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<html>
<head>
<title>Etude personnalis&eacute;e PG 42901</title>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1">
</head>

<body bgcolor="#FFFFFF">
<form method="post" action="/cgi-bin/etu42901.cgi">
  <table width="690" border="0" cellspacing="0" cellpadding="0" align="center">
    <tr align="left"> 
      <td><img src="images/etude.gif" width="220" height="50"></td>
    </tr>
  </table>
  <table width="640" border="0" align="center">
    <tr> 
      <td width="310" bordercolor="#000000"> 
        <table width="320" border="1" cellspacing="0" cellpadding="0" bordercolor="#000000" align="center">
          <tr align="center"> 
            <td width="310"> 
             
              <table width="310" border="0" cellpadding="0" cellspacing="0">
                <tr> 
                 <td rowspan="2" width="60"><img src="images/vous.gif" width="58" height="58"></td>
                  <td width="110"><font face="Arial, Helvetica, sans-serif" size="1">Nom :</font></td>
                  <td width="140"> 
                    <input type="text" name="Nom" size="25">
                  </td>
                </tr>
                <tr> 
                  <td width="100"><font face="Arial, Helvetica, sans-serif" size="1">Pr&eacute;nom 
                    :</font></td>
                  <td width="140"> 
                    <input type="text" name="Prenom" size="25">
                  </td>
                </tr>
                <tr> 
                  <td width="60">&nbsp;</td>
                  <td width="100"><font face="Arial, Helvetica, sans-serif" size="1">Date 
                    de naissance :</font></td>
                  <td width="140"> 
                    <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 width="60">&nbsp;</td>
                  <td width="100"><font face="Arial, Helvetica, sans-serif" size="1">Profession 
                    :</font></td>
                  <td width="140"> 
                    <input type="text" name="Profession" size="25">
                  </td>
                </tr>
                <tr> 
                  <td valign="middle" width="60" align="center"><font face="Arial, Helvetica, sans-serif" size="1">Vous 
                    &ecirc;tes :</font></td>
                  <td valign="middle" width="100" align="center"> 
                    <input type="radio" name="statut" value="Assure social">
                    <font face="Arial, Helvetica, sans-serif" size="1"><br>
                    Assur&eacute; social</font></td>
                  <td valign="middle" width="140" align="center"> 
                    <div align="center"> 
                      <input type="radio" name="statut" value="Travailleur independant">
                      <font face="Arial, Helvetica, sans-serif" size="1"><br>
                      Travailleur ind&eacute;pendant</font></div>
                  </td>
                </tr>
              </table>
            </td>
          </tr>
        </table>
      </td>
      <td width="640"> 
        <table width="320" border="1" cellspacing="0" cellpadding="0" bordercolor="#000000">
          <tr align="center"> 
            <td width="310"> 
              <table width="310" border="0" cellpadding="0" cellspacing="0" bordercolor="#000000">
                <tr> 
                  <td rowspan="2" width="65"><img src="images/conj.gif" width="58" height="58"></td>
                  <td width="105"><font face="Arial, Helvetica, sans-serif" size="1">Nom 
                    :</font></td>
                  <td width="140"> 
                    <input type="text" name="Nomc" size="25">
                  </td>
                </tr>
                <tr> 
                  <td width="105"><font face="Arial, Helvetica, sans-serif" size="1">Pr&eacute;nom 
                    :</font></td>
                  <td width="140"> 
                    <input type="text" name="Prenomc" size="25">
                  </td>
                </tr>
                <tr> 
                  <td width="65">&nbsp;</td>
                  <td width="105"><font face="Arial, Helvetica, sans-serif" size="1">
		  Date de naissance:</font></td>
                  <td width="140"> 
                    <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 width="65">&nbsp;</td>
                  <td width="105"><font face="Arial, Helvetica, sans-serif" size="1">Profession 
                    :</font></td>
                  <td width="140"> 
                    <input type="text" name="Professionc" size="25">
                  </td>
                </tr>
                <tr> 
                  <td valign="middle" width="65" align="center"><font face="Arial, Helvetica, sans-serif" size="1">Vous 
                    &ecirc;tes :</font></td>
                  <td valign="middle" width="105" align="center"> 
                    <input type="radio" name="statutc" value="Assure social">
                    <br>
                    <font face="Arial, Helvetica, sans-serif" size="1"> Assur&eacute; 
                    social</font></td>
                  <td valign="middle" width="140" align="center"> 
                    <input type="radio" name="statutc" value="Travailleur independant">
                    <font face="Arial, Helvetica, sans-serif" size="1"><br>
                    Travailleur ind&eacute;pendant</font></td>
                </tr>
              </table>
            </td>
          </tr>
        </table>
      </td>
    </tr>
    <tr> 
      <td bordercolor="#000000" height="23" colspan="2">&nbsp;</td>
    </tr>
    <tr> 
      <td colspan="2" height="72"> 
        <table width="620" border="0">
          <tr> 
            <td width="85"><font face="Arial, Helvetica, sans-serif" size="1">Adresse 
              </font><font size="1">:</font></td>
            <td colspan="5"> 
              <input type="text" name="Adresse" size="80">
            </td>
          </tr>
          <tr> 
            <td width="85"><font face="Arial, Helvetica, sans-serif" size="1">Code 
