{"id":10854,"date":"2025-06-18T14:44:38","date_gmt":"2025-06-18T12:44:38","guid":{"rendered":"https:\/\/www.vdl-interass.be\/assutop-incendie-particuliers\/"},"modified":"2025-06-24T09:49:06","modified_gmt":"2025-06-24T07:49:06","slug":"assutop-incendie-particuliers","status":"publish","type":"page","link":"https:\/\/www.vdl-interass.be\/fr\/assutop-incendie-particuliers\/","title":{"rendered":"Assutop Incendie Particuliers"},"content":{"rendered":"<div class=\"fusion-fullwidth fullwidth-box fusion-builder-row-1 fusion-flex-container has-pattern-background has-mask-background nonhundred-percent-fullwidth non-hundred-percent-height-scrolling\" style=\"--awb-border-radius-top-left:0px;--awb-border-radius-top-right:0px;--awb-border-radius-bottom-right:0px;--awb-border-radius-bottom-left:0px;--awb-flex-wrap:wrap;\" ><div class=\"fusion-builder-row fusion-row fusion-flex-align-items-flex-start fusion-flex-content-wrap\" style=\"max-width:1456px;margin-left: calc(-4% \/ 2 );margin-right: calc(-4% \/ 2 );\"><div class=\"fusion-layout-column fusion_builder_column fusion-builder-column-0 fusion_builder_column_1_1 1_1 fusion-flex-column\" style=\"--awb-bg-size:cover;--awb-width-large:100%;--awb-margin-top-large:0px;--awb-spacing-right-large:1.92%;--awb-margin-bottom-large:20px;--awb-spacing-left-large:1.92%;--awb-width-medium:100%;--awb-order-medium:0;--awb-spacing-right-medium:1.92%;--awb-spacing-left-medium:1.92%;--awb-width-small:100%;--awb-order-small:0;--awb-spacing-right-small:1.92%;--awb-spacing-left-small:1.92%;\"><div class=\"fusion-column-wrapper fusion-column-has-shadow fusion-flex-justify-content-flex-start fusion-content-layout-column\"><script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_12' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Assutop incendie particuliers<\/h2>\n                            <p class='gform_description'><\/p>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>\u00ab\u00a0<span class=\"gfield_required gfield_required_asterisk\">*<\/span>\u00a0\u00bb indique les champs n\u00e9cessaires<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_12'  action='\/fr\/wp-json\/wp\/v2\/pages\/10854' data-formid='12' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_12' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_12_80\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_admin_only exclude entry_lang field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_administrative\"  ><input name='input_80' id='input_12_80' class='gform_hidden' type='hidden' value='fr'\/><\/div><div id=\"field_12_76\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_76'><span class='gform-field-label__text'>Agent<\/span><\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_76' id='input_12_76' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_77\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_77'><span class='gform-field-label__text'>Gestionnaire<\/span><\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_77' id='input_12_77' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_79\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_79'><span class='gform-field-label__text'>Date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input readonly='readonly' name='input_79' id='input_12_79' type='text' value='25\/10\/2026' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_75\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_75'><span class='gform-field-label__text'>Email<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_75' id='input_12_75' type='email' value='' class='large'    aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_12_6\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Preneur d&#039;assurance<\/h3><\/div><fieldset id=\"field_12_3\" class=\"gfield gfield--type-name gfield--input-type-name field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Nom<\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_12_3'>\n                            \n                            <span id='input_12_3_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.3' id='input_12_3_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_12_3_3' class='gform-field-label gform-field-label--type-sub '>Nom de famille<\/label>\n                                                <\/span>\n                            \n                            <span id='input_12_3_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_3.6' id='input_12_3_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_12_3_6' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_12_38\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_38'><span class='gform-field-label__text'>Date de naissance<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='jj\/mm\/aaaa'\n\t\t\t\t\tid='input_12_38'\n\t\t\t\t\tclass='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_38'\n\t\t\t\t value=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_12_38' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_12_38' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_12_38' aria-label='Date de naissance: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><fieldset id=\"field_12_5\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Adresse<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip ginput_container_address gform-grid-row' id='input_12_5' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_12_5_1_container' >\n                                        <input