%PDF- %PDF-
Direktori : /home/kfvehpdt/mutuelles-presence.fr/ |
Current File : /home/kfvehpdt/mutuelles-presence.fr///etu.htm |
<html> <head><title>Etude personnalisée Présence Individuelle</title> <meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1"> </head> <body bgcolor="#FFCCFF"> <form method="get" action="http://www.mutuelles-presence.fr/formpresencepart.php"> <table border="0" align="center" width="640"> <tr align="center"> <td colspan="2" height="186"> <table bgcolor="#ffccff" border="0" cellpadding="0" cellspacing="0" width="720"> <!-- fwtable fwsrc="haut-etu.png" fwbase="haut-etu.gif" fwstyle="Dreamweaver" fwdocid = "742308039" fwnested="1" --> <tr> <td bgcolor="#ffccff"><img src="images/spacer.gif" width="1" height="1" border="0"></td> <td> <table bgcolor="#ffccff" border="0" cellpadding="0" cellspacing="0" width="110"> <tr> <td bgcolor="#ffccff"><a href="accpart.htm"><img src="images/fleche-tabind.gif" width="34" height="37" border="0"></a></td> </tr> <tr> <td><img name="etulogo" src="images/etu-logo.gif" width="110" height="110" border="0"></td> </tr> <tr> <td bgcolor="#ffccff"><img src="images/spacer.gif" width="1" height="1" border="0"></td> </tr> </table> </td> <td bgcolor="#ffccff"><img src="images/spacer.gif" width="1" height="1" border="0"></td> <td align="right" valign="bottom"> <table bgcolor="#ffccff" border="0" cellpadding="0" cellspacing="0" width="162"> <tr> <td bgcolor="#ffccff"><img src="images/spacer.gif" width="1" height="1" border="0"></td> </tr> <tr> <td><img name="etuvieux" src="images/etu-fam.gif" width="162" height="182" border="0"></td> </tr> </table> </td> <td> <table bgcolor="#ffccff" border="0" cellpadding="0" cellspacing="0" width="335"> <tr> <td> <table bgcolor="#ffccff" border="0" cellpadding="0" cellspacing="0" width="335"> <tr> <td><img name="etupat" src="images/etu-pat.gif" width="213" height="145" border="0"></td> <td bgcolor="#ffccff"><img src="images/spacer.gif" width="1" height="1" border="0"></td> </tr> </table> </td> </tr> <tr> <td><img name="etuslog" src="images/etu-slog.gif" width="335" height="55" border="0"></td> </tr> </table> </td> </tr> </table> </td> </tr> <tr align="center"> <td valign="middle" bordercolor="#000000" width="360"> <table border="1" cellspacing="0" cellpadding="0" bordercolor="#000000" height="230"> <tr align="center"> <td> <table border="0" cellpadding="2" cellspacing="2" bordercolor="#000000" height="230" align="center"> <tr> <td rowspan="2"><img src="images/etu-vous.gif" width="75" height="50"></td> <td><font face="Arial, Helvetica, sans-serif" size="1">Nom :</font></td> <td> <input type="text" name="Nom" size="25"> </td> </tr> <tr> <td><font face="Arial, Helvetica, sans-serif" size="1">Prénom :</font></td> <td> <input type="text" name="Prenom" size="25"> </td> </tr> <tr> <td> </td> <td><font face="Arial, Helvetica, sans-serif" size="1">Date de naissance :</font></td> <td> <input type="text" name="Jn" size="2"> / <input type="text" name="Mn" size="2"> / <input type="text" name="An"" size="2"> </td> </tr> <tr> <td> </td> <td><font face="Arial, Helvetica, sans-serif" size="1">Profession :</font></td> <td> <input type="text" name="Profession" size="25"> </td> </tr> <tr> <td valign="middle" align="center"><font face="Arial, Helvetica, sans-serif" size="1">Vous êtes :</font></td> <td valign="middle" align="center"> <input type="radio" name="statut" value="Assure social"> <font face="Arial, Helvetica, sans-serif" size="1"><br> Assuré social</font></td> <td valign="middle" align="center"> <div align="center"> <input type="radio" name="statut" value="Travailleur independant"> <font face="Arial, Helvetica, sans-serif" size="1"><br> Travailleur indépendant</font></div> </td> </tr> <tr> <td valign="middle" colspan="3" align="center"><font face="Arial, Helvetica, sans-serif" size="1">N° S.Sociale :</font> <input type="text" name="Sx" size="1"> <input type="text" name="Adn" size="2"> <input type="text" name="Mdn"" size="2"> <input type="text" name="Dp"" size="2"> <input