{"id":393,"date":"2024-12-11T19:40:12","date_gmt":"2024-12-11T19:40:12","guid":{"rendered":"https:\/\/pga.ententeinsurance.ca\/entente-application\/"},"modified":"2025-01-21T21:57:46","modified_gmt":"2025-01-21T21:57:46","slug":"entente-application","status":"publish","type":"page","link":"https:\/\/pga.ententeinsurance.ca\/fr\/entente-application\/","title":{"rendered":"Demande d&#8217;adh\u00e9sion au programme d&#8217;assurance collective Entente"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"393\" class=\"elementor elementor-393 elementor-239\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-313f1988 e-flex e-con-boxed e-con e-parent\" data-id=\"313f1988\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-453ee158 elementor-widget elementor-widget-text-editor\" data-id=\"453ee158\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<script>\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 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#112337;--gf-ctrl-label-color-secondary: #112337;--gf-ctrl-choice-size: var(--gf-ctrl-choice-size-md);--gf-ctrl-checkbox-check-size: var(--gf-ctrl-checkbox-check-size-md);--gf-ctrl-radio-check-size: var(--gf-ctrl-radio-check-size-md);--gf-ctrl-btn-font-size: var(--gf-ctrl-btn-font-size-md);--gf-ctrl-btn-padding-x: var(--gf-ctrl-btn-padding-x-md);--gf-ctrl-btn-size: var(--gf-ctrl-btn-size-md);--gf-ctrl-btn-border-color-secondary: #686e77;--gf-ctrl-file-btn-bg-color-hover: #EBEBEB;--gf-field-img-choice-size: var(--gf-field-img-choice-size-md);--gf-field-img-choice-card-space: var(--gf-field-img-choice-card-space-md);--gf-field-img-choice-check-ind-size: var(--gf-field-img-choice-check-ind-size-md);--gf-field-img-choice-check-ind-icon-size: var(--gf-field-img-choice-check-ind-icon-size-md);--gf-field-pg-steps-number-color: rgba(17, 35, 55, 0.8);}<\/style><div id='gf_5' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5' class='cmn-form' action='\/fr\/wp-json\/wp\/v2\/pages\/393#gf_5' data-formid='5' novalidate>\n        <div id='gf_progressbar_wrapper_5' class='gf_progressbar_wrapper' data-start-at-zero=''>\n        \t<p class=\"gf_progressbar_title\">\u00c9tape <span class='gf_step_current_page'>1<\/span> sur <span class='gf_step_page_count'>8<\/span><span class='gf_step_page_name'><\/span>\n        \t<\/p>\n            <div class='gf_progressbar gf_progressbar_custom' aria-hidden='true'>\n                <div class='gf_progressbar_percentage percentbar_custom percentbar_12' style='width:12%; color:; background-color:#B00407;'><span>12%<\/span><\/div>\n            <\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_5_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_121\" class=\"gfield gfield--type-honeypot gform_validation_container field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_121'>URL<\/label><div class='ginput_container'><input name='input_121' id='input_5_121' type='text' value='' autocomplete='new-password'\/><\/div><div class='gfield_description' id='gfield_description_5_121'>Ce champ n\u2019est utilis\u00e9 qu\u2019\u00e0 des fins de validation et devrait rester inchang\u00e9.<\/div><\/div><div id=\"field_5_65\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Informations personnelles<\/h3><\/div><div id=\"field_5_118\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.\"><\/i><span>Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.<\/span><\/div><label class='gfield_label gform-field-label' for='input_5_118'>Num\u00e9ro d&#039;identification PGA<\/label><div class='ginput_container ginput_container_text'><input name='input_118' id='input_5_118' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_17\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.\"><\/i><span>Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.<\/span><\/div><label class='gfield_label gform-field-label' for='input_5_17'>num\u00e9ro de membre de la PGA<\/label><div class='ginput_container ginput_container_number'><input name='input_17' id='input_5_17' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_5_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nom l\u00e9gal<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_5_1'>\n                            \n                            <span id='input_5_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.3' id='input_5_1_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_1_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            \n                            <span id='input_5_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_1.6' id='input_5_1_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_1_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_119\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_119'>Langue de communication pr\u00e9f\u00e9r\u00e9e<\/label><div class='ginput_container ginput_container_select'><select name='input_119' id='input_5_119' class='large gfield_select'     aria-invalid=\"false\" ><option value='Anglais' >Anglais<\/option><option value='Fran\u00e7ais' >Fran\u00e7ais<\/option><\/select><\/div><\/div><fieldset id=\"field_5_6\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.\"><\/i><span>Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.