{"id":1191,"date":"2020-05-22T16:22:30","date_gmt":"2020-05-22T14:22:30","guid":{"rendered":"https:\/\/swissglobalinsurance.com\/bulletin-dafiliation\/"},"modified":"2024-04-24T18:55:21","modified_gmt":"2024-04-24T16:55:21","slug":"application-form","status":"publish","type":"page","link":"https:\/\/swissglobalinsurance.com\/en\/application-form\/","title":{"rendered":"Application form"},"content":{"rendered":"\n\n\n[et_pb_section][et_pb_row][et_pb_column type=&#8221;4_4&#8243;][et_pb_text]\n\n<!-- divi:paragraph -->\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f1190-o1\" lang=\"fr-FR\" dir=\"ltr\" data-wpcf7-id=\"1190\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/1191\/#wpcf7-f1190-o1\" method=\"post\" class=\"wpcf7-form init bulletin_form\" aria-label=\"Formulaire de contact\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"1190\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fr_FR\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f1190-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<div class=\"form_part\" id=\"form_part_1\">\n\t<fieldset class=\"field_text\">\n\t\t<p><label>Family Name :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"user_lastname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"user_lastname\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text\">\n\t\t<p><label>First Name :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"user_firstname\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"user_firstname\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_date\">\n\t\t<p><label>Effective date of coverage must be on the 1st of each month :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"effective_date_day\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"effective_date_day\"><option value=\"01\">01<\/option><\/select><\/span> \/ <span class=\"wpcf7-form-control-wrap\" data-name=\"effective_date_month\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"effective_date_month\"><option value=\"\"><\/option><option value=\"01\">01<\/option><option value=\"02\">02<\/option><option value=\"03\">03<\/option><option value=\"04\">04<\/option><option value=\"05\">05<\/option><option value=\"06\">06<\/option><option value=\"07\">07<\/option><option value=\"08\">08<\/option><option value=\"09\">09<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><\/select><\/span> \/ <span class=\"wpcf7-form-control-wrap\" data-name=\"effective_date_year\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"effective_date_year\"><option value=\"\"><\/option><\/select><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_checkbox\">\n\t\t<p><label>SWISS GLOBAL INSURANCE Plan :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox_contrat_desired\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox_contrat_desired\" value=\"DIAMOND\" \/><span class=\"wpcf7-list-item-label\">DIAMOND<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkbox_contrat_desired\" value=\"PLATINUM\" \/><span class=\"wpcf7-list-item-label\">PLATINUM<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkbox_contrat_desired\" value=\"CLASSIC\" \/><span class=\"wpcf7-list-item-label\">CLASSIC<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox_contrat_desired\" value=\"ESSENTIAL\" \/><span class=\"wpcf7-list-item-label\">ESSENTIAL<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_checkbox field_below\">\n\t\t<p><label>Zone of coverage :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox_zone_couverture\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox_zone_couverture\" value=\"Zone A: worldwide coverage including USA &amp; Canada, excluding Switzerland. Premiums in USD\" \/><span class=\"wpcf7-list-item-label\">Zone A: worldwide coverage including USA &amp; Canada, excluding Switzerland. Premiums in USD<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkbox_zone_couverture\" value=\"Zone B: worldwide coverage excluding USA &amp; Canada, including Switzerland. Premiums in CHF\" \/><span class=\"wpcf7-list-item-label\">Zone B: worldwide coverage excluding USA &amp; Canada, including Switzerland. Premiums in CHF<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox_zone_couverture\" value=\"Zone C: worldwide coverage excluding USA, Canada, Switzerland. Premiums in EUR\" \/><span class=\"wpcf7-list-item-label\">Zone C: worldwide coverage excluding USA, Canada, Switzerland. Premiums in EUR<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<h2>APPLICANT DETAILS:\n\t<\/h2>\n\t<fieldset class=\"field_checkbox\">\n\t\t<p><label>Gender :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox_sexe\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox_sexe\" value=\"M.\" \/><span class=\"wpcf7-list-item-label\">M.<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox_sexe\" value=\"F.\" \/><span class=\"wpcf7-list-item-label\">F.<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_date\">\n\t\t<p><label>Date of Birth :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"dob_day\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"dob_day\"><option value=\"\"><\/option><\/select><\/span> \/ <span class=\"wpcf7-form-control-wrap\" data-name=\"dob_month\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"dob_month\"><option value=\"\"><\/option><option value=\"01\">01<\/option><option value=\"02\">02<\/option><option value=\"03\">03<\/option><option value=\"04\">04<\/option><option value=\"05\">05<\/option><option value=\"06\">06<\/option><option value=\"07\">07<\/option><option value=\"08\">08<\/option><option value=\"09\">09<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><\/select><\/span> \/ <span class=\"wpcf7-form-control-wrap\" data-name=\"dob_year\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"dob_year\"><option value=\"\"><\/option><\/select><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text\">\n\t\t<p><label>Nationality :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"nationality\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nationality\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_checkbox\">\n\t\t<p><label>Family status :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox_family_situation\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox_family_situation\" value=\"Single\" \/><span class=\"wpcf7-list-item-label\">Single<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkbox_family_situation\" value=\"Married\" \/><span