type='text' name='input_5.1' id='input_12_5_1' value=''    aria-required='true'    \/>\n                                        <label for='input_12_5_1' id='input_12_5_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_12_5_3_container' >\n                                    <input type='text' name='input_5.3' id='input_12_5_3' value=''    aria-required='true'    \/>\n                                    <label for='input_12_5_3' id='input_12_5_3_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_5.4' id='input_12_5_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_12_5_5_container' >\n                                    <input type='text' name='input_5.5' id='input_12_5_5' value=''    aria-required='true'    \/>\n                                    <label for='input_12_5_5' id='input_12_5_5_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_5.6' id='input_12_5_6' value='' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_12_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Risque<\/h3><\/div><fieldset id=\"field_12_8\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Situation identique \u00e0 l&#039;adresse du preneur<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_8'>\n\t\t\t<div class='gchoice gchoice_12_8_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Oui'  id='choice_12_8_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_8_0' id='label_12_8_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_8_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_8' type='radio' value='Non'  id='choice_12_8_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_8_1' id='label_12_8_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Type de b\u00e2timent<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_28'>\n\t\t\t<div class='gchoice gchoice_12_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Maison unifamiliale'  id='choice_12_28_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_12_28\"   \/>\n\t\t\t\t\t<label for='choice_12_28_0' id='label_12_28_0' class='gform-field-label gform-field-label--type-inline'>Maison unifamiliale<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Appartement'  id='choice_12_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_28_1' id='label_12_28_1' class='gform-field-label gform-field-label--type-inline'>Appartement<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_12_28'>En cas de risque sp\u00e9cial (ex : chalet, mobil-home, immeuble, etc.) veuillez contacter Interass.<\/div><\/fieldset><fieldset id=\"field_12_32\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Qualit\u00e9 du preneur<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_32'>\n\t\t\t<div class='gchoice gchoice_12_32_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Propri\u00e9taire'  id='choice_12_32_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_32_0' id='label_12_32_0' class='gform-field-label gform-field-label--type-inline'>Propri\u00e9taire<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_32_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_32' type='radio' value='Locataire'  id='choice_12_32_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_32_1' id='label_12_32_1' class='gform-field-label gform-field-label--type-inline'>Locataire<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_9\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Adresse<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip has_country ginput_container_address gform-grid-row' id='input_12_9' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_12_9_1_container' >\n                                        <input type='text' name='input_9.1' id='input_12_9_1' value=''    aria-required='true'    \/>\n                                        <label for='input_12_9_1' id='input_12_9_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_12_9_3_container' >\n                                    <input type='text' name='input_9.3' id='input_12_9_3' value=''    aria-required='true'    \/>\n                                    <label for='input_12_9_3' id='input_12_9_3_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_9.4' id='input_12_9_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_12_9_5_container' >\n                                    <input type='text' name='input_9.5' id='input_12_9_5' value=''    aria-required='true'    \/>\n                                    <label for='input_12_9_5' id='input_12_9_5_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                <\/span><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_12_9_6_container' >\n                                        <select name='input_9.6' id='input_12_9_6'   aria-required='true'    ><option value='' ><\/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='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' >Azerba\u00efdjan<\/option><option value='BS' >Bahamas<\/option><option value='BH' >Bahre\u00efn<\/option><option value='BD' >Bangladesh<\/option><option value='BY' >Belarus<\/option><option value='BE' >Belgique<\/option><option value='BZ' >Belize<\/option><option value='BJ' >B\u00e9nin<\/option><option value='BM' >Bermudes<\/option><option value='BT' >Bhoutan<\/option><option value='BO' >Bolivie<\/option><option value='BQ' >Bonaire, Saint-Eustache et Saba<\/option><option value='BA' >Bosnie-Herz\u00e9govine<\/option><option value='BW' >Botswana<\/option><option value='BR' >Br\u00e9sil<\/option><option value='BN' >Brunei