type="text" name="C1"" size="3"> <input type="text" name="C2"" size="3"> <input type="text" name="Cl"" size="2"> </td> </tr> </table> </td> </tr> </table> </td> <td width="360" valign="middle"> <table border="1" cellspacing="0" cellpadding="0" bordercolor="#000000" align="center"> <tr align="center"> <td> <table border="0" cellpadding="2" cellspacing="2" bordercolor="#000000" height="230"> <tr> <td rowspan="2"><img src="images/etu-conj.gif" width="75" height="50"></td> <td><font face="Arial, Helvetica, sans-serif" size="1">Nom :</font></td> <td> <input type="text" name="Nomc" size="25"> </td> </tr> <tr> <td><font face="Arial, Helvetica, sans-serif" size="1">Prénom :</font></td> <td> <input type="text" name="Prenomc" size="25"> </td> </tr> <tr> <td> </td> <td><font face="Arial, Helvetica, sans-serif" size="1"> Date de naissance:</font></td> <td> <input type="text" name="Jnc" size="2"> / <input type="text" name="Mnc" size="2"> / <input type="text" name="Anc" size="2"> </td> </tr> <tr> <td> </td> <td><font face="Arial, Helvetica, sans-serif" size="1">Profession :</font></td> <td> <input type="text" name="Professionc" size="25"> </td> </tr> <tr> <td valign="middle" align="center"><font face="Arial, Helvetica, sans-serif" size="1">Vous êtes :</font></td> <td valign="middle" align="center"> <input type="radio" name="statutc" value="Assure social"> <br> <font face="Arial, Helvetica, sans-serif" size="1"> Assuré social</font></td> <td valign="middle" align="center"> <input type="radio" name="statutc" value="Travailleur independant"> <font face="Arial, Helvetica, sans-serif" size="1"><br> Travailleur indépendant</font></td> </tr> <tr> <td valign="middle" colspan="3" align="center"><font face="Arial, Helvetica, sans-serif" size="1">N° S. Sociale :</font> <input type="text" name="Sxc" size="1"> <input type="text" name="Adnc" size="2"> <input type="text" name="Mdnc"" size="2"> <input type="text" name="Dpc"" size="2"> <input type="text" name="C1c"" size="3"> <input type="text" name="C2c"" size="3"> <input type="text" name="Clc"" size="2"> </td> </tr> </table> </td> </tr> </table> </td> </tr> <tr> <td colspan="2" height="72"> <table width="100%" border="0" cellpadding="2" cellspacing="2"> <tr> <td width="85"><font face="Arial, Helvetica, sans-serif" size="1">Adresse </font><font size="1">:</font></td> <td colspan="7"> <div align="left"> <input type="text" name="Adresse" size="80"> <font face="Arial, Helvetica, sans-serif" size="1" color="#FF0000">* obligatoire</font></div> </td> </tr> <tr> <td width="85"><font face="Arial, Helvetica, sans-serif" size="1">CP :</font></td> <td width="85"> <div align="left"> <input type="text" name="CP" size="5"> </div> </td> <td width="85"><font face="Arial, Helvetica, sans-serif" size="1">Ville :</font></td> <td width="250"> <input type="text" name="Ville" size="35"> </td> <td width="85"><font face="Arial, Helvetica, sans-serif" size="1">Tél 1 :</font></td> <td width="100"> <div align="left"> <input type="text" name="Tel" size="14"> </div> </td> <td width="100"><font face="Arial, Helvetica, sans-serif" size="1">Tél 2 :</font></td> <td width="100"> <div align="left"> <input type="text" name="Tel2" size="14"> </div> </td> </tr> <tr> <td width="85"><font face="Arial, Helvetica, sans-serif" size="1">Email </font><font size="1">:</font></td> <td colspan="7"> <div align="left"> <input type="text" name="EMAIL" size="80"> <font face="Arial, Helvetica, sans-serif" size="1" color="#FF0000">* obligatoire</font></div> </td> </tr> </table> </td> </tr> <tr> <td height="25" colspan="2"> <hr noshade size=2 color="#336633"> </td> </tr> <tr> <td width="357"> <table width="100%" border="0" cellspacing="2" cellpadding="2" align="center"> <tr> <td colspan="4"><font face="Arial, Helvetica, sans-serif" size="1">• Enfants à charge</font></td> </tr> <tr> <td width="55" valign="bottom"><font face="Arial, Helvetica, sans-serif" size="1">Prénom :</font></td> <td width="130" valign="bottom"> <div align="left"> <input