{"id":6060,"date":"2019-02-10T23:19:47","date_gmt":"2019-02-10T23:19:47","guid":{"rendered":"https:\/\/sgp-sa.com\/?page_id=6060"},"modified":"2019-02-10T23:19:47","modified_gmt":"2019-02-10T23:19:47","slug":"demande-doffre-lamal","status":"publish","type":"page","link":"https:\/\/sgp-sa.com\/fr\/demande-doffre-lamal\/","title":{"rendered":"Demande d\u2019offre LAMal"},"content":{"rendered":"<div class=\"wpforms-container wpforms-container-full\" id=\"wpforms-6058\"><form id=\"wpforms-form-6058\" class=\"wpforms-validate wpforms-form\" data-formid=\"6058\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/fr\/wp-json\/wp\/v2\/pages\/6060\" data-token=\"f267e473925e4d34993187b37dffdd02\"><noscript class=\"wpforms-error-noscript\">Veuillez activer JavaScript dans votre navigateur pour remplir ce formulaire.<\/noscript><div class=\"wpforms-field-container\"><div id=\"wpforms-6058-field_1-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"1\"><label class=\"wpforms-field-label\" for=\"wpforms-6058-field_1\">Nom et Pr\u00e9nom  <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-6058-field_1\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][1][first]\" required><label for=\"wpforms-6058-field_1\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Pr\u00e9nom<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-6058-field_1-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][1][last]\" required><label for=\"wpforms-6058-field_1-last\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Nom<\/label><\/div><\/div><\/div><div id=\"wpforms-6058-field_20-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"20\"><label class=\"wpforms-field-label\" for=\"wpforms-6058-field_20\">Date de naissance  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6058-field_20\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"99\/99\/9999\" name=\"wpforms[fields][20]\" required><\/div><div id=\"wpforms-6058-field_17-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"17\"><label class=\"wpforms-field-label\" for=\"wpforms-6058-field_17\">Rue et num\u00e9ro  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6058-field_17\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][17]\" required><\/div><div id=\"wpforms-6058-field_2-container\" class=\"wpforms-field wpforms-field-name\" data-field-id=\"2\"><label class=\"wpforms-field-label\" for=\"wpforms-6058-field_2\">Code Postal et Ville  <span class=\"wpforms-required-label\">*<\/span><\/label><div class=\"wpforms-field-row wpforms-field-medium\"><div class=\"wpforms-field-row-block wpforms-first wpforms-one-half\"><input type=\"text\" id=\"wpforms-6058-field_2\" class=\"wpforms-field-name-first wpforms-field-required\" name=\"wpforms[fields][2][first]\" required><label for=\"wpforms-6058-field_2\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Pr\u00e9nom<\/label><\/div><div class=\"wpforms-field-row-block wpforms-one-half\"><input type=\"text\" id=\"wpforms-6058-field_2-last\" class=\"wpforms-field-name-last wpforms-field-required\" name=\"wpforms[fields][2][last]\" required><label for=\"wpforms-6058-field_2-last\" class=\"wpforms-field-sublabel after wpforms-sublabel-hide\">Nom<\/label><\/div><\/div><\/div><div id=\"wpforms-6058-field_7-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"7\"><label class=\"wpforms-field-label\" for=\"wpforms-6058-field_7\">Quelle assurance  <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-6058-field_7\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-6058-field_7_1\" name=\"wpforms[fields][7]\" value=\"LaMal \" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6058-field_7_1\">LaMal<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-6058-field_7_2\" name=\"wpforms[fields][7]\" value=\"LCA ( compl\u00e9mentaire)\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6058-field_7_2\">LCA ( compl\u00e9mentaire)<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-6058-field_7_3\" name=\"wpforms[fields][7]\" value=\"LaMal et LCA\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6058-field_7_3\">LaMal et LCA<\/label><\/li><\/ul><\/div><div id=\"wpforms-6058-field_15-container\" class=\"wpforms-field wpforms-field-radio\" data-field-id=\"15\"><label class=\"wpforms-field-label\" for=\"wpforms-6058-field_15\">Mod\u00e8le Lamal  <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-6058-field_15\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-6058-field_15_1\" name=\"wpforms[fields][15]\" value=\"Basic \" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6058-field_15_1\">Basic<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-6058-field_15_2\" name=\"wpforms[fields][15]\" value=\"M\u00e9decin de famille \/ Telmed \" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6058-field_15_2\">M\u00e9decin de famille \/ Telmed<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"radio\" id=\"wpforms-6058-field_15_3\" name=\"wpforms[fields][15]\" value=\"R\u00e9seaux de soins \/ Delta \/ Pharmed \" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6058-field_15_3\">R\u00e9seaux de soins \/ Delta \/ Pharmed<\/label><\/li><\/ul><\/div><div id=\"wpforms-6058-field_8-container\" class=\"wpforms-field wpforms-field-select\" data-field-id=\"8\"><label class=\"wpforms-field-label\" for=\"wpforms-6058-field_8\">Franchise LaMal<\/label><select id=\"wpforms-6058-field_8\" class=\"wpforms-field-medium\" name=\"wpforms[fields][8]\"><option value=\"\" class=\"placeholder\" disabled  selected='selected'>Veuillez choisir <\/option><option value=\"300\/0\" >300\/0<\/option><option value=\"500\" >500<\/option><option value=\"1000\" >1000<\/option><option