Darussalam<\/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='CY' >Chypre<\/option><option value='CO' >Colombie<\/option><option value='KM' >Comores<\/option><option value='CG' >Congo<\/option><option value='KR' >Cor\u00e9e (R\u00e9publique de)<\/option><option value='KP' >Cor\u00e9e (R\u00e9publique populaire d\u00e9mocratique de)<\/option><option value='CR' >Costa Rica<\/option><option value='CI' >C\u00f4te d\u2019Ivoire<\/option><option value='HR' >Croatie<\/option><option value='CU' >Cuba<\/option><option value='CW' >Cura\u00e7ao<\/option><option value='DK' >Danemark<\/option><option value='DJ' >Djibouti<\/option><option value='DM' >Dominique<\/option><option value='EG' >\u00c9gypte<\/option><option value='AE' >\u00c9mirats arabes unis<\/option><option value='EC' >\u00c9quateur<\/option><option value='ER' >\u00c9rythr\u00e9e<\/option><option value='ES' >Espagne<\/option><option value='EE' >Estonie<\/option><option value='SZ' >Eswatini<\/option><option value='PS' >\u00c9tat palestinien<\/option><option value='US' >\u00c9tats-Unis<\/option><option value='ET' >\u00c9thiopie<\/option><option value='RU' >F\u00e9d\u00e9ration Russe<\/option><option value='FJ' >Fidji<\/option><option value='FI' >Finlande<\/option><option value='FR' >France<\/option><option value='GA' >Gabon<\/option><option value='GM' >Gambie<\/option><option value='GE' >G\u00e9orgie<\/option><option value='GS' >G\u00e9orgie du Sud et \u00celes Sandwich du Sud<\/option><option value='GH' >Ghana<\/option><option value='GI' >Gibraltar<\/option><option value='GR' >Gr\u00e8ce<\/option><option value='GD' >Grenade<\/option><option value='GL' >Groenland<\/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='GF' >Guyane<\/option><option value='GY' >Guyane<\/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='BV' >\u00cele Bouvet<\/option><option value='CX' >\u00cele Christmas<\/option><option value='IM' >\u00cele de Man<\/option><option value='MU' >\u00cele Maurice<\/option><option value='NF' >\u00cele Norfolk<\/option><option value='AX' >\u00celes \u00c5land<\/option><option value='KY' >\u00celes Cayman<\/option><option value='CC' >\u00celes Cocos<\/option><option value='CK' >\u00celes Cook<\/option><option value='SJ' >\u00celes de Svalbard et Jan Mayen<\/option><option value='FK' >\u00celes Falkland<\/option><option value='FO' >\u00celes F\u00e9ro\u00e9<\/option><option value='HM' >\u00celes Heard et McDonald<\/option><option value='MP' >\u00celes Mariannes du Nord<\/option><option value='MH' >\u00celes Marshall<\/option><option value='UM' >\u00celes mineures am\u00e9ricaines<\/option><option value='PN' >\u00celes Pitcairn<\/option><option value='SB' >\u00celes Salomon<\/option><option value='TC' >\u00celes Turques et Ca\u00efques<\/option><option value='VI' >\u00celes Vierges am\u00e9ricaines<\/option><option value='VG' >\u00celes Vierges britanniques<\/option><option value='IN' >Inde<\/option><option value='ID' >Indon\u00e9sie<\/option><option value='IQ' >Irak<\/option><option value='IR' >Iran<\/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='KG' >Kirghizistan<\/option><option value='KI' >Kiribati<\/option><option value='KW' >Kowe\u00eft<\/option><option value='BB' >La Barbade<\/option><option value='RE' >La R\u00e9union<\/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<\/option><option value='MK' >Mac\u00e9doine du Nord<\/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='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' >Mont\u00e9n\u00e9gro<\/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='NP' >N\u00e9pal<\/option><option value='NI' >Nicaragua<\/option><option value='NE' >Niger<\/option><option value='NG' >Nig\u00e9ria<\/option><option value='NU' >Niu\u00e9<\/option><option value='NO' >Norv\u00e8ge<\/option><option value='NC' >Nouvelle-Cal\u00e9donie<\/option><option value='NZ' >Nouvelle-Z\u00e9lande<\/option><option value='OM' >Oman<\/option><option value='UG' >Ouganda<\/option><option value='UZ' >Ouzb\u00e9kistan<\/option><option value='PK' >Pakistan<\/option><option value='PW' >Palau<\/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='PE' >P\u00e9rou<\/option><option value='PH' >Philippines<\/option><option value='PL' >Pologne<\/option><option value='PF' >Polyn\u00e9sie fran\u00e7aise<\/option><option value='PR' >Porto Rico<\/option><option value='PT' >Portugal<\/option><option value='QA' >Qatar<\/option><option value='SY' >R\u00e9publique arabe syrienne<\/option><option value='CF' >R\u00e9publique centrafricaine<\/option><option value='CD' >R\u00e9publique d\u00e9mocratique du Congo<\/option><option value='LA' >R\u00e9publique d\u00e9mocratique populaire du Laos<\/option><option value='DO' >R\u00e9publique Dominicaine<\/option><option value='CZ' >R\u00e9publique Tch\u00e8que<\/option><option value='RO' >Roumanie<\/option><option value='GB' >Royaume-Uni<\/option><option value='RW' >Rwanda<\/option><option value='EH' >Sahara occidental<\/option><option value='BL' >Saint Barth\u00e9lemy<\/option><option value='MF' >Saint Martin<\/option><option value='PM' >Saint Pierre et Miquelon<\/option><option value='KN' >Saint-Christophe-et-Nevis<\/option><option value='SM' >Saint-Marin<\/option><option value='VA' >Saint-Si\u00e8ge<\/option><option value='VC' >Saint-Vincent-et-les Grenadines<\/option><option value='SH' >Sainte-H\u00e9l\u00e8ne, Ascension et Tristan da Cunha<\/option><option value='LC' >Sainte-Lucie<\/option><option value='SV' >Salvador<\/option><option value='WS' >Samoa<\/option><option value='AS' >Samoa