class=\"wpcf7-list-item-label\">Married<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkbox_family_situation\" value=\"Divorced\" \/><span class=\"wpcf7-list-item-label\">Divorced<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox_family_situation\" value=\"Other Occupation\" \/><span class=\"wpcf7-list-item-label\">Other Occupation<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text\">\n\t\t<p><label>Occupation :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"profession\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"profession\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_checkbox field_below_inline\">\n\t\t<p><label>Are you (or your spouse) eligible for benefits from any Social Security or government plan reimbursement, or do you have any<br \/>\nother group medical insurance in force today ? <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox_prestation\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox_prestation\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox_prestation\" value=\"No\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text\">\n\t\t<p><label>If Yes, please describe :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"prestation_oui\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"prestation_oui\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text\">\n\t\t<p><label>Country of your Social Security plan :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pays_programme\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"pays_programme\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><\/select><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text\">\n\t\t<p><label> Social Security ID Number(s) : <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"num_secu\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"num_secu\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<h2>SPOUSE (or Partner) and dependent CHILDREN to be covered:\n\t<\/h2>\n\t<div class=\"description_section\">\n\t\t<p>If you have dependent children aged more than 21, please join to this form a certificate of attendance at school or university\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"field_table\">\n\t\t<ul class=\"table_title\">\n\t\t\t<li>\n\t\t\t\t<p><label>Familiy Name <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/li>\n\t\t\t<li>\n\t\t\t\t<p><label>First Name <\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/li>\n\t\t\t<li>\n\t\t\t\t<p><label>Date of Birth<\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/li>\n\t\t\t<li>\n\t\t\t\t<p><label>Gender (M or F) \/ Spouse\/Child (S or P)<\/label>\n\t\t\t\t<\/p>\n\t\t\t<\/li>\n\t\t<\/ul>\n\t\t<ul class=\"table_value\" id=\"person_family_1\">\n\t\t\t<li>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"family_lastname_1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"family_lastname_1\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/li>\n\t\t\t<li>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"family_firstname_1\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"family_firstname_1\" \/><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/li>\n\t\t\t<li class=\"family_dob\">\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"family_dob_1_day\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"family_dob_1_day\"><option value=\"\"><\/option><\/select><\/span> \/ <span class=\"wpcf7-form-control-wrap\" data-name=\"family_dob_1_month\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"family_dob_1_month\"><option value=\"\"><\/option><option value=\"01\">01<\/option><option value=\"02\">02<\/option><option value=\"03\">03<\/option><option value=\"04\">04<\/option><option value=\"05\">05<\/option><option value=\"06\">06<\/option><option value=\"07\">07<\/option><option value=\"08\">08<\/option><option value=\"09\">09<\/option><option value=\"10\">10<\/option><option value=\"11\">11<\/option><option value=\"12\">12<\/option><\/select><\/span> \/ <span class=\"wpcf7-form-control-wrap\" data-name=\"family_dob_1_year\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"family_dob_1_year\"><option value=\"\"><\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/li>\n\t\t\t<li>\n\t\t\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"family_sexe_status_1\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"family_sexe_status_1\"><option value=\"\"><\/option><option value=\"Male Spouse\">Male Spouse<\/option><option value=\"Male Child\">Male Child<\/option><option value=\"Female Spouse\">Female Spouse<\/option><option value=\"Female Child\">Female Child<\/option><\/select><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/li>\n\t\t<\/ul>\n\t\t<div class=\"clearfix\">\n\t\t<\/div>\n\t<\/div>\n\t<div class=\"add_person_family\" data-numfamily=\"0\">\n\t\t<p><span>+<\/span> Add person\n\t\t<\/p>\n\t<\/div>\n\t<p><input type=\"button\" name=\"next_button_form_part_1\" id=\"next_button_form_part_1\" data-stepid=\"1\" class=\"next_button_form\" value=\"Suivant\" \/>\n\t<\/p>\n<\/div>\n<div class=\"form_part\" id=\"form_part_2\">\n\t<h2>Applicant's mailing addres\n\t<\/h2>\n\t<div class=\"description_section\">\n\t\t<p>Address in country of expatriation:\n\t\t<\/p>\n\t<\/div>\n\t<fieldset class=\"field_text field_half\">\n\t\t<p><label>Street :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"rue_expat\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rue_expat\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text field_half\">\n\t\t<p><label>City :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"ville_expat\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ville_expat\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text field_half\">\n\t\t<p><label>Postal code :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"zip_expat\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"zip_expat\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text field_half\">\n\t\t<p><label>Country :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pays_expat\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pays_expat\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><\/select><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text\">\n\t\t<p><label>Phone number :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"prefix_phone_mobile_expat\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"prefix_phone_mobile_expat\"><option value=\"\"><\/option><\/select><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"phone_mobile_expat\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"phone_mobile_expat\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text\">\n\t\t<p><label>E-mail :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"email_expat\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"email_expat\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<div class=\"description_section\">\n\t\t<p>Address in home country:\n\t\t<\/p>\n\t<\/div>\n\t<fieldset class=\"field_text field_half\">\n\t\t<p><label>Street :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"rue_origin\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rue_origin\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text field_half\">\n\t\t<p><label>City :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"ville_origin\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ville_origin\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text field_half\">\n\t\t<p><label>Postal code :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"zip_origin\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"zip_origin\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text field_half\">\n\t\t<p><label>Country :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pays_origin\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pays_origin\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><\/select><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text\">\n\t\t<p><label>Phone number :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"prefix_phone_mobile_origin\"><select class=\"wpcf7-form-control wpcf7-select\" aria-invalid=\"false\" name=\"prefix_phone_mobile_origin\"><option value=\"\"><\/option><\/select><\/span><span class=\"wpcf7-form-control-wrap\" data-name=\"phone_mobile_origin\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"phone_mobile_origin\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<h2>Payment of premiums:\n\t<\/h2>\n\t<fieldset class=\"field_checkbox\">\n\t\t<p><label>Payment frequency :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox_frequence_paiement\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox_frequence_paiement\" value=\"Quarterly\" \/><span class=\"wpcf7-list-item-label\">Quarterly<\/span><\/span><span class=\"wpcf7-list-item\"><input type=\"checkbox\" name=\"checkbox_frequence_paiement\" value=\"Half - Yearly\" \/><span class=\"wpcf7-list-item-label\">Half - Yearly<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox_frequence_paiement\" value=\"Yearly\" \/><span class=\"wpcf7-list-item-label\">Yearly<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_checkbox\">\n\t\t<p><label>Would you like to do your payment by :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"checkbox_paiement\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first\"><input type=\"checkbox\" name=\"checkbox_paiement\" value=\"Credit card\" \/><span class=\"wpcf7-list-item-label\">Credit card<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"checkbox\" name=\"checkbox_paiement\" value=\"Bank Transfer\" \/><span class=\"wpcf7-list-item-label\">Bank Transfer<\/span><\/span><\/span><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<h2>Reimbursements of claims\n\t<\/h2>\n\t<fieldset class=\"field_text\">\n\t\t<p><label>Currency of your bank account :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"devise_compte\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"devise_compte\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text\">\n\t\t<p><label>Account Beneficiary Name :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"nom_beneficaire_compte\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nom_beneficaire_compte\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<div class=\"description_section\">\n\t\t<p>For bank-to-bank transfers, please complete the following and attach a deposit slip\n\t\t<\/p>\n\t<\/div>\n\t<fieldset class=\"field_text\">\n\t\t<p><label>Account N\u00b0 :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"num_compte_banque\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"num_compte_banque\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text\">\n\t\t<p><label>Name of Bank :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"nom_banque\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nom_banque\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text field_half\">\n\t\t<p><label>IBAN :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"iban_banque\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"iban_banque\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text field_half\">\n\t\t<p><label>BIC \u2013 \u20ac, ABA \u2013 US$) :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"bic_banque\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"bic_banque\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<div class=\"description_section\">\n\t\t<p>Address of Bank:\n\t\t<\/p>\n\t<\/div>\n\t<fieldset class=\"field_text field_half\">\n\t\t<p><label>Street :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"rue_banque\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"rue_banque\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text field_half\">\n\t\t<p><label>City :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"ville_banque\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"ville_banque\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text field_half\">\n\t\t<p><label>Postal \/ ZIP Code :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"zip_banque\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"zip_banque\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<fieldset class=\"field_text field_half\">\n\t\t<p><label>Country :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"pays_banque\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"pays_banque\"><option value=\"\">&#8212;Veuillez choisir une option&#8212;<\/option><\/select><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<p><input type=\"button\" name=\"next_button_form_part_2\" id=\"next_button_form_part_2\" data-stepid=\"2\" class=\"next_button_form\"value=\"Next\" \/>\n\t<\/p>\n<\/div>\n<div class=\"form_part\" id=\"form_part_3\">\n\t<h2>Confidential Medical Questionaire\n\t<\/h2>\n\t<div class=\"description_section\">\n\t\t<p><strong>Have you, or any person named in page 1 been treated for, or have had a history of:<\/strong>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"description_section\">\n\t\t<p>(Please tick if Yes)\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"w3-bar w3-black\">\n\t\t<div class=\"w3-bar-item w3-button tab_person_family_0 tab_person_family_active\" onclick=\"openBeneficiaire('tab_person_family_0')\">\n\t\t\t<p>Applicant\n\t\t\t<\/p>\n\t\t<\/div>\n\t\t<div class=\"clearfix\">\n\t\t<\/div>\n\t<\/div>\n\t<div id=\"tab_person_family_0\" class=\"tab_person_family\">\n\t\t<fieldset class=\"field_textarea\">\n\t\t\t<p><label>1. Diabetes, thyroid and other endocrine disorders <small>(including obesity)<\/small><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_checkbox_1\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"tab_person_family_0_checkbox_1\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"tab_person_family_questions\" id=\"tab_person_family_0_questions_1\">\n\t\t\t\t<p><label>Type of treatment or illness, drugs, injury,symptoms, examination(what was diagnosed ?)