              Postal :</font></td>
            <td width="85"> 
              <input type="text" name="CP" size="5">
            </td>
            <td width="85"><font face="Arial, Helvetica, sans-serif" size="1">Ville 
              :</font></td>
            <td width="250"> 
              <input type="text" name="Ville" size="40">
            </td>
            <td width="85"><font face="Arial, Helvetica, sans-serif" size="1">T&eacute;l&eacute;phone 
              :</font></td>
            <td width="100"> 
              <input type="text" name="Tel" size="14">
            </td>
          </tr>
          <tr> 
            <td width="85"><font face="Arial, Helvetica, sans-serif" size="1">Email 
              </font><font size="1">:</font></td>
            <td colspan="5"> 
              <input type="text" name="EMAIL" size="80">
            </td>
          </tr>
        </table>
      </td>
    </tr>
    <tr> 
      <td height="25" colspan="2">&nbsp;</td>
    </tr>
    <tr> 
      <td colspan="2"> 
        <table width="620" border="0" cellspacing="0" cellpadding="0" align="center">
          <tr> 
            <td colspan="4"><font face="Arial, Helvetica, sans-serif" size="1">&#149; 
              Enfants &agrave; charge</font></td>
          </tr>
          <tr> 
            <td width="100"><font face="Arial, Helvetica, sans-serif" size="1">Pr&eacute;nom 
              :</font></td>
            <td width="240"> 
              <input type="text" name="Penfant1" size="25">
            </td>
            <td colspan="2" width="280"><font face="Arial, Helvetica, sans-serif" size="1">Date 
              de naissance :</font><font face="Arial, Helvetica, sans-serif"> 
              <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="100"><font face="Arial, Helvetica, sans-serif" size="1">Pr&eacute;nom 
              :</font></td>
            <td width="240"> 
              <input type="text" name="Penfant2" size="25">
            </td>
            <td width="280" colspan="2"><font face="Arial, Helvetica, sans-serif" size="1">Date 
              de naissance :</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="100"><font face="Arial, Helvetica, sans-serif" size="1">Pr&eacute;nom 
              :</font></td>
            <td width="240"> 
              <input type="text" name="Penfant3" size="25">
            </td>
            <td width="280" colspan="2"><font face="Arial, Helvetica, sans-serif" size="1">Date 
              de naissance :</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="100"><font face="Arial, Helvetica, sans-serif" size="1">Pr&eacute;nom 
              :</font></td>
            <td width="240"> 
              <input type="text" name="Penfant4" size="25">
            </td>
            <td width="280" colspan="2"><font face="Arial, Helvetica, sans-serif" size="1">Date 
              de naissance :</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>
      </td>
    </tr>
    <tr> 
      <td colspan="2">&nbsp;</td>
    </tr>
    <tr> 
      <td height="22" colspan="2"><font face="Arial, Helvetica, sans-serif" size="1">&#149; 
        Avez-vous une mutuelle actuellement ?</font></td>
    </tr>
    <tr> 
      <td colspan="2"><font face="Arial, Helvetica, sans-serif" size="1">Si oui 
        laquelle ?</font> 
        <input type="text" name="mutuactu" size="30">
      </td>
    </tr>
    <tr> 
      <td height="21" colspan="2" width="640">&nbsp;</td>
    </tr>
    <tr> 
      <td width="640" colspan="2"> 
        <table border="0" cellspacing="0" cellpadding="0">
          <tr> 
            <td><font face="Arial, Helvetica, sans-serif" size="1">&#149; Votre 
              budget familial pour votre compl&eacute;mentaire sant&eacute; ?</font></td>
            <td width="130" valign="middle"> 
              <input type="text" name="budgetmut" size="10">
            </td>
          </tr>
        </table>
      </td>
    </tr>
    <tr> 
      <td colspan="2" width="640" height="18">&nbsp;</td>
    </tr>
    <tr> 
      <td width="640" colspan="2"> 
        <table width="630" border="1" cellspacing="0" cellpadding="0" align="center">
          <tr align="center" valign="middle" bordercolor="#000000"> 
            <td rowspan="2" width="90"><font face="Arial, Helvetica, sans-serif" size="1">Garantie 
              envisag&eacute;e<br>
              par l'adh&eacute;rent</font></td>
            <td width="90"><font face="Arial, Helvetica, sans-serif" size="1">Brio</font></td>
            <td width="90"><font face="Arial, Helvetica, sans-serif" size="1">Chic</font></td>
            <td width="90"><font face="Arial, Helvetica, sans-serif" size="1">R&eacute;cital</font></td>
                     </tr>
          <tr> 
            <td align="center" valign="middle" width="90"> 
              <input type="radio" name="garantie" value="Trio">
            </td>
            <td align="center" valign="middle" width="90"> 
              <input type="radio" name="garantie" value="Chic">
            </td>
            <td align="center" valign="middle" width="90"> 
              <input type="radio" name="garantie" value="Recital">
           </td>
          </tr>
        </table>
      </td>
    </tr>
    <tr> 
      <td colspan="2" width="640">&nbsp;</td>
    </tr>
    <tr> 
 <td height="30" valign="middle"><font face="Arial, Helvetica, sans-serif" size="1"> 
        <input type="checkbox" name="ph" value="Presence Hospitaliere">
        Pr&eacute;sence Hospitali&egrave;re<br>
        </font></td>
      <td height="30" valign="middle"><font face="Arial, Helvetica, sans-serif" size="1"> 
        <input type="checkbox" name="amj" value="Assurance multigaranties jeune 20-28 ans">
        Assurance multigaranties jeunes 20-28 ans
        </font></td>
     </tr>
    <tr> 
      <td colspan="2" width="640">&nbsp;</td>
    </tr>
    <tr align="center" valign="middle"> 
      <td width="640" 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="Envoyer">
            </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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