<\/span><\/div><legend class='gfield_label gform-field-label gfield_label_before_complex' >Adresse courriel personnelle<\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_5_6_container'>\n                                <span id='input_5_6_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_6' id='input_5_6' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_5_6' class='gform-field-label gform-field-label--type-sub '>Saisissez un e-mail<\/label>\n                                <\/span>\n                                <span id='input_5_6_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <input class='' type='email' name='input_6_2' id='input_5_6_2' value=''     aria-invalid=\"false\"  \/>\n                                    <label for='input_5_6_2' class='gform-field-label gform-field-label--type-sub '>Confirmez l\u2019e-mail<\/label>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_5_7\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_7'>t\u00e9l\u00e9phone principal<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_7' id='input_5_7' type='tel' value='' class='large'   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_8\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_8'>Num\u00e9ro de t\u00e9l\u00e9phone secondaire<\/label><div class='ginput_container ginput_container_phone'><input name='input_8' id='input_5_8' type='tel' value='' class='large'    aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_9\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_9'>Date de naissance (JJ\/MM\/AAAA)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_9' id='input_5_9' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_5_9_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_5_9_date_format' class='screen-reader-text'>JJ slash MM slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_9' class='gform_hidden' value='https:\/\/pga.ententeinsurance.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_120\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_120'>J&#039;ai un r\u00e9gime d&#039;assurance maladie gouvermental (p.ex. RAMQ)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_120' id='input_5_120' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Oui' >Oui<\/option><option value='Non' >Non<\/option><\/select><\/div><\/div><div id=\"field_5_11\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_11'>Genre indiqu\u00e9 sur votre carte Sant\u00e9 provinciale\/territoriale<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_5_11' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Homme' selected='selected'>Homme<\/option><option value='Femme' >Femme<\/option><option value='X' >X<\/option><\/select><\/div><\/div><fieldset id=\"field_5_12\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Adresse<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_12' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_12_1_container' >\n                                        <input type='text' name='input_12.1' id='input_5_12_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_12_1' id='input_5_12_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_12_2_container' >\n                                        <input type='text' name='input_12.2' id='input_5_12_2' value=''     aria-required='false'   \/>\n                                        <label for='input_5_12_2' id='input_5_12_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_12_3_container' >\n                                    <input type='text' name='input_12.3' id='input_5_12_3' value=''    aria-required='true'    \/>\n                                    <label for='input_5_12_3' id='input_5_12_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_12_4_container' >\n                                        <select name='input_12.4' id='input_5_12_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_5_12_4' id='input_5_12_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_12_5_container' >\n                                    <input type='text' name='input_12.5' id='input_5_12_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_12_5' id='input_5_12_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_12.6' id='input_5_12_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><input type=\"hidden\" name=\"gpaa_place_12\" class=\"gform_hidden\" value=\"\"><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_5_116' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant - D\u00e9tails sur la sant\u00e9 et l&#039;assurance'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_2' class='gform_page' data-js='page-field-id-116' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_27\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">D\u00e9tails sur la sant\u00e9 et l&#039;assurance<\/h3><\/div><fieldset id=\"field_5_28\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Choisir la meilleure option en fonction de votre couverture d\u2019assurance actuelle\/pr\u00e9c\u00e9dente<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_28'>\n\t\t\t<div class='gchoice gchoice_5_28_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='J\u2019ai\/Mon conjoint(e)\/partenaire a\/avons eu une couverture de frais m\u00e9dicaux compl\u00e9mentaires, dentaires et\/ou hospitaliers au cours des 60 derniers jours.'  id='choice_5_28_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_28_0' id='label_5_28_0' class='gform-field-label gform-field-label--type-inline'>J\u2019ai\/Mon conjoint(e)\/partenaire a\/avons eu une couverture de frais m\u00e9dicaux compl\u00e9mentaires, dentaires et\/ou hospitaliers au cours des 60 derniers jours.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_28_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_28' type='radio' value='Aucune. Au cours des 60\u202fderniers jours, je n\u2019ai \u00e9t\u00e9 assur\u00e9 avec aucun r\u00e9gime'  id='choice_5_28_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_28_1' id='label_5_28_1' class='gform-field-label gform-field-label--type-inline'>Aucune. Au cours des 60\u202fderniers jours, je n\u2019ai \u00e9t\u00e9 assur\u00e9 avec aucun r\u00e9gime<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_67\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><\/div><div id=\"field_5_31\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_31'>Nom de la compagnie d\u2019assurance<\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_5_31' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_32'>Num\u00e9ro de