{"id":212,"date":"2014-07-04T14:27:19","date_gmt":"2014-07-04T13:27:19","guid":{"rendered":"http:\/\/www.esdras-assurances.fr\/assurance\/?page_id=212"},"modified":"2016-05-02T20:48:31","modified_gmt":"2016-05-02T19:48:31","slug":"demande-de-devis-sante","status":"publish","type":"page","link":"https:\/\/www.esdras-assurances.fr\/assurance\/?page_id=212","title":{"rendered":"Demande de devis Sant\u00e9"},"content":{"rendered":"<script>jQuery(document).ready(function(){});<\/script><script type=\"text\/javascript\"> var xyz_cfm_date_format = \"m\/d\/Y\";function xyz_cfm_7_1_check(){var firstErrorId = \"\"; var xyz_cfm_client_error = 0;var xyz_cfm_name_datenaissance_235_1 = document.getElementById(\"datenaissance_235_1\").value;\nif(xyz_cfm_name_datenaissance_235_1.trim() == \"\"){\ndocument.getElementById(\"text_datenaissance_235_1\").innerHTML = \"Remplir champ de texte\";\nif(firstErrorId ==  \"\"){\nfirstErrorId = \n\"datenaissance_235_1\";\n}\nxyz_cfm_client_error = 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\"\"){\ndocument.getElementById(\"email_yourEmail_226_1\").innerHTML = \"Campo Texto completo\";\nif(firstErrorId ==  \"\"){\nfirstErrorId = \n\"yourEmail_226_1\";\n}\nxyz_cfm_client_error = 1;\n}else{\ndocument.getElementById(\"email_yourEmail_226_1\").innerHTML = \"\";\n}\nif(xyz_cfm_client_error == 1){\nif(firstErrorId !=  \"\"){\ndocument.getElementById(firstErrorId).focus();\n}\nreturn false;\n}}<\/script>\n<div id=\"xyz_cfm_form7_1_success\" style=\"background: #C8FCBB;  text-align: center;  border-radius: 15px; margin-bottom: 20px;\"><\/div>\n<form name=\"xyz_cfm_7_1\" method=\"POST\" id=\"xyz_cfm_7_1\" enctype=\"multipart\/form-data\" onSubmit=\"return xyz_cfm_7_1_check();\">\n<div class=\"xyz_cfm_theme_div_id_0\"><p><span style=\"text-decoration: underline;\">Veuillez s\u00e9lectionner les besoins pour lesquels vous avez besoin d'une couverture forte<\/span>\u00a0\u00a0\u00a0<\/p>\n<table style=\"width: 100%; vertical-align: top;\">\n<tbody>\n<tr>\n<td>Les champs marqu\u00e9s d'un<span style=\"color: #ff0000;\">(*)<\/span>sont obligatoires.<\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td><span style=\"text-decoration: underline;\"><strong><span style=\"font-size: small;\"><span style=\"font-weight: bold;\">Informations adh\u00e9rent :<\/span><\/span><\/strong><\/span><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>Date de naissance :<\/td>\n<td><input  class=\"\"  type=\"text\" id=\"datenaissance_235_1\" name=\"datenaissance\"  value=\"\"  ><span style=\"color:red;\">*<\/span><div style=\"font-weight: normal;color:red;\" id=\"text_datenaissance_235_1\"><\/div>\n<\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>R\u00e9gime de couverture:<\/td>\n<td><select id=\"regimecouv_236_1\" name=\"regimecouv\" class=\"\" ><option value=\"\">Select<\/option><option value=\"S\u00e9curit\u00e9 sociale\">S\u00e9curit\u00e9 sociale<\/option><option value=\"CPS\">CPS<\/option><option value=\"TNS\">TNS<\/option><option value=\"R\u00e9gime Alsace Moselle\">R\u00e9gime Alsace Moselle<\/option><\/select><div style=\"font-weight: normal;color:red; \" id=\"dropdown_regimecouv_236_1\"><\/div><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>Date d'effet :<\/td>\n<td><input  class=\"\"  type=\"text\" id=\"Dateeffet1_326_1\" name=\"Dateeffet1\"  value=\"\"  ><div style=\"font-weight: normal;color:red;\" id=\"text_Dateeffet1_326_1\"><\/div>\n<\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td><span style=\"text-decoration: underline;\"><strong><span style=\"font-size: small;\"><span style=\"font-weight: bold;\">Informations <span style=\"font-weight: bold;\">conjoint<\/span> :<\/span><\/span><\/strong><\/span><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>Date de naissance :<\/td>\n<td><input  class=\"\"  type=\"text\" id=\"datenaiss2_238_1\" name=\"datenaiss2\"  value=\"\"  ><span