type="text" name="Penfant1" size="15"> </div> </td> <td colspan="2" width="170"><font face="Arial, Helvetica, sans-serif" size="1">Date de naissance :</font><font face="Arial, Helvetica, sans-serif"> <br> <input type="text" name="Jne1" size="2"> / <input type="text" name="Mne1" size="2"> / <input type="text" name="Ane1" size="2"> </font> </td> </tr> <tr> <td width="55" valign="bottom"><font face="Arial, Helvetica, sans-serif" size="1">Prénom :</font></td> <td width="130" valign="bottom"> <div align="left"> <input type="text" name="Penfant2" size="15"> </div> </td> <td width="170" colspan="2"><font face="Arial, Helvetica, sans-serif" size="1">Date de naissance :<br> </font> <font face="Arial, Helvetica, sans-serif"> <input type="text" name="Jne2" size="2"> / <input type="text" name="Mne2" size="2"> / <input type="text" name="Ane2" size="2"> </font> </td> </tr> <tr> <td width="55" valign="bottom"><font face="Arial, Helvetica, sans-serif" size="1">Prénom :</font></td> <td width="130" valign="bottom"> <div align="left"> <input type="text" name="Penfant3" size="15"> </div> </td> <td width="170" colspan="2"><font face="Arial, Helvetica, sans-serif" size="1">Date de naissance :<br> </font> <font face="Arial, Helvetica, sans-serif"> <input type="text" name="Jne3" size="2"> / <input type="text" name="Mne3" size="2"> / <input type="text" name="Ane3" size="2"> </font> </td> </tr> <tr> <td width="55" valign="bottom"><font face="Arial, Helvetica, sans-serif" size="1">Prénom :</font></td> <td width="130" valign="bottom"> <div align="left"> <input type="text" name="Penfant4" size="15"> </div> </td> <td width="170" colspan="2"><font face="Arial, Helvetica, sans-serif" size="1">Date de naissance :<br> </font> <font face="Arial, Helvetica, sans-serif"> <input type="text" name="Jne4" size="2"> / <input type="text" name="Mne4" size="2"> / <input type="text" name="Ane4" size="2"> </font> </td> </tr> </table> <br> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="1">• Avez-vous une mutuelle actuellement ?<br> </font></td> </tr> <tr> <td width="50%"><font face="Arial, Helvetica, sans-serif" size="1">oui <input type="radio" name="avoirmut" value="OUI"> </font></td> <td width="50%"><font face="Arial, Helvetica, sans-serif" size="1">non <input type="radio" name="avoirmut" value="NON"> </font></td> </tr> <tr> <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="1"><br> Si oui, laquelle?</font></td> </tr> <tr> <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="1"> <input type="text" name="mutuactu" size="30"> <br> <br> </font></td> </tr> </table> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td colspan="2" height="22"><font face="Arial, Helvetica, sans-serif" size="1">• En cas d'hospitalisation (maternité comprise) choisirez-vous plutôt ?</font></td> </tr> <tr> <td> <input type="radio" name="hospitalisation" value="hopital"> <font face="Arial, Helvetica, sans-serif" size="1"> l'hôpital</font></td> <td> <input type="radio" name="hospitalisation" value="clinique privee"> <font face="Arial, Helvetica, sans-serif" size="1"> une clinique privée </font></td> </tr> <tr> <td colspan="2" height="22"><font face="Arial, Helvetica, sans-serif" size="1">Dans ce cas, souhaitez-vous bénéficier d'une chambre particulière ?</font></td> </tr> <tr> <td width="50%"> <input type="radio" name="chambre" value="OUI"> <font face="Arial, Helvetica, sans-serif" size="1">Oui </font></td> <td width="50%"> <input type="radio" name="chambre" value="NON"> <font face="Arial, Helvetica, sans-serif" size="1">Non</font></td> </tr> </table> <br> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td colspan="3" height="22"><font face="Arial, Helvetica, sans-serif" size="1">• Vous arrive-t-il de consulter des spécialistes qui pratiquent des dépassements d'honoraires ?