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_1\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_1\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Treatment from \u2013 to (month-year):<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_2\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_2\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Name and address of doctors,hospitals; who can provide further information:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_3\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_3\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>When did treatment \/symptoms cease ?:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_4\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_4\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/fieldset>\n\t\t<fieldset class=\"field_textarea\">\n\t\t\t<p><label>2.Heart or circulatory disorders <small>(including high blood pressure)<\/small><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_checkbox_2\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"tab_person_family_0_checkbox_2\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"tab_person_family_questions\" id=\"tab_person_family_0_questions_2\">\n\t\t\t\t<p><label>Type of treatment or illness, drugs, injury,symptoms, examination(what was diagnosed ?)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_5\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_5\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Treatment from \u2013 to (month-year):<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_6\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_6\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Name and address of doctors,hospitals; who can provide further information:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_7\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_7\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>When did treatment \/symptoms cease ?:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_8\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_8\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/fieldset>\n\t\t<fieldset class=\"field_textarea\">\n\t\t\t<p><label>3. Cancer, tumour or growth <small>(including polyps or breast lumps)<\/small><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_checkbox_3\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"tab_person_family_0_checkbox_3\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"tab_person_family_questions\" id=\"tab_person_family_0_questions_3\">\n\t\t\t\t<p><label>Type of treatment or illness, drugs, injury,symptoms, examination(what was diagnosed ?)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_9\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_9\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Treatment from \u2013 to (month-year):<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_10\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_10\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Name and address of doctors,hospitals; who can provide further information:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_11\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_11\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>When did treatment \/symptoms cease ?:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_12\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_12\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/fieldset>\n\t\t<fieldset class=\"field_textarea\">\n\t\t\t<p><label>4. Musle and skeletal problems <small>(including back pain, traumatism, joint pain or problems)<\/small><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_checkbox_4\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"tab_person_family_0_checkbox_4\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"tab_person_family_questions\" id=\"tab_person_family_0_questions_4\">\n\t\t\t\t<p><label>Type of treatment or illness, drugs, injury,symptoms, examination(what was diagnosed ?)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_13\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_13\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Treatment from \u2013 to (month-year):<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_14\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_14\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Name and address of doctors,hospitals; who can provide further information<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_15\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_15\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>When did treatment \/symptoms cease ?:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_16\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_16\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/fieldset>\n\t\t<fieldset class=\"field_textarea\">\n\t\t\t<p><label>5. Asthma, allergies, breathing or respiratory disorders <small>(including chest infections, shortness of breath, tuberculosis)<\/small><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_checkbox_5\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"tab_person_family_0_checkbox_5\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"tab_person_family_questions\" id=\"tab_person_family_0_questions_5\">\n\t\t\t\t<p><label>Type of treatment or illness, drugs, injury,symptoms, examination(what was diagnosed ?)