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<html>
<head>
<title>Etude Pr&eacute;sence en pr&eacute;voyance collective</title>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1">
</head>

<body bgcolor="#FFFFFF">
<form method="post" action="/cgi-bin/etuc.cgi">
  <table width="640" border="0" align="center">
    <tr align="center"> 
      <td colspan="2" width="640">&nbsp;</td>
    </tr>
    <tr> 
      <td width="660" bordercolor="#000000" colspan="2"> 
        <table width="630" border="1" cellspacing="0" cellpadding="0" align="center">
          <tr align="center"> 
            <td width="310"> 
              <table width="620" border="0" cellpadding="0" cellspacing="0">
                <tr> 
                  <td rowspan="2" width="60"><img src="images/ent.gif" width="100" height="24"></td>
                  <td width="110"><font face="Arial, Helvetica, sans-serif" size="1">Nom 
                    :</font></td>
                  <td width="420" colspan="3"> 
                    <input type="text" name="entreprise" size="50">
                  </td>
                </tr>
                <tr> 
                  <td width="100"><font face="Arial, Helvetica, sans-serif" size="1">Adresse 
                    :</font></td>
                  <td width="420" colspan="3"> 
                    <input type="text" name="adresse" size="50">
                  </td>
                </tr>
                <tr> 
                  <td width="120">&nbsp;</td>
                  <td width="100"><font face="Arial, Helvetica, sans-serif" size="1">Code 
                    Postal :</font></td>
                  <td width="80"> 
                    <input type="text" name="CP" size="10">
                  </td>
                  <td width="60"><font face="Arial, Helvetica, sans-serif" size="1">Ville 
                    :</font></td>
                  <td width="140"> 
                    <input type="text" name="ville" size="40">
                  </td>
                </tr>
                <tr> 
                  <td width="120">&nbsp;</td>
                  <td width="100"><font face="Arial, Helvetica, sans-serif" size="1">T&eacute;l 
                    :</font></td>
                  <td width="80"> 
                    <input type="text" name="tel" size="14">
                  </td>
                  <td width="60"><font face="Arial, Helvetica, sans-serif" size="1">Fax 
                    :</font></td>
                  <td width="140"> 
                    <input type="text" name="fax" size="14">
                  </td>
                </tr>
              </table>
            </td>
          </tr>
        </table>
      </td>
    </tr>
    <tr> 
      <td bordercolor="#000000" height="23" colspan="2">&nbsp;</td>
    </tr>
    <tr align="center" valign="middle"> 
      <td colspan="2" height="72"> 
        <table width="620" border="1" cellspacing="1" cellpadding="1" align="center">
          <tr> 
            <td align="center" valign="middle"><font face="Arial, Helvetica, sans-serif" size="1">Forme 
              juridique </font></td>
            <td align="center" valign="middle"><font face="Arial, Helvetica, sans-serif" size="1">Convention 
              collective </font></td>
            <td align="center" valign="middle"><font face="Arial, Helvetica, sans-serif" size="1">Code 
              NAF </font></td>
          </tr>
          <tr> 
            <td align="center" valign="middle"> 
              <input type="text" name="fj" size="25">
            </td>
            <td align="center" valign="middle"> 
              <input type="text" name="cc" size="25">
            </td>
            <td align="center" valign="middle"> 
              <input type="text" name="NAF" size="25">
            </td>
          </tr>
        </table>
      </td>
    </tr>
    <tr> 
      <td height="25" colspan="2">&nbsp;</td>
    </tr>
    <tr align="center" valign="middle"> 
      <td colspan="2"> 
        <table width="620" border="1" cellspacing="1" cellpadding="1" align="center">
          <tr> 
            <td align="center" valign="middle"><font face="Arial, Helvetica, sans-serif" size="1">Cadres</font></td>
            <td align="center" valign="middle"><font face="Arial, Helvetica, sans-serif" size="1">Ma&icirc;trise</font></td>
            <td align="center" valign="middle"><font face="Arial, Helvetica, sans-serif" size="1">Employ&eacute;s</font></td>
            <td align="center" valign="middle"><font face="Arial, Helvetica, sans-serif" size="1">Ouvriers</font></td>
            <td align="center" valign="middle"><font face="Arial, Helvetica, sans-serif" size="1">TOTAL 
              Effectif </font></td>
          </tr>
          <tr> 
            <td align="center" valign="middle"> 
              <input type="text" name="cadres" size="10">
            </td>
            <td align="center" valign="middle"> 
              <input type="text" name="maitrise" size="10">
            </td>
            <td align="center" valign="middle"> 
              <input type="text" name="employes" size="10">
            </td>
            <td align="center" valign="middle"> 
              <input type="text" name="ouvriers" size="10">
            </td>
            <td align="center" valign="middle"> 
              <input type="text" name="total" size="10">
