</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="675409c692c61"> <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 current-menu-item page_item page-item-2185 current_page_item"><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"><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"> Soumission </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-2185" class="page post-2185 type-page status-publish hentry"> <div class="frm_forms with_frm_style frm_center_submit frm_style_style-formidable" id="frm_form_8_container" > <form enctype="multipart/form-data" method="post" class="frm-show-form frm_js_validate frm_pro_form frm_ajax_submit " id="form_tlag" > <div class="frm_form_fields form-group"> <fieldset> <legend class="frm_hidden">Soumission</legend> <div class="frm_fields_container"> <input type="hidden" name="frm_action" value="create" /> <input type="hidden" name="form_id" value="8" /> <input type="hidden" name="frm_hide_fields_8" id="frm_hide_fields_8" value="" /> <input type="hidden" name="form_key" value="tlag" /> <input type="hidden" name="item_meta[0]" value="" /> <input type="hidden" id="frm_submit_entry_8" name="frm_submit_entry_8" value="ddfa157c52" /><input type="hidden" name="_wp_http_referer" value="/soumission/" /><label for="frm_verify_8" 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_8" name="frm_verify" value="" /> <div id="frm_field_91_container" class="frm_form_field frm_section_heading form-field frm_first frm_half"> <h3 class="frm_pos_top frm_section_spacing">Informations générales</h3> <div id="frm_field_114_container" class="frm_form_field form-field frm_required_field form-group frm_top_container frm_first frm_half"> <label for="field_5fx34" class="frm_primary_label control-label">Prénom <span class="frm_required">*</span> </label> <input type="text" id="field_5fx34" name="item_meta[114]" value="" data-sectionid="91" style="width:300px" maxlength="50" 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_80_container" class="frm_form_field form-field frm_required_field form-group frm_top_container frm_first frm_half"> <label for="field_jxjfj" class="frm_primary_label control-label">Nom <span class="frm_required">*</span> </label> <input type="text" id="field_jxjfj" name="item_meta[80]" value="" data-sectionid="91" style="width:300px" maxlength="50" 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_83_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_radio radio-inline radio"><label for="field_zbkxa-0"> <input type="radio" name="item_meta[83]" id="field_zbkxa-0" value="Femme" data-sectionid="91" data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Sexe est non valide" /> Femme</label></div> <div class="frm_radio radio-inline radio"><label for="field_zbkxa-1"> <input type="radio" name="item_meta[83]" id="field_zbkxa-1" value="Homme" data-sectionid="91" data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Sexe est non valide" /> Homme</label></div> </div> </div> <div id="frm_field_81_container" class="frm_form_field form-field frm_required_field form-group frm_top_container"> <label for="field_zf6xy" class="frm_primary_label control-label">Adresse <span class="frm_required">*</span> </label> <input type="text" id="field_zf6xy" name="item_meta[81]" value="" data-sectionid="91" style="width:300px" maxlength="50" data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Adresse est non valide" class="auto_width form-control" /> </div> <div id="frm_field_85_container" class="frm_form_field form-field frm_required_field form-group frm_top_container frm_first frm_half"> <label for="field_8b2uq" class="frm_primary_label control-label">Ville <span class="frm_required">*</span> </label> <input type="text" id="field_8b2uq" name="item_meta[85]" value="" data-sectionid="91" maxlength="25" data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Ville est non valide" class="form-control" /> </div> <div id="frm_field_115_container" class="frm_form_field form-field frm_required_field form-group frm_top_container"> <label for="field_mthr0" class="frm_primary_label control-label">Code Postal <span class="frm_required">*</span> </label> <input type="text" id="field_mthr0" name="item_meta[115]" value="" data-sectionid="91" data-frmmask="a9a 