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_17\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_17\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Treatment from \u2013 to (month-year):<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_18\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_18\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Name and address of doctors,hospitals; who can provide further information:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_19\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_19\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>When did treatment \/symptoms cease ?:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_60\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_60\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/fieldset>\n\t\t<fieldset class=\"field_textarea\">\n\t\t\t<p><label>6. 6 Gall bladder, stomach, intestinal, gastric or liver problems <small>(including irritable bowel disease, Crohn\u2019s disease, hernia or haemorrhoids)<\/small><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_checkbox_6\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"tab_person_family_0_checkbox_6\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"tab_person_family_questions\" id=\"tab_person_family_0_questions_6\">\n\t\t\t\t<p><label>Type of treatment or illness, drugs, injury,symptoms, examination(what was diagnosed ?)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_21\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_21\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Treatment from \u2013 to (month-year):<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_22\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_22\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Name and address of doctors,hospitals; who can provide further information:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_23\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_23\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>When did treatment \/symptoms cease ?:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_24\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_24\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/fieldset>\n\t\t<fieldset class=\"field_textarea\">\n\t\t\t<p><label>7. Urinary or reproductive disorders <small>(including fertility, periods or prostate problems)<\/small><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_checkbox_7\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"tab_person_family_0_checkbox_7\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"tab_person_family_questions\" id=\"tab_person_family_0_questions_7\">\n\t\t\t\t<p><label>Type of treatment or illness, drugs, injury,symptoms, examination(what was diagnosed ?)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_25\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_25\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Treatment from \u2013 to (month-year):<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_26\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_26\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Name and address of doctors,hospitals; who can provide further information:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_27\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_27\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>When did treatment \/symptoms cease ?:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_28\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_28\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/fieldset>\n\t\t<fieldset class=\"field_textarea\">\n\t\t\t<p><label>8. Brain or neurogical disorders <small>(including epilepsy, strokes, shingles or nerve pain) <\/small><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_checkbox_8\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"tab_person_family_0_checkbox_8\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"tab_person_family_questions\" id=\"tab_person_family_0_questions_8\">\n\t\t\t\t<p><label>Type of treatment or illness, drugs, injury,symptoms, examination(what was diagnosed ?)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_29\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_29\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Treatment from \u2013 to (month-year):<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_30\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_30\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Name and address of doctors,hospitals; who can provide further information:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_31\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_31\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>When did treatment \/symptoms cease ?:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_32\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_32\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/fieldset>\n\t\t<fieldset class=\"field_textarea\">\n\t\t\t<p><label>9. Skin problems <small>(including eczema, allergic reactions, cysts, dermatitis or psoriasis)<\/small><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_checkbox_9\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"tab_person_family_0_checkbox_9\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"tab_person_family_questions\" id=\"tab_person_family_0_questions_9\">\n\t\t\t\t<p><label>Type of treatment or illness, drugs, injury,symptoms, examination(what was diagnosed ?)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_33\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_33\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Treatment from \u2013 to (month-year):<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_34\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_34\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Name and address of doctors,hospitals; who can provide further information:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_35\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_35\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>When did treatment \/symptoms cease ?:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_36\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_36\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/fieldset>\n\t\t<fieldset class=\"field_textarea\">\n\t\t\t<p><label>10. Blood infective or immune disorders <small>(including High cholesterol, anemia, malaria ou HIV)<\/small><\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_checkbox_10\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"tab_person_family_0_checkbox_10\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"tab_person_family_questions\" id=\"tab_person_family_0_questions_10\">\n\t\t\t\t<p><label>Type of treatment or illness, drugs, injury,symptoms, examination(what was diagnosed ?)