am\u00e9ricaines<\/option><option value='ST' >Sao Tom\u00e9 et Principe<\/option><option value='SN' >S\u00e9n\u00e9gal<\/option><option value='RS' >Serbie<\/option><option value='SC' >Seychelles<\/option><option value='SL' >Sierra Leone<\/option><option value='SG' >Singapour<\/option><option value='SX' >Sint Maarten<\/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='SE' >Su\u00e8de<\/option><option value='CH' >Suisse<\/option><option value='SR' >Suriname<\/option><option value='TJ' >Tadjikistan<\/option><option value='TW' >Ta\u00efwan<\/option><option value='TZ' >Tanzanie (R\u00e9publique-Unie de)<\/option><option value='TD' >Tchad<\/option><option value='TF' >Terres Australes Fran\u00e7aises<\/option><option value='IO' >Territoire britannique de l\u2019oc\u00e9an Indien<\/option><option value='TH' >Tha\u00eflande<\/option><option value='TL' >Timor oriental<\/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='UA' >Ukraine<\/option><option value='UY' >Uruguay<\/option><option value='VU' >Vanuatu<\/option><option value='VE' >Venezuela<\/option><option value='VN' >Vietnam<\/option><option value='WF' >Wallis et Futuna<\/option><option value='YE' >Y\u00e9men<\/option><option value='ZM' >Zambie<\/option><option value='ZW' >Zimbabwe<\/option><\/select>\n                                        <label for='input_12_9_6' id='input_12_9_6_label' class='gform-field-label gform-field-label--type-sub '>Pays<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><fieldset id=\"field_12_11\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Garanties<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_11'><div class='gchoice gchoice_12_11_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.1' type='checkbox'  value='B\u00e2timent'  id='choice_12_11_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_11_1' id='label_12_11_1' class='gform-field-label gform-field-label--type-inline'>B\u00e2timent<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_11_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.2' type='checkbox'  value='Contenu'  id='choice_12_11_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_11_2' id='label_12_11_2' class='gform-field-label gform-field-label--type-inline'>Contenu<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_11_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_11.3' type='checkbox'  value='Vol'  id='choice_12_11_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_11_3' id='label_12_11_3' class='gform-field-label gform-field-label--type-inline'>Vol<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_12\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Formules d&#039;\u00e9valuation b\u00e2timent<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_12'>\n\t\t\t<div class='gchoice gchoice_12_12_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Montant \u00e0 assurer'  id='choice_12_12_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_12_0' id='label_12_12_0' class='gform-field-label gform-field-label--type-inline'>Montant \u00e0 assurer<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_12_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_12' type='radio' value='Plan de pi\u00e8ces'  id='choice_12_12_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_12_1' id='label_12_12_1' class='gform-field-label gform-field-label--type-inline'>Plan de pi\u00e8ces<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_44\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Formules d&#039;\u00e9valuation b\u00e2timent<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_44'>\n\t\t\t<div class='gchoice gchoice_12_44_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Montant \u00e0 assurer'  id='choice_12_44_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_44_0' id='label_12_44_0' class='gform-field-label gform-field-label--type-inline'>Montant \u00e0 assurer<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_44_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='Plan de pi\u00e8ces'  id='choice_12_44_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_44_1' id='label_12_44_1' class='gform-field-label gform-field-label--type-inline'>Plan de pi\u00e8ces<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_44_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_44' type='radio' value='20x le prix du loyer annuel'  id='choice_12_44_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_44_2' id='label_12_44_2' class='gform-field-label gform-field-label--type-inline'>20x le prix du loyer annuel<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Formules d&#039;\u00e9valuation contenu<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_23'>\n\t\t\t<div class='gchoice gchoice_12_23_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Montant \u00e0 assurer'  id='choice_12_23_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_23_0' id='label_12_23_0' class='gform-field-label gform-field-label--type-inline'>Montant \u00e0 assurer<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_23_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Plan de pi\u00e8ces'  id='choice_12_23_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_23_1' id='label_12_23_1' class='gform-field-label gform-field-label--type-inline'>Plan de pi\u00e8ces<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_23_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_23' type='radio' value='Limite par objet (seulement AXA)'  