9a9" style="width:300px" data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Code Postal est non valide" class="auto_width form-control" pattern="[a-z]\d[a-z] \d[a-z]\d$" /> </div> <div id="frm_field_86_container" class="frm_form_field form-field form-group frm_top_container"> <label for="field_mypj2" class="frm_primary_label control-label">Province <span class="frm_required"></span> </label> <input type="text" id="field_mypj2" name="item_meta[86]" value="Québec" data-sectionid="91" style="width:300px" maxlength="25" data-frmval="Québec" data-invmsg="Province est non valide" class="auto_width form-control" /> </div> <div id="frm_field_87_container" class="frm_form_field form-field frm_required_field form-group frm_top_container"> <label for="field_oq9f3" class="frm_primary_label control-label">Téléphone <span class="frm_required">*</span> </label> <input type="tel" id="field_oq9f3" name="item_meta[87]" value="" data-sectionid="91" style="width:300px" maxlength="12" data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Téléphone est non valide" class="auto_width form-control" pattern="((\+\d{1,3}(-|.| )?\(?\d\)?(-| |.)?\d{1,5})|(\(?\d{2,6}\)?))(-|.| )?(\d{3,4})(-|.| )?(\d{4})(( x| ext)\d{1,5}){0,1}$" /> </div> <div id="frm_field_88_container" class="frm_form_field form-field frm_required_field form-group frm_top_container"> <label for="field_5is3e" class="frm_primary_label control-label">Courriel <span class="frm_required">*</span> </label> <input type="email" id="field_5is3e" name="item_meta[88]" value="" data-sectionid="91" style="width:300px" maxlength="35" data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Courriel est non valide" class="auto_width form-control" /> </div> </div> <input type="hidden" name="item_meta[84]" id="field_9hoyt" value="" data-frmval=""/> <div id="frm_field_95_container" class="frm_form_field frm_section_heading form-field frm_half"> <h3 class="frm_pos_top frm_section_spacing">Choix du type d'assurance</h3> <div id="frm_field_98_container" class="frm_form_field form-field frm_required_field form-group frm_top_container frm_half"> <label for="field_ky7a6" class="frm_primary_label control-label">Type d'assurance <span class="frm_required">*</span> </label> <select name="item_meta[98]" id="field_ky7a6" data-sectionid="95" data-frmval="Choisir ..." data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Type d'assurance est non valide" class="auto_width form-control" > <option value="Choisir ..." selected="selected" class=""> Choisir ... </option> <option value="Assurance Vie" class=""> Assurance Vie </option> <option value="Assurance Hypothécaire" class=""> Assurance Hypothécaire </option> <option value="Assurance Prêt ( auto / marge de crédit / carte de crédit / etc. )" class=""> Assurance Prêt ( auto / marge de crédit / carte de crédit / etc. ) </option> <option value="Assurance Invalidité" class=""> Assurance Invalidité </option> <option value="Assurance Maladie Grave" class=""> Assurance Maladie Grave </option> <option value="Assurance Sans Examen Médicale" class=""> Assurance Sans Examen Médicale </option> <option value="Assurancce Pour Les 50 ans Et Plus" class=""> Assurancce Pour Les 50 ans Et Plus </option> <option value="Assurance Succesorale" class=""> Assurance Succesorale </option> <option value="Assurance soins de longue durée" class=""> Assurance soins de longue durée </option> <option value="Autre. . ." class=""> Autre. . . </option> </select> </div> <div id="frm_field_106_container" class="frm_form_field form-field frm_required_field form-group frm_top_container frm_half horizontal_radio"> <label class="frm_primary_label control-label">Fumeur <span class="frm_required">*</span> </label> <div class="frm_opt_container"> <div class="frm_radio radio-inline radio"><label for="field_1xosn-0"> <input type="radio" name="item_meta[106]" id="field_1xosn-0" value="Oui" data-sectionid="95" data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Fumeur est non valide" /> Oui</label></div> <div class="frm_radio radio-inline radio"><label for="field_1xosn-1"> <input type="radio" name="item_meta[106]" id="field_1xosn-1" value="Non" data-sectionid="95" data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Fumeur est non valide" /> Non</label></div> </div> </div> <div id="frm_field_105_container" class="frm_form_field