frm_required"></span> </label> <div class="frm_opt_container"> <div class="frm_checkbox checkbox" id="frm_checkbox_417-389-0"><label for="field_3ds0z-0"><input type="checkbox" name="item_meta[417][]" id="field_3ds0z-0" value="  Remplacement de salaire" data-sectionid="389" data-invmsg=" est non valide" />   Remplacement de salaire</label></div> <div class="frm_checkbox checkbox" id="frm_checkbox_417-389-1"><label for="field_3ds0z-1"><input type="checkbox" name="item_meta[417][]" id="field_3ds0z-1" value="  Prêt commercial" data-sectionid="389" data-invmsg=" est non valide" />   Prêt commercial</label></div> <div class="frm_checkbox checkbox" id="frm_checkbox_417-389-2"><label for="field_3ds0z-2"><input type="checkbox" name="item_meta[417][]" id="field_3ds0z-2" value="  Frais généraux (frais fix d'entreprise)" data-sectionid="389" data-invmsg=" est non valide" />   Frais généraux (frais fix d'entreprise)</label></div> <div class="frm_checkbox checkbox" id="frm_checkbox_417-389-3"><label for="field_3ds0z-3"><input type="checkbox" name="item_meta[417][]" id="field_3ds0z-3" value="  Rachat de parts" data-sectionid="389" data-invmsg=" est non valide" />   Rachat de parts</label></div> <div class="frm_checkbox checkbox" id="frm_checkbox_417-389-4"><label for="field_3ds0z-4"><input type="checkbox" name="item_meta[417][]" id="field_3ds0z-4" value="  Personne clé" data-sectionid="389" data-invmsg=" est non valide" />   Personne clé</label></div> <div class="frm_checkbox checkbox" id="frm_checkbox_417-389-5"><label for="field_3ds0z-5"><input type="checkbox" name="item_meta[417][]" id="field_3ds0z-5" value="  Maladie graves" data-sectionid="389" data-invmsg=" est non valide" />   Maladie graves</label></div> <div class="frm_checkbox checkbox" id="frm_checkbox_417-389-6"><label for="field_3ds0z-6"><input type="checkbox" name="item_meta[417][]" id="field_3ds0z-6" value="  Soins de longue durée" data-sectionid="389" data-invmsg=" est non valide" />   Soins de longue durée</label></div> </div> </div> <input type="hidden" name="item_meta[391]" id="field_lyogx-0" value="" data-sectionid="389" data-invmsg="Assurance chômage est non valide" class="form-control" /> <input type="hidden" name="item_meta[392]" id="field_4iuxx-0" value="" data-sectionid="389" data-invmsg="CSST est non valide" class="form-control" /> <div id="frm_field_396_container" class="frm_form_field frm_html_container form-field"><!-- <h4 style="text-align: justify;"><span style="color: #ffffff;"><b> Autre assurance accident, maladie ou invalidité en vigueur</b></span></h4> --></div> <input type="hidden" name="item_meta[414]" id="field_2sozu-0" value="" data-sectionid="389" data-invmsg="Autre assurance accident, maladie ou invalidité est non valide" class="form-control" /> <input type="hidden" name="item_meta[394]" id="field_xi3d7-0" value="" data-sectionid="389" data-invmsg="Individuelle est non valide" class="form-control" /> <input type="hidden" name="item_meta[395]" id="field_qtjoo-0" value="" data-sectionid="389" data-invmsg="Collective est non valide" class="form-control" /> <input type="hidden" name="item_meta[397]" id="field_lhdur" value="" data-sectionid="389" data-invmsg="<span class="frm_checkbox checkbox-inline checkbox"> Montant de la couverture</span> est non valide" class="form-control" /> <input type="hidden" name="item_meta[398]" id="field_3jb05" value="" data-sectionid="389" data-invmsg="<span class="frm_checkbox checkbox-inline checkbox"> Délai de carence (en jours)</span> est non valide" class="form-control" /> <input type="hidden" name="item_meta[399]" id="field_v5724" value="" data-sectionid="389" data-invmsg="<span class="frm_checkbox checkbox-inline checkbox"> Durée des prestations</span> est non valide" class="form-control" /> <input type="hidden" name="item_meta[401]" id="field_i9kkc-0" value="" data-sectionid="389" data-invmsg="Imposable est non valide" class="form-control" /> </div> <div id="frm_field_403_container" class="frm_form_field frm_section_heading form-field frm_third"> <h3 