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_37\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_37\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Treatment from \u2013 to (month-year):<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_38\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_38\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Name and address of doctors,hospitals; who can provide further information:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_39\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_39\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>When did treatment \/symptoms cease ?:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_40\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_40\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/fieldset>\n\t\t<fieldset class=\"field_textarea\">\n\t\t\t<p><label>11. Do you have any illness, condition or symptom not already mentioned above ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_checkbox_11\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"tab_person_family_0_checkbox_11\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"tab_person_family_questions\" id=\"tab_person_family_0_questions_11\">\n\t\t\t\t<p><label>Type of treatment or illness, drugs, injury,symptoms, examination(what was diagnosed ?)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_41\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_41\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Treatment from \u2013 to (month-year):<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_42\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_42\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Name and address of doctors,hospitals; who can provide further information:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_43\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_43\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>When did treatment \/symptoms cease ?:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_44\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_44\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/fieldset>\n\t\t<fieldset class=\"field_textarea\">\n\t\t\t<p><label>12. Are you currently under m\u00e9dical supervision (therapy, m\u00e9dical care) and\/or<br \/>\nare you taking prescribed m\u00e9dication (other than contraceptives) ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_checkbox_12\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"tab_person_family_0_checkbox_12\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"tab_person_family_questions\" id=\"tab_person_family_0_questions_12\">\n\t\t\t\t<p><label>Type of treatment or illness, drugs, injury,symptoms, examination(what was diagnosed ?)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_45\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_45\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Treatment from \u2013 to (month-year):<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_46\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_46\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Name and address of doctors,hospitals; who can provide further information:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_47\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_47\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>When did treatment \/symptoms cease ?:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_48\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_48\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/fieldset>\n\t\t<fieldset class=\"field_textarea\">\n\t\t\t<p><label>13. Have you been or are you scheduled to be hospitalised for surgery, illness or<br \/>\nany other reason (exclusive of caeserean sections or appendectomies, or<br \/>\nvaricose veins, tonsils, adenoids or gallbladder removals) ?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_checkbox_13\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"tab_person_family_0_checkbox_13\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"tab_person_family_questions\" id=\"tab_person_family_0_questions_13\">\n\t\t\t\t<p><label>Type of treatment or illness, drugs, injury,symptoms, examination(what was diagnosed ?)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_49\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_49\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Treatment from \u2013 to (month-year):<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_50\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_50\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Name and address of doctors,hospitals; who can provide further information:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_51\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_51\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>When did treatment \/symptoms cease ?:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_52\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_52\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/fieldset>\n\n <!--       <fieldset class=\"field_textarea\">\n            <label>14. Are you currently pregnant ? <\/label> <span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_checkbox_14\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"tab_person_family_0_checkbox_14\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><\/span><\/span>\n        <\/fieldset>\n-->\n\t\t<fieldset class=\"field_textarea\">\n\t\t\t<p><label>14. Are you currently pregnant ? <\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_checkbox_14\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"tab_person_family_0_checkbox_14\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"tab_person_family_questions\" id=\"tab_person_family_0_questions_14\">\n\t\t\t\t<p><label>Type of treatment or illness, drugs, injury,symptoms, examination(what was diagnosed ?)