form-field frm_required_field form-group frm_top_container frm_half"> <label for="field_kcq9g" class="frm_primary_label control-label">Date de naissance <span class="frm_required">*</span> </label> <input type="text" id="field_kcq9g" name="item_meta[105]" value="" data-sectionid="95" data-frmmask="99-99-9999" data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Date de naissance est non valide" class="form-control" pattern="\d\d-\d\d-\d\d\d\d$" /> </div> <div id="frm_field_111_container" class="frm_form_field form-field form-group frm_top_container frm_half"> <label for="field_pjkpo" class="frm_primary_label control-label">Montant d'assurance <span class="frm_required"></span> </label> <select name="item_meta[111]" id="field_pjkpo" data-sectionid="95" data-frmval="Choisir ..." data-invmsg="Montant d'assurance est non valide" class="form-control" > <option value="Choisir ..." selected="selected" class=""> Choisir ... </option> <option value="5,000" class=""> 5,000 </option> <option value="10,000" class=""> 10,000 </option> <option value="15,000" class=""> 15,000 </option> <option value="20,000" class=""> 20,000 </option> <option value="25,000" class=""> 25,000 </option> <option value="30,000" class=""> 30,000 </option> <option value="35,000" class=""> 35,000 </option> <option value="40,000" class=""> 40,000 </option> <option value="45,000" class=""> 45,000 </option> <option value="50,000" class=""> 50,000 </option> <option value="75,000" class=""> 75,000 </option> <option value="100,000" class=""> 100,000 </option> <option value="125,000" class=""> 125,000 </option> <option value="150,000" class=""> 150,000 </option> <option value="175,000" class=""> 175,000 </option> <option value="200,000" class=""> 200,000 </option> <option value="225,000" class=""> 225,000 </option> <option value="250,000" class=""> 250,000 </option> <option value="300,000" class=""> 300,000 </option> <option value="325,000" class=""> 325,000 </option> <option value="350,000" class=""> 350,000 </option> <option value="375,000" class=""> 375,000 </option> <option value="400,000" class=""> 400,000 </option> <option value="425,000" class=""> 425,000 </option> <option value="450,000" class=""> 450,000 </option> <option value="475,000" class=""> 475,000 </option> <option value="500,000" class=""> 500,000 </option> <option value="550,000" class=""> 550,000 </option> <option value="600,000" class=""> 600,000 </option> <option value="700,000" class=""> 700,000 </option> <option value="800,000" class=""> 800,000 </option> <option value="900,000" class=""> 900,000 </option> <option value="1,000,000" class=""> 1,000,000 </option> <option value="1,500,000" class=""> 1,500,000 </option> <option value="2,000,000" class=""> 2,000,000 </option> <option value="3,000,000" class=""> 3,000,000 </option> <option value="4,000,000" class=""> 4,000,000 </option> <option value="5,000,000" class=""> 5,000,000 </option> <option value="Autre ..." class=""> Autre ... </option> </select> </div> <div id="frm_field_112_container" class="frm_form_field form-field frm_required_field form-group frm_top_container frm_half"> <label for="field_tq4x" class="frm_primary_label control-label">Meilleur moment pour vous contacter <span class="frm_required">*</span> </label> <select name="item_meta[112]" id="field_tq4x" data-sectionid="95" data-frmval="Choisir ..." data-reqmsg="Ce champ ne peut pas être vide" data-invmsg="Meilleur moment 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> <div id="frm_field_113_container" class="frm_form_field form-field form-group frm_top_container frm_half"> <label for="field_6zlc5" class="frm_primary_label control-label">Commentaires <span class="frm_required"></span> </label> <textarea name="item_meta[113]" id="field_6zlc5" rows="5" data-sectionid="95" data-invmsg="Commentaires est non valide" class="form-control" ></textarea> </div> </div> <div id="frm_field_459_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_4mnup" class="g-recaptcha" data-sitekey="6LcFfD8UAAAAALAdMMv5JxWDatevDaguw_Gp_1Rk" data-size="normal" data-theme="light"></div> </div> <input type="hidden" name="item_key" value="" /> <div class="form-group frm_submit"> <input class="frm_button_submit btn btn-default 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