            </td>
          </tr>
        </table>
      </td>
    </tr>
    <tr> 
      <td colspan="2">&nbsp;</td>
    </tr>
    <tr align="center" valign="middle"> 
      <td colspan="2"> 
        <table width="620" border="1" cellspacing="1" cellpadding="1" align="center">
          <tr> 
            <td align="center" valign="middle"><font face="Arial, Helvetica, sans-serif" size="1">Nom 
            du demandeur</font></td>
            <td align="center" valign="middle"><font face="Arial, Helvetica, sans-serif" size="1">Fonction 
              </font></td>
            <td align="center" valign="middle"><font face="Arial, Helvetica,
sans-serif" size="1">Email</font></td>           </tr>
          <tr> 
            <td align="center" valign="middle"> 
              <input type="text" name="demandeur" size="25">
            </td>
            <td align="center" valign="middle"> 
              <input type="text" name="fonction" size="25">
            </td>
            <td align="center" valign="middle"> 
              <input type="text" name="EMAIL" size="25">
            </td>
          </tr>
        </table>
      </td>
    </tr>
    <tr> 
      <td colspan="2">&nbsp;</td>
    </tr>
    <tr align="center" valign="middle"> 
      <td colspan="2"> 
        <table width="620" border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td colspan="2" height="22"><font face="Arial, Helvetica, sans-serif" size="1">&#149; 
              Avez-vous une garantie en pr&eacute;voyance collective ?</font></td>
          </tr>
          <tr> 
            <td> 
              <input type="checkbox" name="regimesante;" value="OUI">
              <font face="Arial, Helvetica, sans-serif" size="1"> R&eacute;gime 
              sant&eacute;</font></td>
            <td> <font face="Arial, Helvetica, sans-serif" size="1">Si oui laquelle 
              ?</font> 
              <input type="text" name="valsante" size="30">
            </td>
          </tr>
          <tr> 
            <td> 
              <input type="checkbox" name="regimeprev" value="OUI">
              <font face="Arial, Helvetica, sans-serif" size="1">R&eacute;gime 
              de pr&eacute;voyance</font></td>
            <td><font face="Arial, Helvetica, sans-serif" size="1">Si oui laquelle 
              ?</font> 
              <input type="text" name="valprev" size="30">
            </td>
          </tr>
        </table>
      </td>
    </tr>
    <tr align="center" valign="middle"> 
      <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="1"><br>
        Je souhaite recevoir un Conseiller en Pr&eacute;voyance collective Mutuelle 
        Pr&eacute;sence Sant&eacute; pour &eacute;tudier une proposition adapt&eacute;e 
        &agrave; mon entreprise.<br>
        </font></td>
    </tr>
    <tr> 
      <td colspan="2"> 
        <table width="620" border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td width="840" colspan="3" height="22"><font face="Arial, Helvetica, sans-serif" size="3"><b>&#149; 
              Garanties R&eacute;gime Sant&eacute;</b></font></td>
          </tr>
          <tr align="left"> 
            <td width="20">&nbsp; </td>
            <td width="220"> 
              <input type="radio" name="grs" value="libre">              
          <font face="Arial, Helvetica, sans-serif" size="1">&agrave; libre    
           adh&eacute;sion </font> </td>             <td width="220">&nbsp;
</td>           </tr>
          <tr align="left"> 
            <td width="20">&nbsp;</td>
            <td width="220"> 
              <input type="radio" name="grs"
value="obligatoire">               <font face="Arial, Helvetica, sans-serif"
size="1">&agrave; caract&egrave;re                obligatoire </font></td>
            <td width="220">&nbsp;</td>
          </tr>
          <tr align="left"> 
            <td width="20">&nbsp;</td>
            <td width="440" colspan="2"><font face="Arial, Helvetica, sans-serif" size="1">(articles 
              39 et 83 du C.G.I. et art L-242-1 du code de s&eacute;curit&eacute; 
              sociale)</font></td>
          </tr>
          <tr align="left"> 
            <td width="20">&nbsp;</td>
            <td width="440" colspan="2">&nbsp;</td>
          </tr>
          <tr align="left"> 
            <td width="20">&nbsp;</td>
            <td width="440" colspan="2"><font face="Arial, Helvetica, sans-serif" size="2"><b>Cat&eacute;gorie 
              de salari&eacute;s concern&eacute;s :</b></font> </td>
          </tr>
          <tr align="left"> 
            <td width="20">&nbsp;</td>
            <td width="440" colspan="2"> 
              <table width="99%" border="0">
                <tr> 
                  <td align="left" valign="middle"> 
                    <input type="checkbox" name="ensemble" value="OUI">
                    <font face="Arial, Helvetica, sans-serif" size="1"> Ensemble 
                    du personnel</font></td>
                  <td align="left" valign="middle"> 
                    <input type="radio" name="perso" value="cadres">
                    <font face="Arial, Helvetica, sans-serif" size="1"> Cadres</font></td>
                  <td align="left" valign="middle"> 
                    <input type="radio" name="perso" value="maitrise">