class="frm_pos_top frm_section_spacing">Informations professionnels</h3> <div id="frm_field_405_container" class="frm_form_field form-field form-group frm_top_container"> <label for="field_5zitc" class="frm_primary_label control-label">Profession <span class="frm_required"></span> </label> <input type="text" id="field_5zitc" name="item_meta[405]" value="" data-sectionid="403" data-invmsg="Profession est non valide" class="form-control" /> </div> <div id="frm_field_406_container" class="frm_form_field form-field form-group frm_top_container"> <label for="field_fmgg9" class="frm_primary_label control-label">Diplôme <span class="frm_required"></span> </label> <input type="text" id="field_fmgg9" name="item_meta[406]" value="" data-sectionid="403" data-invmsg="Diplôme est non valide" class="form-control" /> </div> <div id="frm_field_407_container" class="frm_form_field form-field form-group frm_top_container"> <label for="field_bt1h4" class="frm_primary_label control-label">Fonctions <span class="frm_required"></span> </label> <input type="text" id="field_bt1h4" name="item_meta[407]" value="" data-sectionid="403" data-invmsg="Fonctions est non valide" class="form-control" /> </div> <div id="frm_field_408_container" class="frm_form_field form-field form-group frm_top_container"> <label for="field_r8pum" class="frm_primary_label control-label">Genre d'entreprise <span class="frm_required"></span> </label> <input type="text" id="field_r8pum" name="item_meta[408]" value="" data-sectionid="403" data-invmsg="Genre d'entreprise est non valide" class="form-control" /> </div> <div id="frm_field_409_container" class="frm_form_field frm_html_container form-field"> <h3 style="text-align: justify;"><span style="color: #ffffff;"><b><br /> Type de travail</b></span></h3> </div> <div id="frm_field_410_container" class="frm_form_field form-field form-group frm_top_container"> <label for="field_r3yo6" class="frm_primary_label control-label">Travail manuel (%) <span class="frm_required"></span> </label> <input type="text" id="field_r3yo6" name="item_meta[410]" value="" data-sectionid="403" data-invmsg="Travail manuel (%) est non valide" class="form-control" /> </div> <div id="frm_field_411_container" class="frm_form_field form-field form-group frm_top_container"> <label for="field_a5r1s" class="frm_primary_label control-label">Supervision (%) <span class="frm_required"></span> </label> <input type="text" id="field_a5r1s" name="item_meta[411]" value="" data-sectionid="403" data-invmsg="Supervision (%) est non valide" class="form-control" /> </div> <div id="frm_field_412_container" class="frm_form_field form-field form-group frm_top_container"> <label for="field_5d1et" class="frm_primary_label control-label">Travail de bureau (%) <span class="frm_required"></span> </label> <input type="text" id="field_5d1et" name="item_meta[412]" value="" data-sectionid="403" data-invmsg="Travail de bureau (%) est non valide" class="form-control" /> </div> <div id="frm_field_413_container" class="frm_form_field form-field form-group frm_top_container"> <label for="field_wymaz" class="frm_primary_label control-label">Autre (vente, rep sur la route, ... et %) <span class="frm_required"></span> </label> <input type="text" id="field_wymaz" name="item_meta[413]" value="" data-sectionid="403" data-invmsg="Autre (vente, rep sur la route, ... et %) est non valide" class="form-control" /> </div> </div> <div id="frm_field_461_container" class="frm_form_field form-field form-group frm_none_container"> <label class="frm_primary_label control-label">reCAPTCHA <span class="frm_required"></span> </label> <div id="field_hudd1" class="g-recaptcha" data-sitekey="6LcFfD8UAAAAALAdMMv5JxWDatevDaguw_Gp_1Rk" data-size="normal" data-theme="light"></div> </div> <input type="hidden" name="item_meta[463]" id="field_byjnq" value="" data-frmval=""/> <input type="hidden" name="item_key" value="" /> <div class="form-group frm_submit"> <button class="frm_button_submit btn 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