police<\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_5_32' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_33'>Num\u00e9ro d\u2019identification<\/label><div class='ginput_container ginput_container_text'><input name='input_33' id='input_5_33' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_38\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >R\u00e9gime Frais m\u00e9dicaux compl\u00e9mentaires<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_38'>\n\t\t\t<div class='gchoice gchoice_5_38_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Individuel'  id='choice_5_38_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_38_0' id='label_5_38_0' class='gform-field-label gform-field-label--type-inline'>Individuel<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_38_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Couple'  id='choice_5_38_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_38_1' id='label_5_38_1' class='gform-field-label gform-field-label--type-inline'>Couple<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_38_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='Famille'  id='choice_5_38_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_38_2' id='label_5_38_2' class='gform-field-label gform-field-label--type-inline'>Famille<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_38_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_38' type='radio' value='S.O.'  id='choice_5_38_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_38_3' id='label_5_38_3' class='gform-field-label gform-field-label--type-inline'>S.O.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_39\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Taper de r\u00e9gime de soins de sant\u00e9 prolong\u00e9s<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_39'>\n\t\t\t<div class='gchoice gchoice_5_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Individuel'  id='choice_5_39_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_39_0' id='label_5_39_0' class='gform-field-label gform-field-label--type-inline'>Individuel<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Couple'  id='choice_5_39_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_39_1' id='label_5_39_1' class='gform-field-label gform-field-label--type-inline'>Couple<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_39_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Famille'  id='choice_5_39_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_39_2' id='label_5_39_2' class='gform-field-label gform-field-label--type-inline'>Famille<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_39_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='S.O.'  id='choice_5_39_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_39_3' id='label_5_39_3' class='gform-field-label gform-field-label--type-inline'>S.O.<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_41\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >R\u00e9gime Frais hospitaliers et soins de convalescence <\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_41'>\n\t\t\t<div class='gchoice gchoice_5_41_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Individuel'  id='choice_5_41_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_41_0' id='label_5_41_0' class='gform-field-label gform-field-label--type-inline'>Individuel<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_41_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Couple'  id='choice_5_41_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_41_1' id='label_5_41_1' class='gform-field-label gform-field-label--type-inline'>Couple<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_41_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Famille'  id='choice_5_41_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_41_2' id='label_5_41_2' class='gform-field-label gform-field-label--type-inline'>Famille<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_41_3'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='S.O.'  id='choice_5_41_3' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_41_3' id='label_5_41_3' class='gform-field-label gform-field-label--type-inline'>S.O.<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_41_4'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_41' type='radio' value='Inclus avec mon r\u00e9gime Frais m\u00e9dicaux compl\u00e9mentaires'  id='choice_5_41_4' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_41_4' id='label_5_41_4' class='gform-field-label gform-field-label--type-inline'>Inclus avec mon r\u00e9gime Frais m\u00e9dicaux compl\u00e9mentaires<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_37\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_37'>Date de cessation du r\u00e9gime d\u2019assurance dentaire<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_37' id='input_5_37' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_5_37_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_37_date_format' class='screen-reader-text'>JJ slash MM slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_37' class='gform_hidden' value='https:\/\/pga.ententeinsurance.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_40\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_40'>Date de cessation du r\u00e9gime Frais m\u00e9dicaux compl\u00e9mentaires<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_40' id='input_5_40' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_5_40_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_40_date_format' class='screen-reader-text'>JJ slash MM slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_40' class='gform_hidden' value='https:\/\/pga.ententeinsurance.