id='choice_12_23_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_23_2' id='label_12_23_2' class='gform-field-label gform-field-label--type-inline'>Limite par objet (seulement AXA)<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_43\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Limite par objet (ABEX 775)<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_43'>\n\t\t\t<div class='gchoice gchoice_12_43_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='4.195,01 EUR'  id='choice_12_43_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_43_0' id='label_12_43_0' class='gform-field-label gform-field-label--type-inline'>4.195,01 EUR<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_43_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='8.390,01 EUR'  id='choice_12_43_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_43_1' id='label_12_43_1' class='gform-field-label gform-field-label--type-inline'>8.390,01 EUR<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_43_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='14.682,53 EUR'  id='choice_12_43_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_43_2' id='label_12_43_2' class='gform-field-label gform-field-label--type-inline'>14.682,53 EUR<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_43_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_43' type='radio' value='20.973,54 EUR'  id='choice_12_43_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_43_3' id='label_12_43_3' class='gform-field-label gform-field-label--type-inline'>20.973,54 EUR<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_45\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_45'><span class='gform-field-label__text'>Montant du loyer mensuel<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_45' id='input_12_45' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_40\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_40'><span class='gform-field-label__text'>Situation de l\u2019appartement<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_40' id='input_12_40' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div data-fieldId=\"40\" class=\"spacer gfield\" style=\"grid-column: span 8;\" data-groupId=\"7e03d7db\"><\/div><div id=\"field_12_14\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_14'><span class='gform-field-label__text'>Montant \u00e0 assurer b\u00e2timent<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_14' id='input_12_14' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_12_19\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_19'><span class='gform-field-label__text'>Montant \u00e0 assurer contenu<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_19' id='input_12_19' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_12_35\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Nombre de pi\u00e8ces<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Chambres \u00e0 coucher<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Autres pi\u00e8ces &gt;4m\u00b2<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">B\u00e2timent annexe &gt;&gt;20 m\u00b2<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Emplacements dans les garages<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Grenier<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Cave<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_35_cell1 gform-grid-col' data-label='Chambres \u00e0 coucher'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_12_35\" aria-label='Chambres \u00e0 coucher, Ligne 1' data-aria-label-template='Chambres \u00e0 coucher, Ligne {0}' type='text' name='input_35[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_35_cell2 gform-grid-col' data-label='Autres pi\u00e8ces &gt;4m\u00b2'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_12_35\" aria-label='Autres pi\u00e8ces &gt;4m\u00b2, Ligne 1' data-aria-label-template='Autres pi\u00e8ces &gt;4m\u00b2, Ligne {0}' type='text' name='input_35[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_35_cell3 gform-grid-col' data-label='B\u00e2timent annexe &gt;&gt;20 m\u00b2'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_12_35\" aria-label='B\u00e2timent annexe &gt;&gt;20 m\u00b2, Ligne 1' data-aria-label-template='B\u00e2timent annexe &gt;&gt;20 m\u00b2, Ligne {0}' type='text' name='input_35[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_35_cell4 gform-grid-col' data-label='Emplacements dans les garages'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_12_35\" aria-label='Emplacements dans les garages, Ligne 1' data-aria-label-template='Emplacements dans les garages, Ligne {0}' type='text' name='input_35[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_35_cell5 gform-grid-col' data-label='Grenier'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_12_35\" aria-label='Grenier, Ligne 1' data-aria-label-template='Grenier, Ligne {0}' type='text' name='input_35[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_35_cell6 gform-grid-col' data-label='Cave'><input aria-invalid='false' aria-required=\"true\" aria-describedby=\"gfield_description_12_35\" aria-label='Cave, Ligne 1' data-aria-label-template='Cave, Ligne {0}' type='text' name='input_35[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Ajouter une autre ligne' onclick='gformAddListItem(this, 0)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Supprimer la ligne {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Retirer<\/button><\/div><\/div><\/div><\/div><\/div><div