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_61\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_61\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Treatment from \u2013 to (month-year):<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_62\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_62\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Name and address of doctors,hospitals; who can provide further information:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_63\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_63\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>When did treatment \/symptoms cease ?:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_64\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_64\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/fieldset>\n\t\t<fieldset class=\"field_textarea\">\n\t\t\t<p><label>15. 5 Are you currently receiving dental care or are you scheduled to do so over the next 24 months?<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_checkbox_15\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-exclusive-checkbox\"><span class=\"wpcf7-list-item first last\"><input type=\"checkbox\" name=\"tab_person_family_0_checkbox_15\" value=\"Yes\" \/><span class=\"wpcf7-list-item-label\">Yes<\/span><\/span><\/span><\/span>\n\t\t\t<\/p>\n\t\t\t<div class=\"tab_person_family_questions\" id=\"tab_person_family_0_questions_15\">\n\t\t\t\t<p><label>Type of treatment or illness, drugs, injury,symptoms, examination(what was diagnosed ?)<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_57\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_57\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Treatment from \u2013 to (month-year):<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_58\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_58\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>Name and address of doctors,hospitals; who can provide further information:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_59\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_59\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t\t<p><label>When did treatment \/symptoms cease ?:<\/label><br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"tab_person_family_0_textarea_60\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"tab_person_family_0_textarea_60\"><\/textarea><\/span>\n\t\t\t\t<\/p>\n\t\t\t<\/div>\n\t\t<\/fieldset>\n\t\t<fieldset class=\"field_text\">\n\t\t\t<p><label>Weight (kg) :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"poids_0\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"poids_0\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/fieldset>\n\t\t<fieldset class=\"field_text\">\n\t\t\t<p><label>Height (cm) :<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"taille_0\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"taille_0\" \/><\/span>\n\t\t\t<\/p>\n\t\t<\/fieldset>\n\t<\/div>\n\t<p><input type=\"button\" name=\"next_button_form_part_3\" id=\"next_button_form_part_3\" data-stepid=\"3\" class=\"next_button_form\" value=\"Next\" \/>\n\t<\/p>\n<\/div>\n<div class=\"form_part\" id=\"form_part_4\">\n\t<h2>FRAUD NOTICE\n\t<\/h2>\n\t<p><br \/>\nAny person who (1) dishonestly files an application for insurance or a claim under a policy containing information he knows to be untrue or misleading; or who (2) in making an application for insurance or claim under a policy dishonestly fails to disclose information which has beenasked for, may commit fraud.<br \/>\nWe will investigate any claims or applications for insurance which we have grounds to believe may be fraudulent. Committing fraud may result in your policy being terminated and any claims you make under not being paid.<br \/>\nWe may, for the purposes of the detection and prevention of fraud, share information relating to suspected fraud with other insurance companies and\/or with law enforcement authorities.\n\t<\/p>\n\t<h2>Statement\n\t<\/h2>\n\t<p><br \/>\nI hereby certify that the foregoing declarations are accurate, complete and fair and have been correctly written to the best of my knowledge and belief.<br \/>\nI have been informed and I accept that any intentional withholding of significant information or false declaration by me or on my behalf may lead to the cancellation of the insurance cover.<br \/>\nI may examine and correct any personal information in the files maintained by SWISS GLOBAL INSURANCE on my behalf. For underwriting and claim purposes, I hereby authorize any physician who has examined me to transmit medical data to the physician of the Insurer and\/or its Plan Administrator.<br \/>\nI accept these terms and conditions and I wish to be covered by this policy.\n\t<\/p>\n\t<div class=\"description_section_big\">\n\t\t<p>Please send us a copy of your passport:\n\t\t<\/p>\n\t<\/div>\n\t<fieldset class=\"field_file\">\n\t\t<p><span class=\"wpcf7-form-control-wrap\" data-name=\"file_passport\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file wpcf7-validates-as-required\" accept=\".pdf,.png,.jpg,.jpeg\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" name=\"file_passport\" \/><\/span>\n\t\t<\/p>\n\t<\/fieldset>\n\t<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/>\n\t<\/p>\n<\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n\n<!-- \/divi:paragraph -->\n\n[\/et_pb_text][\/et_pb_column][\/et_pb_row][\/et_pb_section]\n\n\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":4,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_seopress_robots_primary_cat":"","_seopress_titles_title":"","_seopress_titles_desc":"","_seopress_robots_index":"","_et_pb_use_builder":"off","_et_pb_old_content":"\n\n<!-- wp:paragraph -->\n<p>[contact-form-7 id=\"1190\" html_class=\"bulletin_form\"]<\/p>\n<!-- \/wp:paragraph -->\n\n","_et_gb_content_width":"","footnotes":""},"class_list":["post-1191","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/swissglobalinsurance.com\/en\/wp-json\/wp\/v2\/pages\/1191","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/swissglobalinsurance.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/swissglobalinsurance.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/swissglobalinsurance.com\/en\/wp-json\/wp\/v2\/users\/4"}],"replies":[{"embeddable":true,"href":"https:\/\/swissglobalinsurance.com\/en\/wp-json\/wp\/v2\/comments?post=1191"}],"version-history":[{"count":15,"href":"https:\/\/swissglobalinsurance.com\/en\/wp-json\/wp\/v2\/pages\/1191\/revisions"}],"predecessor-version":[{"id":2839,"href":"https:\/\/swissglobalinsurance.com\/en\/wp-json\/wp\/v2\/pages\/1191\/revisions\/2839"}],"wp:attachment":[{"href":"https:\/\/swissglobalinsurance.com\/en\/wp-json\/wp\/v2\/media?parent=1191"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}