style=\"color:red;\">*<\/span><div style=\"font-weight: normal;color:red;\" id=\"text_datenaiss2_238_1\"><\/div>\n<\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>R\u00e9gime de couverture:<\/td>\n<td><select id=\"regimecouv2_237_1\" name=\"regimecouv2\" class=\"\" ><option value=\"\">Select<\/option><option value=\"s\u00e9curit\u00e9 sociale\">s\u00e9curit\u00e9 sociale<\/option><option value=\"TNS\">TNS<\/option><option value=\"Agricole\">Agricole<\/option><option value=\"Alsace Moselle\">Alsace Moselle<\/option><option value=\"59-62 Ile de France (sauf(77)\">59-62 Ile de France (sauf(77)<\/option><\/select><div style=\"font-weight: normal;color:red; \" id=\"dropdown_regimecouv2_237_1\"><\/div><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td><span style=\"text-decoration: underline;\"><span style=\"font-weight: bold;\">Informations enfants<\/span> :<\/span><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td><span style=\"text-decoration: underline;\">1er enfant<\/span><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>Date de naissance :<\/td>\n<td><input  class=\"\"  type=\"text\" id=\"datenaissenf_239_1\" name=\"datenaissenf\"  value=\"\"  ><span style=\"color:red;\">*<\/span><div style=\"font-weight: normal;color:red;\" id=\"text_datenaissenf_239_1\"><\/div>\n<\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>Sexe :<\/td>\n<td><div><input class=\"\" type=\"radio\" name=\"sexenf1\"  value=\"M&nbsp;\" \/> M&nbsp;<input class=\"\" type=\"radio\" name=\"sexenf1\"  value=\"F\" \/> F<\/div><div style=\"font-weight: normal;color:red;\" id=\"radiobutton_sexenf1_241_1\"><\/div><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>R\u00e9gime de couverture :<\/td>\n<td><select id=\"regimecouvenf1_245_1\" name=\"regimecouvenf1\" class=\"\" ><option value=\"\">Select<\/option><option value=\"s\u00e9curit\u00e9 sociale\">s\u00e9curit\u00e9 sociale<\/option><option value=\"TNS\">TNS<\/option><option value=\"agricole\">agricole<\/option><option value=\"Alsace Moselle\">Alsace Moselle<\/option><option value=\"59-62 Ile de France (sauf 77)\">59-62 Ile de France (sauf 77)<\/option><\/select><div style=\"font-weight: normal;color:red; \" id=\"dropdown_regimecouvenf1_245_1\"><\/div><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td><span style=\"text-decoration: underline;\">2\u00e8me enfant<\/span><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>Date de naissance :<\/td>\n<td><input  class=\"\"  type=\"text\" id=\"datenaissenf2_249_1\" name=\"datenaissenf2\"  value=\"\"  ><div style=\"font-weight: normal;color:red;\" id=\"text_datenaissenf2_249_1\"><\/div>\n<\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>Sexe :<\/td>\n<td><div><input class=\"\" type=\"radio\" name=\"sexenf2\"  value=\"M&nbsp;\" \/> M&nbsp;<input class=\"\" type=\"radio\" name=\"sexenf2\"  value=\"F\" \/> F<\/div><div style=\"font-weight: normal;color:red;\" id=\"radiobutton_sexenf2_242_1\"><\/div><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>R\u00e9gime de couverture :<\/td>\n<td><select id=\"regimecouvenf2_246_1\" name=\"regimecouvenf2\" class=\"\" ><option value=\"\">Select<\/option><option value=\"s\u00e9curit\u00e9 sociale\">s\u00e9curit\u00e9 sociale<\/option><option value=\"TNS\">TNS<\/option><option value=\"agricole\">agricole<\/option><option value=\"Alsace Moselle\">Alsace Moselle<\/option><option value=\"59-62 Ile de France (sauf 77)\">59-62 Ile de France (sauf 77)<\/option><\/select><div style=\"font-weight: normal;color:red; \" id=\"dropdown_regimecouvenf2_246_1\"><\/div><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td><span style=\"text-decoration: underline;\">3\u00e8me enfant<\/span><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>Date de naissance :<\/td>\n<td><input  class=\"\"  type=\"text\" id=\"datenaissenf3_250_1\" name=\"datenaissenf3\"  value=\"\"  ><div style=\"font-weight: normal;color:red;\" id=\"text_datenaissenf3_250_1\"><\/div>\n<\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>Sexe :<\/td>\n<td><div><input class=\"\" type=\"radio\" name=\"sexenf3\"  value=\"M&nbsp;\" \/> M&nbsp;<input class=\"\" type=\"radio\" name=\"sexenf3\"  value=\"F\" \/> F<\/div><div style=\"font-weight: normal;color:red;\" id=\"radiobutton_sexenf3_243_1\"><\/div><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>R\u00e9gime de couverture :<\/td>\n<td><select id=\"regimecouvenf3_247_1\" name=\"regimecouvenf3\" class=\"\" ><option value=\"\">Select<\/option><option value=\"s\u00e9curit\u00e9 sociale\">s\u00e9curit\u00e9 sociale<\/option><option value=\"TNS\">TNS<\/option><option value=\"agricole\">agricole<\/option><option value=\"Alsace Moselle\">Alsace Moselle<\/option><option value=\"59-62 Ile de France (sauf 77)\">59-62 Ile de France (sauf 77)<\/option><\/select><div style=\"font-weight: normal;color:red; \" id=\"dropdown_regimecouvenf3_247_1\"><\/div><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td><span style=\"text-decoration: underline;\">4\u00e8me enfant<\/span><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>Date de naissance :<\/td>\n<td><input  class=\"\"  type=\"text\" id=\"datenaissenf4_251_1\" name=\"datenaissenf4\"  value=\"\"  ><div style=\"font-weight: normal;color:red;\" id=\"text_datenaissenf4_251_1\"><\/div>\n<\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>Sexe :<\/td>\n<td><div><input class=\"\" type=\"radio\" name=\"sexenf4\"  value=\"M&nbsp;\" \/> M&nbsp;<input class=\"\" type=\"radio\" name=\"sexenf4\"  value=\"F\" \/> F<\/div><div style=\"font-weight: normal;color:red;\" id=\"radiobutton_sexenf4_244_1\"><\/div><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>R\u00e9gime de couverture :<\/td>\n<td><select id=\"regimecouvenf4_248_1\" name=\"regimecouvenf4\" class=\"\" ><option value=\"\">Select<\/option><option value=\"s\u00e9curit\u00e9 sociale\">s\u00e9curit\u00e9 sociale<\/option><option value=\"TNS\">TNS<\/option><option value=\"agricole\">agricole<\/option><option value=\"Alsace Moselle\">Alsace Moselle<\/option><option value=\"59-62 Ile de France (sauf 77)\">59-62 Ile de France (sauf 77)<\/option><\/select><div style=\"font-weight: normal;color:red; \" id=\"dropdown_regimecouvenf4_248_1\"><\/div><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>Optique :<\/td>\n<td><div><input class=\"\" type=\"radio\" name=\"ouinon\"  value=\"oui&nbsp;\" \/> oui&nbsp;<input class=\"\" type=\"radio\" name=\"ouinon\"  value=\"non\" \/> non<\/div><div style=\"font-weight: normal;color:red;\" id=\"radiobutton_ouinon_252_1\"><\/div><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>Dentaire :<\/td>\n<td><div><input class=\"\" type=\"radio\" name=\"ouinon2\"  value=\"oui&nbsp;\" \/> oui&nbsp;<input class=\"\" type=\"radio\" name=\"ouinon2\"  value=\"non\" \/> non<\/div><div style=\"font-weight: normal;color:red;\" id=\"radiobutton_ouinon2_253_1\"><\/div><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>Hospitalisation et maternit\u00e9 :<\/td>\n<td><div><input class=\"\" type=\"radio\" name=\"ouinon3\"  value=\"oui&nbsp;\" \/> oui&nbsp;<input class=\"\" type=\"radio\" name=\"ouinon3\"  value=\"non\" \/> non<\/div><div style=\"font-weight: normal;color:red;\" id=\"radiobutton_ouinon3_254_1\"><\/div><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>Soin et pharmacie :<\/td>\n<td><div><input class=\"\" type=\"radio\" name=\"ouinon4\"  value=\"oui&nbsp;\" \/> oui&nbsp;<input class=\"\" type=\"radio\" name=\"ouinon4\"  value=\"non\" \/> non<\/div><div style=\"font-weight: normal;color:red;\" id=\"radiobutton_ouinon4_255_1\"><\/div><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td>A quel niveau \u00eates-vous pris en charge actuellement?