class='gfield_description' id='gfield_description_12_35'>Pi\u00e8ces \u00e0 ne pas compter :\nPi\u00e8ces de moins de 4m\u00b2 \/ Halls d'entr\u00e9e et de nuit, paliers \/ Cuisines \/ S\u00e9jours, salons et salles \u00e0 manger \/ Salles de bain, salles de douche et toilettes \/ Greniers et espaces sous toit non am\u00e9nag\u00e9s \/ Caves, buanderies et chaufferies enti\u00e8rement situ\u00e9s\nsous le niveau de l\u2019entr\u00e9e principale \/ Abris de jardin, serres, pergolas, carports et annexes non habitables \/ Les parties communes en cas d\u2019appartement(s)<\/div><\/fieldset><fieldset id=\"field_12_20\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Limite d\u2019indemnisation<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_20'>\n\t\t\t<div class='gchoice gchoice_12_20_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='25%'  id='choice_12_20_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_20_0' id='label_12_20_0' class='gform-field-label gform-field-label--type-inline'>25%<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_20_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='50%'  id='choice_12_20_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_20_1' id='label_12_20_1' class='gform-field-label gform-field-label--type-inline'>50%<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_20_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_20' type='radio' value='100%'  id='choice_12_20_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_20_2' id='label_12_20_2' class='gform-field-label gform-field-label--type-inline'>100%<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_12_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Contiguit\u00e9 du b\u00e2timent<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_26'>\n\t\t\t<div class='gchoice gchoice_12_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='2 fa\u00e7ades'  id='choice_12_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_26_0' id='label_12_26_0' class='gform-field-label gform-field-label--type-inline'>2 fa\u00e7ades<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='3 fa\u00e7ades'  id='choice_12_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_26_1' id='label_12_26_1' class='gform-field-label gform-field-label--type-inline'>3 fa\u00e7ades<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_26_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='4 fa\u00e7ades'  id='choice_12_26_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_26_2' id='label_12_26_2' class='gform-field-label gform-field-label--type-inline'>4 fa\u00e7ades<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_24\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_12_21\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' ><span class='gform-field-label__text'>Surprimes et options<\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_12_21'><div class='gchoice gchoice_12_21_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.1' type='checkbox'  value='Pertes indirectes'  id='choice_12_21_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_21_1' id='label_12_21_1' class='gform-field-label gform-field-label--type-inline'>Pertes indirectes<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_21_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.2' type='checkbox'  value='Protection juridique'  id='choice_12_21_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_21_2' id='label_12_21_2' class='gform-field-label gform-field-label--type-inline'>Protection juridique<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_21_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.3' type='checkbox'  value='V\u00e9hicules automoteurs au repos'  id='choice_12_21_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_21_3' id='label_12_21_3' class='gform-field-label gform-field-label--type-inline'>V\u00e9hicules automoteurs au repos<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_21_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.4' type='checkbox'  value='Franchise anglaise'  id='choice_12_21_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_21_4' id='label_12_21_4' class='gform-field-label gform-field-label--type-inline'>Franchise anglaise<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_21_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.5' type='checkbox'  value='Abandon de recours du propri\u00e9taire contre le locataire'  id='choice_12_21_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_21_5' id='label_12_21_5' class='gform-field-label gform-field-label--type-inline'>Abandon de recours du propri\u00e9taire contre le locataire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_12_21_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_21.6' type='checkbox'  value='Bijoux et valeurs exclus'  id='choice_12_21_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_12_21_6' id='label_12_21_6' class='gform-field-label gform-field-label--type-inline'>Bijoux et valeurs exclus<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_22\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_22'><span class='gform-field-label__text'>Combien des v\u00e9hicules automoteurs au repos<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_22' id='input_12_22' type='text' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_12_42\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>Anciennet\u00e9 du b\u00e2timent<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_42'>\n\t\t\t<div