                    <font face="Arial, Helvetica, sans-serif" size="1"> Ma&icirc;trise</font></td>
                  <td align="left" valign="middle"> 
                    <input type="radio" name="perso" value="ouvriers">       
             <font face="Arial, Helvetica, sans-serif" size="1">
Employ&eacute;s,                      Ouvriers </font></td>                
</tr>               </table>
            </td>
          </tr>
        </table>
      </td>
    </tr>
    <tr> 
      <td colspan="2">&nbsp;</td>
    </tr>
    <tr> 
      <td colspan="2"> 
        <table width="620" border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td width="840" colspan="3" height="22"><font face="Arial, Helvetica, sans-serif" size="1"><b><font size="3">&#149; 
              Garanties R&eacute;gime de Pr&eacute;voyance </font></b><font size="3">&agrave; 
              caract&egrave;re obligatoire<b> </b></font><b><font size="3"><br>
              </font></b>(articles 39 et 83 du C.G.I. et art L-242-1 du code de 
              s&eacute;curit&eacute; sociale)</font></td>
          </tr>
          <tr align="left"> 
            <td width="20">&nbsp; </td>
            <td width="220">&nbsp; </td>
            <td width="220">&nbsp; </td>
          </tr>
          <tr align="left"> 
            <td width="20">&nbsp;</td>
            <td width="440" colspan="2"><font face="Arial, Helvetica, sans-serif" size="2"><b>Cat&eacute;gorie 
              de salari&eacute;s concern&eacute;s :</b></font> </td>
          </tr>
          <tr align="left"> 
            <td width="20">&nbsp;</td>
            <td width="440" colspan="2"> 
              <table width="99%" border="0">
                <tr> 
                  <td align="left" valign="middle"> 
                    <input type="checkbox" name="ensemble2" value="OUI">
                    <font face="Arial, Helvetica, sans-serif" size="1"> Ensemble 
                    du personnel</font></td>
                  <td align="left" valign="middle"> 
                    <input type="radio" name="perso2" value="cadres2">
                    <font face="Arial, Helvetica, sans-serif" size="1"> Cadres</font></td>
                  <td align="left" valign="middle"> 
                    <input type="radio" name="perso2"
value="maitrise2">                     <font face="Arial, Helvetica,
sans-serif" size="1"> Ma&icirc;trise</font></td>                   <td
align="left" valign="middle">                      <input type="radio"
name="perso2" value="ouvriers2">                     <font
face="Arial, Helvetica, sans-serif" size="1"> Employ&eacute;s,                
     Ouvriers </font></td>                 </tr>
              </table>
            </td>
          </tr>
        </table>
      </td>
    </tr>
    <tr> 
      <td colspan="2">&nbsp;</td>
    </tr>
    <tr> 
      <td colspan="2"> 
        <table width="99%" border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td width="20">&nbsp;</td>
            <td> 
              <input type="checkbox" name="ij" value="OUI">
              <font face="Arial, Helvetica, sans-serif" size="1"> Indemnit&eacute;s 
              journali&egrave;res, rente d'invalidit&eacute;, rente d'incapacit&eacute;</font></td>
          </tr>
          <tr> 
            <td width="20">&nbsp;</td>
            <td> 
              <input type="checkbox" name="cdit" value="OUI">
              <font face="Arial, Helvetica, sans-serif" size="1"> Capital d&eacute;c&egrave;s, invalidit&eacute; totale</font></td>
          </tr>
          <tr> 
            <td width="20">&nbsp;</td>
            <td> 
              <input type="checkbox" name="rc" value="OUI">
              <font face="Arial, Helvetica, sans-serif" size="1"> Rente de conjoint</font></td>
          </tr>
          <tr> 
            <td width="20">&nbsp;</td>
            <td> 
              <input type="checkbox" name="re" value="OUI">
              <font face="Arial, Helvetica, sans-serif" size="1"> Rente d'&eacute;ducation</font></td>
          </tr>
          <tr> 
            <td width="20">&nbsp;</td>
            <td> 
              <input type="checkbox" name="rc" value="OUI">
              <font face="Arial, Helvetica, sans-serif" size="1"> Retraite par 
              capitalisation</font></td>
          </tr>
          <tr> 
            <td width="20">&nbsp;</td>
            <td> 
              <input type="checkbox" name="ifc" value="OUI">
              <font face="Arial, Helvetica, sans-serif" size="1"> Indemnit&eacute;s 
              de fin de carri&egrave;re</font></td>
          </tr>
        </table>
      </td>
    </tr>
    <tr> 
      <td colspan="2">&nbsp;</td>
    </tr>
    <tr align="center" valign="middle"> 
      <td colspan="2"> 
        <table width="600" border="0" cellspacing="0" cellpadding="0">
          <tr align="center" valign="middle"> 
            <td> 
              <input type="reset" value="Annuler" name="reset">
            </td>
            <td> 
              <input type="submit" value="Envoyer"name="submit">
            </td>
            <td> 
              <input type="button" name="Button" value="Retour" onClick="window.close()">
            </td>
          </tr>
        </table>
      </td>
    </tr>
  </table>
</form>
</body>
</html>

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