<br> (Ex : dermatologue, ophtalmologiste, gynécologue, etc…)</font></td> </tr> <tr align="left"> <td width="33%"> <div align="left"> <input type="radio" name="specialiste" value="Fréquemment"> <font face="Arial, Helvetica, sans-serif" size="1">Fréquemment</font></div> </td> <td width="33%"> <div align="left"> <input type="radio" name="specialiste" value="Occasionnellement"> <font face="Arial, Helvetica, sans-serif" size="1">Occasionnellement</font></div> </td> <td width="34%"> <div align="left"> <input type="radio" name="specialiste" value="Jamais"> <font face="Arial, Helvetica, sans-serif" size="1">Jamais</font></div> </td> </tr> </table> <p> </p> </td> <td width="364"> <table width="100%" border="0" cellspacing="2" cellpadding="2"> <tr> <td colspan="3" height="22"><font face="Arial, Helvetica, sans-serif" size="1">• En dentaire, pensez-vous avoir besoin d'un budget ?</font></td> </tr> <tr align="left"> <td width="33%"> <input name="dentaire" type="radio" value="Normal"> <font face="Arial, Helvetica, sans-serif" size="1">Normal</font></td> <td width="33%"> <input name="dentaire" type="radio" value="Important"> <font face="Arial, Helvetica, sans-serif" size="1">Important</font></td> <td width="33%"> <input name="dentaire" type="radio" value="Très important"> <font face="Arial, Helvetica, sans-serif" size="1">Très important</font></td> </tr> <tr align="left"> <td colspan="3"><font face="Arial, Helvetica, sans-serif" size="1">Pour quels types de soins ?</font> <input type="text" name="denactu" size="30"> </td> </tr> </table> <br> <table border="0" cellspacing="2" cellpadding="2" width="100%"> <tr> <td colspan="2" height="22"><font face="Arial, Helvetica, sans-serif" size="1">• Envisagez-vous des soins d'orthodontie dans votre famille ?</font></td> </tr> <tr> <td width="50%"> <input type="radio" name="ortho" value="OUI"> <font face="Arial, Helvetica, sans-serif" size="1"> Oui</font></td> <td width="50%"> <input type="radio" name="ortho" value="NON"> <font face="Arial, Helvetica, sans-serif" size="1"> Non</font></td> </tr> </table> <br> <table width="100%" border="0" cellspacing="2" cellpadding="2"> <tr> <td colspan="3" height="22"><font face="Arial, Helvetica, sans-serif" size="1">• Certaines personnes de votre famille ont-elles des problèmes de vue ?</font></td> </tr> <tr align="left"> <td width="33%"> <input type="checkbox" name="Lunettes" value="OUI"> <font face="Arial, Helvetica, sans-serif" size="1">Lunettes</font></td> <td width="33%"> <input type="checkbox" name="Lentilles" value="OUI"> <font face="Arial, Helvetica, sans-serif" size="1">Lentilles</font></td> <td width="33%"> <input type="checkbox" name="Verrespro" value="OUI"> <font face="Arial, Helvetica, sans-serif" size="1">Verres progressifs</font></td> </tr> </table> <br> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td colspan="2" height="22"><font face="Arial, Helvetica, sans-serif" size="1">• Avez-vous des troubles auditifs qui nécessitent un appareillage ?</font></td> </tr> <tr> <td width="50%"> <input type="radio" name="pbauditif" value="OUI"> <font face="Arial, Helvetica, sans-serif" size="1"> Oui</font></td> <td width="50%"> <input type="radio" name="pbauditif" value="NON"> <font face="Arial, Helvetica, sans-serif" size="1"> Non</font></td> </tr> </table> <br> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td colspan="2" height="22"><font face="Arial, Helvetica, sans-serif" size="1">• Questions particulières :</font></td> </tr> <tr> <td colspan="2"> <textarea name="questions" cols="40" rows="5"></textarea> </td> </tr> </table> <p> </p> </td> </tr> <tr> <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="1">Votre budget familial pour votre complémentaire santé ? <input type="text" name="budgcomp" size="40" value="" maxlength="80"> </font></td> </tr> <tr> <td colspan="2"> <hr noshade size=2 color="#336633"> </td> </tr> <tr> <td colspan="2"> <table width="600" border="0" cellspacing="1" cellpadding="2" align="center" bordercolor="#CC99CC"> <tr align="center" valign="middle" bordercolor="#000000"> <td rowspan="5" width="140"><font face="Arial, Helvetica, sans-serif" size="2"><b>GARANTIE SANTE </b></font></td> <td width="80"><b><font