class='gchoice gchoice_12_42_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='B\u00e2timent en construction'  id='choice_12_42_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_42_0' id='label_12_42_0' class='gform-field-label gform-field-label--type-inline'>B\u00e2timent en construction<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_42_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='B\u00e2timent r\u00e9cent (&lt;&lt;10ans)'  id='choice_12_42_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_42_1' id='label_12_42_1' class='gform-field-label gform-field-label--type-inline'>B\u00e2timent r\u00e9cent (&lt;&lt;10ans)<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_42_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='11 \u00e0 20 ans'  id='choice_12_42_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_42_2' id='label_12_42_2' class='gform-field-label gform-field-label--type-inline'>11 \u00e0 20 ans<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_42_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='21 \u00e0 50 ans'  id='choice_12_42_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_42_3' id='label_12_42_3' class='gform-field-label gform-field-label--type-inline'>21 \u00e0 50 ans<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_42_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='&gt;&gt; 50 ans'  id='choice_12_42_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_42_4' id='label_12_42_4' class='gform-field-label gform-field-label--type-inline'>&gt;&gt; 50 ans<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_42_5'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_42' type='radio' value='B\u00e2timent en r\u00e9novation lourde'  id='choice_12_42_5' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_42_5' id='label_12_42_5' class='gform-field-label gform-field-label--type-inline'>B\u00e2timent en r\u00e9novation lourde<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_46\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_12_47\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible gfield--choice-align-vertical\"  ><legend class='gfield_label gform-field-label' ><span class='gform-field-label__text'>A d\u00e9j\u00e0 \u00e9t\u00e9 assur\u00e9<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_12_47'>\n\t\t\t<div class='gchoice gchoice_12_47_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Oui'  id='choice_12_47_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_47_0' id='label_12_47_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_12_47_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_47' type='radio' value='Non'  id='choice_12_47_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_12_47_1' id='label_12_47_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_12_48\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_48'><span class='gform-field-label__text'>Compagnie<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_48' id='input_12_48' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_49\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_49'><span class='gform-field-label__text'>Raison de l&#039;annulation<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_49' id='input_12_49' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_52\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><\/div><div id=\"field_12_50\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_50'><span class='gform-field-label__text'>Sinistres: nombre<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_50' id='input_12_50' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='0' >0<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><\/select><\/div><\/div><div id=\"field_12_53\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Sinistre 1<\/h3><\/div><div id=\"field_12_54\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_54'><span class='gform-field-label__text'>Date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='jj\/mm\/aaaa'\n\t\t\t\t\tid='input_12_54'\n\t\t\t\t\tclass='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_54'\n\t\t\t\t value=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_12_54' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_12_54' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_12_54' aria-label='Date: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_12_55\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_55'><span class='gform-field-label__text'>D\u00e9bours<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_12_55' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_56\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_56'><span class='gform-field-label__text'>Circonstances<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_56' id='input_12_56' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_57\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Sinistre 2<\/h3><\/div><div id=\"field_12_59\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_59'><span class='gform-field-label__text'>Date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='jj\/mm\/aaaa'\n\t\t\t\t\tid='input_12_59'\n\t\t\t\t\tclass='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_59'\n\t\t\t\t value=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_12_59' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_12_59' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_12_59' aria-label='Date: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_12_60\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_60'><span