<\/td>\n<td><select id=\"quelniveau_256_1\" name=\"quelniveau\" class=\"\" ><option value=\"\">Select<\/option><option value=\"100%\">100%<\/option><option value=\"200%\">200%<\/option><option value=\"300%\">300%<\/option><option value=\"400%\">400%<\/option><\/select><div style=\"font-weight: normal;color:red; \" id=\"dropdown_quelniveau_256_1\"><\/div><\/td>\n<td>\u00a0<\/td>\n<td>\u00a0<\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\">\n<hr style=\"width: 97%; height: 1px;\" size=\"1\" width=\"97%\" \/><\/td>\n<\/tr>\n<tr>\n<td><span style=\"text-decoration: underline;\"><span style=\"font-size: small;\"><strong>Vos coordonn\u00e9es<\/strong><\/span><\/span><\/td>\n<td colspan=\"3\">\u00a0<\/td>\n<\/tr>\n<tr>\n<td>Nom:<\/td>\n<td><input  class=\"\"  type=\"text\" id=\"nom_257_1\" name=\"nom\"  value=\"\"  ><span style=\"color:red;\">*<\/span><div style=\"font-weight: normal;color:red;\" id=\"text_nom_257_1\"><\/div>\n<\/td>\n<td>Pr\u00e9nom :<\/td>\n<td><input  class=\"\"  type=\"text\" id=\"prenom_258_1\" name=\"prenom\"  value=\"\"  ><span style=\"color:red;\">*<\/span><div style=\"font-weight: normal;color:red;\" id=\"text_prenom_258_1\"><\/div>\n<\/td>\n<\/tr>\n<tr>\n<td>Adresse 1 :<\/td>\n<td><input  class=\"\"  type=\"text\" id=\"adress1_259_1\" name=\"adress1\"  value=\"\"  ><div style=\"font-weight: normal;color:red;\" id=\"text_adress1_259_1\"><\/div>\n<\/td>\n<td colspan=\"2\">\u00a0<\/td>\n<\/tr>\n<tr>\n<td>Adresse 2 :<\/td>\n<td><input  class=\"\"  type=\"text\" id=\"adress2_260_1\" name=\"adress2\"  value=\"\"  ><div style=\"font-weight: normal;color:red;\" id=\"text_adress2_260_1\"><\/div>\n<\/td>\n<td colspan=\"2\">\u00a0<\/td>\n<\/tr>\n<tr>\n<td>Code Postal :<\/td>\n<td><input  class=\"\"  type=\"text\" id=\"cp_261_1\" name=\"cp\"  value=\"\"  ><span style=\"color:red;\">*<\/span><div style=\"font-weight: normal;color:red;\" id=\"text_cp_261_1\"><\/div>\n<\/td>\n<td>Ville :<\/td>\n<td><input  class=\"\"  type=\"text\" id=\"ville_262_1\" name=\"ville\"  value=\"\"  ><span style=\"color:red;\">*<\/span><div style=\"font-weight: normal;color:red;\" id=\"text_ville_262_1\"><\/div>\n<\/td>\n<\/tr>\n<tr>\n<td>T\u00e9l\u00e9phone fixe :<\/td>\n<td><input  class=\"\"  type=\"text\" id=\"telfix_263_1\" name=\"telfix\"  value=\"\"  ><span style=\"color:red;\">*<\/span><div style=\"font-weight: normal;color:red;\" id=\"text_telfix_263_1\"><\/div>\n<\/td>\n<td>T\u00e9l\u00e9phone mobile :<\/td>\n<td><input  class=\"\"  type=\"text\" id=\"telmob_264_1\" name=\"telmob\"  value=\"\"  ><span style=\"color:red;\">*<\/span><div style=\"font-weight: normal;color:red;\" id=\"text_telmob_264_1\"><\/div>\n<\/td>\n<\/tr>\n<tr>\n<td>Adresse e-mail :<\/td>\n<td><input  class=\"\"  type=\"text\" id=\"yourEmail_226_1\" name=\"yourEmail\"  value=\"\"  ><span style=\"color:red;\">*<\/span><div style=\"font-weight: normal;color:red;\" id=\"email_yourEmail_226_1\"><\/div>\n<\/td>\n<td colspan=\"2\">\u00a0<\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\">\n<hr size=\"1\" width=\"97%\" \/><\/td>\n<\/tr>\n<tr>\n<td colspan=\"4\">\n<p align=\"center\">Les informations ci dessus sont destin\u00e9es au cabinet ESDRAS Assurances, elles ne seront pas transmises \u00e0 des tiers<\/p>\n<p align=\"center\"><input class=\"\"  type=\"submit\" name=\"submit\" id=\"submit_229_1\" value=\"Envoyer\"  ><\/p>\n<\/td>\n<\/tr>\n<\/tbody>\n<\/table><\/div>\n<input type =\"hidden\" name=\"xyz_cfm_frmName_1\"  value=\"form7\" >\n<\/form>\n<p style=\"text-align: center;\"><strong>Merci, <span class=\"st\">nous vous contacterons rapidement.<\/span><\/strong><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Merci, nous vous contacterons rapidement.<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"open","ping_status":"open","template":"","meta":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v18.7 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Demande de devis Sant\u00e9 - Esdras 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