face="Arial, Helvetica, sans-serif" size="2">Modules</font></b></td> <td width="80" bgcolor="#CC99CC"><b><font face="Arial, Helvetica, sans-serif" size="2">0</font></b></td> <td width="80" bgcolor="#FFFFCC"><b><font face="Arial, Helvetica, sans-serif" size="2">1</font></b></td> <td width="80" bgcolor="#FFFF99"><b><font face="Arial, Helvetica, sans-serif" size="2">2</font></b></td> <td width="80" bgcolor="#FFFF66"><b><font face="Arial, Helvetica, sans-serif" size="2">3</font></b></td> </tr> <tr align="center" valign="middle" bordercolor="#000000"> <td width="80"><b><font face="Arial, Helvetica, sans-serif" size="1">Hospitalisation</font></b></td> <td width="80" bgcolor="#CC99CC"> <font face="Arial, Helvetica, sans-serif" size="1"><b>obligatoire</b></font></td> <td width="80" bgcolor="#FFFFCC"> <input type="radio" name="hospi" value="1"> </td> <td width="80" bgcolor="#FFFF99"> <input type="radio" name="hospi" value="2"> </td> <td width="80" bgcolor="#FFFF66"> <input type="radio" name="hospi" value="3"> </td> </tr> <tr align="center" valign="middle" bordercolor="#000000"> <td width="80"><b><font face="Arial, Helvetica, sans-serif" size="1">Dentaire, Optique, Paramedical</font></b></td> <td width="80" bgcolor="#CC99CC"> <input type="radio" name="dentaire" value="0"> </td> <td width="80" bgcolor="#FFFFCC"> <input type="radio" name="dentaire" value="1"> </td> <td width="80" bgcolor="#FFFF99"> <input type="radio" name="dentaire" value="2"> </td> <td width="80" bgcolor="#FFFF66"> <input type="radio" name="dentaire" value="3"> </td> </tr> <tr align="center" valign="middle" bordercolor="#000000"> <td width="80"><b><font face="Arial, Helvetica, sans-serif" size="1">Medecine, Pharmacie </font></b></td> <td width="80" bgcolor="#CC99CC"> <input type="radio" name="medphar" value="0"> </td> <td width="80" bgcolor="#FFFFCC"> <input type="radio" name="medphar" value="1"> </td> <td width="80" bgcolor="#FFFF99"> <input type="radio" name="medphar" value="2"> </td> <td width="80" bgcolor="#FFFF66"> <input type="radio" name="medphar" value="3"> </td> </tr> <tr align="center" valign="middle" bordercolor="#000000"> <td width="80"> <font size="1"><b><font face="Arial, Helvetica, sans-serif">Prestations Particulières </font> </b></font></td> <td width="80" bgcolor="#CC99CC"> <input type="radio" name="particulier" value="0"> </td> <td width="80" bgcolor="#FFFFCC"> <input type="radio" name="particulier" value="1"> </td> <td width="80" bgcolor="#FFFF99"> <input type="radio" name="particulier" value="2"> </td> <td width="80" bgcolor="#FFFF66"> <input type="radio" name="particulier" value="3"> </td> </tr> </table> </td> </tr> <tr align="center"> <td height="30" valign="middle" colspan="2"><font face="Arial, Helvetica, sans-serif" size="1"> </font> <br> <table width="600" border="0" cellspacing="0" cellpadding="0"> <tr> <td> <div align="center"><font size="2" face="Arial, Helvetica, sans-serif"><b>GARANTIE HOSPITALIERE </b></font></div> </td> <td> <div align="center"><font face="Arial, Helvetica, sans-serif" size="1"> <input type="radio" name="gh" value="16 euros"> 16 €</font></div> </td> <td> <div align="center"><font face="Arial, Helvetica, sans-serif" size="1"> <input type="radio" name="gh" value="24 euros"> 24 €</font></div> </td> <td> <div align="center"><font face="Arial, Helvetica, sans-serif" size="1"> <input type="radio" name="gh" value="32 euros"> 32 € </font></div> </td> <td> <div align="center"><font face="Arial, Helvetica, sans-serif" size="1"> <input type="radio" name="gh" value="40 euros"> 40 €</font></div> </td> </tr> </table> <br> </td> </tr> <tr align="center" valign="middle"> <td colspan="2"> <table width="390" border="0" cellspacing="0" cellpadding="0" align="center"> <tr align="center" valign="middle"> <td> <input type="reset" value="Annuler" name="reset"> </td> <td> <INPUT TYPE="submit" VALUE="Envoyer"> </td> <td> <input type="button" name="Button" value="Retour" onClick="window.close()"> </td> </tr> </table> </td> </tr> </table> </form> </body> </html>