class='gform-field-label__text'>D\u00e9bours<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_60' id='input_12_60' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_61\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_61'><span class='gform-field-label__text'>Circonstances<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_61' id='input_12_61' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_62\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Sinistre 3<\/h3><\/div><div id=\"field_12_63\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_63'><span class='gform-field-label__text'>Date<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n\t\t\t\t\t<input\n\t\t\t\t\tplaceholder='jj\/mm\/aaaa'\n\t\t\t\t\tid='input_12_63'\n\t\t\t\t\tclass='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'\n\t\t\t\t\ttype='text'\n\t\t\t\t\tname='input_63'\n\t\t\t\t value=''\n\t\t\t\t\t \n\t\t\t\t\taria-invalid=\"false\" \n\t\t\t\t\taria-required=\"true\"\n\t\t\t\t\t \n\t\t\t\t\t\n\t\t\t\t\tdata-mask=\"99\/99\/9999\"\n\t\t\t\t\t\/>\n\t\t\t\t<kbd id='keyboardHint_input_12_63' hidden class='down'><\/kbd>\n\t\t\t\t<button type='button' id='datepicker_toggle_input_12_63' class='gform-datepicker-toggle gform-datepicker-toggle--default accCalendar aria-date-picker gform-button gform-theme-button gform-theme-button--simple gform-theme-button--simple-in-ctrl' aria-expanded='false' aria-controls='input_12_63' aria-label='Date: Choose date on calendar' >\n\t\t\t\t\t\t\t<span class=\"gform-calendar-icon gform-datepicker-toggle-icon gform-datepicker-toggle-icon--default dashicons dashicons-calendar-alt\" aria-hidden=\"true\"><\/span>\n\t\t\t\t\t\t<\/button>\n\t\t\t<\/div><\/div><div id=\"field_12_64\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_64'><span class='gform-field-label__text'>D\u00e9bours<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_12_64' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_65\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_65'><span class='gform-field-label__text'>Circonstances<\/span><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_65' id='input_12_65' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_12_67\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_12_30\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_30'><span class='gform-field-label__text'>Remarques<\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_30' id='input_12_30' class='textarea large'  aria-describedby=\"gfield_description_12_30\"    aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_12_30'>Ex: ajouter des packs (jardin, piscine,...)?<\/div><\/div><div id=\"field_12_31\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_12_31'><span class='gform-field-label__text'>Fichier<\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='268435456' \/><input name='input_31' id='input_12_31' type='file' class='large' aria-describedby=\"gfield_upload_rules_12_31\" onchange='javascript:gformValidateFileSize( this, 268435456 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_12_31'>Taille max. des fichiers\u00a0: 256 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_12_31'><\/div> <\/div><\/div><div id=\"field_12_73\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h2>Clause de confidentialit\u00e9<\/h2><\/div><div id=\"field_12_74\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><p>Le(s) soussign\u00e9(s) autorise(nt), par la pr\u00e9sente, VDL-Interass SA, en tant que responsable du traitement, \u00e0 traiter toutes les donn\u00e9es personnelles pour autant que cela soit l\u00e9galement requis ou autoris\u00e9, ou pour autant que cela soit n\u00e9cessaire ou recommand\u00e9 pour la gestion et l\u2019ex\u00e9cution des contrats conclus, l\u2019\u00e9valuation de la relation client\u00e8le, l\u2019appr\u00e9ciation du risque, la pr\u00e9vention d\u2019abus et la lutte contre la fraude.<\/p>\n\n<p>Le soussign\u00e9 dispose (ont) d'un droit d'acc\u00e8s et de rectification de ses (leurs) donn\u00e9es personnelles. Il peut en faire la demande \u00e9crite \u00e0 VDL-Interass SA, en joignant une copie de sa carte d'identit\u00e9. Il peut en outre consulter le registre public de la Commission pour la protection de la vie priv\u00e9e.  <\/p>\n\n<p>(Loi du 8 d\u00e9cembre 1992 relative \u00e0 la protection de la vie priv\u00e9e \u00e0 l\u2019\u00e9gard des traitements de donn\u00e9es \u00e0 caract\u00e8re personnel).<\/p><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button type='submit' id='gform_submit_button_12' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' >Envoyer<\/button> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_12' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_12' id='gform_theme_12' value='gravity-theme' \/>\n            <input type='hidden' class='gform_hidden' name='gform_style_settings' data-js='gform_style_settings_12' id='gform_style_settings_12' value='[]' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_12' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='12' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_currency' data-currency='EUR' value='C9EjpEMoFL0ucZJn2NU8bcW1jZgEqbhYhMhPAh+XxpvHAK\/s+5FR5RSKVpHQTioEUuew1dADRTH4GNipGujl352FD7cIQ+HHaJW17D8OOja1TA8=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_12' 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