value=\"1500\" >1500<\/option><option value=\"2000\" >2000<\/option><option value=\"2500\" >2500<\/option><\/select><div class=\"wpforms-field-description\">Adulte\/enfant<\/div><\/div><div id=\"wpforms-6058-field_16-container\" class=\"wpforms-field wpforms-field-radio wpforms-list-inline\" data-field-id=\"16\"><label class=\"wpforms-field-label\" for=\"wpforms-6058-field_16\">Suppl\u00e9ment accident  <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-6058-field_16\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"radio\" id=\"wpforms-6058-field_16_1\" name=\"wpforms[fields][16]\" value=\"Oui\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6058-field_16_1\">Oui<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"radio\" id=\"wpforms-6058-field_16_2\" name=\"wpforms[fields][16]\" value=\"Non\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6058-field_16_2\">Non<\/label><\/li><\/ul><\/div><div id=\"wpforms-6058-field_21-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"21\"><label class=\"wpforms-field-label\" for=\"wpforms-6058-field_21\">LCA ( compl\u00e9mentaire)<\/label><ul id=\"wpforms-6058-field_21\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-6058-field_21_1\" name=\"wpforms[fields][21][]\" value=\"Compl\u00e9mentaire extra \/ Compl\u00e9ta \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6058-field_21_1\">Compl\u00e9mentaire extra \/ Compl\u00e9ta<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-6058-field_21_2\" name=\"wpforms[fields][21][]\" value=\"Mondia\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6058-field_21_2\">Mondia<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-6058-field_21_3\" name=\"wpforms[fields][21][]\" value=\"Hospitalisation Priv\u00e9e \/ Semi-Priv\u00e9e\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6058-field_21_3\">Hospitalisation Priv\u00e9e \/ Semi-Priv\u00e9e<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-6058-field_21_4\" name=\"wpforms[fields][21][]\" value=\"Dentaire\"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6058-field_21_4\">Dentaire<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-6058-field_21_5\" name=\"wpforms[fields][21][]\" value=\"Capital accident \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6058-field_21_5\">Capital accident<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-6058-field_21_6\" name=\"wpforms[fields][21][]\" value=\"Pas de compl\u00e9mentaire \"  ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6058-field_21_6\">Pas de compl\u00e9mentaire<\/label><\/li><\/ul><\/div><div id=\"wpforms-6058-field_19-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-6058-field_19\">Num\u00e9ro de t\u00e9l\u00e9phone  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"text\" id=\"wpforms-6058-field_19\" class=\"wpforms-field-medium wpforms-field-required wpforms-masked-input\" data-rule-inputmask-incomplete=\"1\" data-inputmask-mask=\"+99 99 999 99 99\" name=\"wpforms[fields][19]\" required><\/div><div id=\"wpforms-6058-field_6-container\" class=\"wpforms-field wpforms-field-email\" data-field-id=\"6\"><label class=\"wpforms-field-label\" for=\"wpforms-6058-field_6\">Adresse e-mail  <span class=\"wpforms-required-label\">*<\/span><\/label><input type=\"email\" id=\"wpforms-6058-field_6\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][6]\" spellcheck=\"false\" required><\/div><div id=\"wpforms-6058-field_12-container\" class=\"wpforms-field wpforms-field-gdpr-checkbox\" data-field-id=\"12\"><label class=\"wpforms-field-label\" for=\"wpforms-6058-field_12\">J\u2019accepte <span class=\"wpforms-required-label\">*<\/span><\/label><ul id=\"wpforms-6058-field_12\" class=\"wpforms-field-required\"><li class=\"choice-1\"><input type=\"checkbox\" id=\"wpforms-6058-field_12_1\" name=\"wpforms[fields][12][]\" value=\"En cochant cette case, j&#039;accepte de recevoir des emailings et je reconnais avoir pris connaissance de la POLITIQUE DE CONFIDENTIALIT\u00c9\" required ><label class=\"wpforms-field-label-inline\" for=\"wpforms-6058-field_12_1\">En cochant cette case, j'accepte de recevoir des emailings et je reconnais avoir pris connaissance de la POLITIQUE DE CONFIDENTIALIT\u00c9<\/label><\/li><\/ul><\/div><\/div><!-- .wpforms-field-container --><div class=\"wpforms-field wpforms-field-hp\"><label for=\"wpforms-6058-field-hp\" class=\"wpforms-field-label\">Website<\/label><input type=\"text\" name=\"wpforms[hp]\" id=\"wpforms-6058-field-hp\" class=\"wpforms-field-medium\"><\/div><div class=\"wpforms-submit-container\" ><input type=\"hidden\" name=\"wpforms[id]\" value=\"6058\"><input type=\"hidden\" name=\"wpforms[author]\" value=\"2\"><button type=\"submit\" name=\"wpforms[submit]\" id=\"wpforms-submit-6058\" class=\"wpforms-submit\" data-alt-text=\"Sending...\" data-submit-text=\"Envoyer\" aria-live=\"assertive\" value=\"wpforms-submit\">Envoyer<\/button><\/div><\/form><\/div>  <!-- .wpforms-container -->\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"_links":{"self":[{"href":"https:\/\/sgp-sa.com\/fr\/wp-json\/wp\/v2\/pages\/6060"}],"collection":[{"href":"https:\/\/sgp-sa.com\/fr\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/sgp-sa.com\/fr\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/sgp-sa.com\/fr\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/sgp-sa.com\/fr\/wp-json\/wp\/v2\/comments?post=6060"}],"version-history":[{"count":0,"href":"https:\/\/sgp-sa.com\/fr\/wp-json\/wp\/v2\/pages\/6060\/revisions"}],"wp:attachment":[{"href":"https:\/\/sgp-sa.com\/fr\/wp-json\/wp\/v2\/media?parent=6060"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}