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<html>
<head>
<title>Etude Pr&eacute;sence en pr&eacute;voyance collective</title>
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</head>

<body bgcolor="#CCFFFF">
<form method="get" action="http://www.mutuelles-presence.fr/formpresenceentr.php">
  <table bgcolor="#CCFFFF" border="0" cellpadding="0" cellspacing="0" width="640" align="center">
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    <tr bgcolor="#CCFFFF"> 
      <td colspan="5"><a href="presentr.htm"><img src="images/fleche-etuc.gif" width="34" height="37" border="0"></a></td>
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            <td><img name="etuclogo" src="images/prev-logo.gif" width="110" height="110" border="0"></td>
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      <td rowspan="2" bgcolor="#CCFFFF">&nbsp;</td>
      <td> 
        <div align="center"><img name="etuctitre" src="images/etuc-titre.gif" border="0" width="360" height="154"></div>
      </td>
      <td rowspan="2" bgcolor="#CCFFFF">&nbsp;</td>
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                <tr> 
                  <td rowspan="4" align="left" valign="middle"><img src="images/etuc-entr.gif" width="110" height="40"></td>
                  <td width="110"><font face="Arial, Helvetica, sans-serif" size="1">Raison 
                    Sociale :</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">
                    <font face="Arial, Helvetica, sans-serif" size="1" color="#FF0000">* 
                    obligatoire</font> </td>
                </tr>
                <tr> 
                  <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="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>
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      </td>
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      <td bordercolor="#000000" height="23" colspan="2"> 
        <hr noshade size=2 color="#000066">
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        <table width="620" border="0" 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="100%" border="0" cellspacing="1" cellpadding="1" align="center">
          <tr> 
            <td align="center" valign="middle" rowspan="2"><font size="2" face="Arial, Helvetica, sans-serif">EFFECTIFS</font></td>
            <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">ETAM</font></td>
            <td align="center" valign="middle"><font face="Arial, Helvetica, sans-serif" size="1">NON 
              CADRES </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" width="20%"> 
              <input type="text" name="cadres" size="10">
            </td>
            <td align="center" valign="middle" width="20%"> 
              <input type="text" name="etam" size="10">
            </td>
            <td align="center" valign="middle" width="20%"> 
              <input type="text" name="ncadres" size="10">
            </td>
            <td align="center" valign="middle" width="20%"> 
              <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="100%" border="0" cellspacing="1" cellpadding="1" align="center">
          <tr> 
            <td align="center" valign="middle" width="25%"><font face="Arial, Helvetica, sans-serif" size="1">Nom 
              du demandeur</font></td>
            <td align="center" valign="middle" width="25%"><font face="Arial, Helvetica, sans-serif" size="1">Fonction 
              </font></td>
            <td align="center" valign="middle" width="25%"><font face="Arial, Helvetica,
sans-serif" size="1">Telephone</font></td>
            <td align="center" valign="middle" width="25%"><font size="1" face="Arial, Helvetica, sans-serif">E-Mail</font></td>
          </tr>
          <tr> 
            <td align="center" valign="middle" width="33%"> 
              <input type="text" name="demandeur" size="20">
            </td>
            <td align="center" valign="middle" width="33%"> 
              <input type="text" name="fonction" size="20">
            </td>
            <td align="center" valign="middle" width="34%"> 
              <input type="text" name="dtel" size="20">
            </td>
            <td align="center" valign="middle" width="34%">
              <input type="text" name="EMAIL" size="20">
            </td>
          </tr>
        </table>
      </td>
    </tr>
    <tr> 
      <td colspan="2"> 
        <div align="center"> 
          <hr noshade size=2 color="#000066">
          <font size="2" face="Arial, Helvetica, sans-serif"></font></div>
      </td>
    </tr>
    <tr align="center" valign="middle"> 
      <td colspan="2"><font size="2" face="Arial, Helvetica, sans-serif"><b>QUELLES 
        SOLUTIONS SOUHAITEZ-VOUS DECOUVRIR ?</b></font></td>
    </tr>
    <tr align="center" valign="middle"> 
      <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="1"><br>
        </font></td>
    </tr>
    <tr> 
      <td colspan="2"> 
        <table width="100%" border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td width="840" colspan="3" height="22"><font face="Arial, Helvetica, sans-serif" size="3"><b><font size="2">&#149; 
              Garanties Sant&eacute;</font></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" width="25%"> 
                    <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" width="25%"> 
                    <input type="radio" name="perso" value="cadres">
                    <font face="Arial, Helvetica, sans-serif" size="1"> Cadres</font></td>
                  <td align="left" valign="middle" width="25%"> 
                    <input type="radio" name="perso" value="etam">
                    <font face="Arial, Helvetica, sans-serif" size="1"> Etam</font></td>
                  <td align="left" valign="middle" width="25%"> 
                    <input type="radio" name="perso" value="non-cadres">
                    <font face="Arial, Helvetica, sans-serif" size="1"> Non cadres</font></td>
                </tr>
              </table>
            </td>
          </tr>
        </table>
      </td>
    </tr>
    <tr> 
      <td colspan="2">&nbsp;</td>
    </tr>
    <tr> 
      <td colspan="2"> 
        <table width="100%" 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; 
              <font size="2">Garantie Pr&eacute;voyance</font> </font></b>&agrave; 
              caract&egrave;re obligatoire<font size="3"><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" width="25%"> 
                    <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" width="25%"> 
                    <input type="radio" name="perso2" value="cadres">
                    <font face="Arial, Helvetica, sans-serif" size="1"> Cadres</font></td>
                  <td align="left" valign="middle" width="25%"> 
                    <input type="radio" name="perso2"
value="etam">
                    <font face="Arial, Helvetica,
sans-serif" size="1"> Etam</font></td>
                  <td
align="left" valign="middle" width="25%"> 
                    <input type="radio"
name="perso2" value="non-cadres">
                    <font
face="Arial, Helvetica, sans-serif" size="1"> Non cadres</font></td>
                </tr>
              </table>
            </td>
          </tr>
        </table>
      </td>
    </tr>
    <tr> 
      <td colspan="2">&nbsp;</td>
    </tr>
    <tr> 
      <td colspan="2"> 
        <table width="100%" border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td width="50">&nbsp;</td>
            <td width="401"> 
              <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>
            <td rowspan="7" width="221"> 
              <div align="right"><img src="images/etuc-pat.gif"></div>
            </td>
          </tr>
          <tr> 
            <td width="50">&nbsp;</td>
            <td width="401"> 
              <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="50">&nbsp;</td>
            <td width="401"> 
              <input type="checkbox" name="rc" value="OUI">
              <font face="Arial, Helvetica, sans-serif" size="1"> Rente de conjoint</font></td>
          </tr>
          <tr> 
            <td width="50">&nbsp;</td>
            <td width="401"> 
              <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="50">&nbsp;</td>
            <td width="401"> 
              <input type="checkbox" name="retc" value="OUI">
              <font face="Arial, Helvetica, sans-serif" size="1"> Retraite par 
              capitalisation</font></td>
          </tr>
          <tr> 
            <td width="50">&nbsp;</td>
            <td width="401"> 
              <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>
          <tr> 
            <td width="50">&nbsp;</td>
            <td width="401"> 
              <input type="checkbox" name="es" value="OUI">
              <font face="Arial, Helvetica, sans-serif" size="1"> Epargne salariale</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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