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_5_42\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_42'>Date de fin du r\u00e9gime hospitalier et de soins de convalescence<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_42' id='input_5_42' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_5_42_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_42_date_format' class='screen-reader-text'>JJ slash MM slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_42' class='gform_hidden' value='https:\/\/pga.ententeinsurance.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_45' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Dos'  \/> <input type='button' id='gform_next_button_5_45' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant - Inscription \u00e0 l&#039;Entente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_3' class='gform_page' data-js='page-field-id-45' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_44\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Adh\u00e9sion \u00e0 Entente<\/h3><\/div><fieldset id=\"field_5_50\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >S\u00e9lectionnez les plans auxquels vous souhaitez vous inscrire (s\u00e9lectionnez tous ceux qui s\u2019appliquent):<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox gfield_choice--select_all_enabled' id='input_5_50'><div class='gchoice gchoice_5_50_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.1' type='checkbox'  value='R\u00e9gime d\u2019assurance-maladie compl\u00e9mentaire'  id='choice_5_50_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_50_1' id='label_5_50_1' class='gform-field-label gform-field-label--type-inline'>R\u00e9gime d\u2019assurance-maladie compl\u00e9mentaire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_50_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.2' type='checkbox'  value='R\u00e9gime de soins dentaires'  id='choice_5_50_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_50_2' id='label_5_50_2' class='gform-field-label gform-field-label--type-inline'>R\u00e9gime de soins dentaires<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_50_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_50.3' type='checkbox'  value='Plan d\u2019hospitalisation et de convalescence'  id='choice_5_50_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_50_3' id='label_5_50_3' class='gform-field-label gform-field-label--type-inline'>Plan d\u2019hospitalisation et de convalescence<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gfield-choice-toggle-all\"><button type=\"button\" id=\"button_50_select_all\" class=\"gfield_choice_all_toggle gform-theme-button--size-sm\" onclick=\"gformToggleCheckboxes( this )\" data-checked=\"0\" data-label-select=\"Tout s\u00e9lectionner\" data-label-deselect=\"Tout d\u00e9s\u00e9lectionner\">Tout s\u00e9lectionner<\/button><\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_68' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Dos'  \/> <input type='button' id='gform_next_button_5_68' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant - Soins de sant\u00e9 compl\u00e9mentaires'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_4' class='gform_page' data-js='page-field-id-68' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_63\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">R\u00e9gime d\u2019assurance-maladie compl\u00e9mentaire<\/h3><div class='gsection_description' id='gfield_description_5_63'>Taper de r\u00e9gime d\u2019assurance-maladie compl\u00e9mentaire (votre conjoint\/partenaire ou les personnes \u00e0 charge admissibles peuvent d\u00e9tenir une couverture individuelle, m\u00eame si vous n\u2019adh\u00e9rez pas \u00e0 ce r\u00e9gime.)<\/div><\/div><fieldset id=\"field_5_51\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Participants au r\u00e9gime<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_51'>\n\t\t\t<div class='gchoice gchoice_5_51_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Individuel' checked='checked' id='choice_5_51_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_51_0' id='label_5_51_0' class='gform-field-label gform-field-label--type-inline'>Individuel<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_51_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Couple'  id='choice_5_51_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_51_1' id='label_5_51_1' class='gform-field-label gform-field-label--type-inline'>Couple<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_51_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_51' type='radio' value='Famille'  id='choice_5_51_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_51_2' id='label_5_51_2' class='gform-field-label gform-field-label--type-inline'>Famille<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_70\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.\"><\/i><span>Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.<\/span><\/div><h3 class=\"gsection_title\">Volet couple\/famille<\/h3><\/div><fieldset id=\"field_5_52\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Votre conjoint\/partenaire poss\u00e8de-t-il une carte Sant\u00e9 provinciale\/territoriale valide?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_52'>\n\t\t\t<div class='gchoice gchoice_5_52_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Oui'  id='choice_5_52_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_52_0' id='label_5_52_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_52_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_52' type='radio' value='Non'  id='choice_5_52_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_52_1' id='label_5_52_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_53\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_53'>Nom du conjoint\/partenaire indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale<\/label><div class='ginput_container ginput_container_text'><input name='input_53' id='input_5_53' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_54\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_54'>Genre du conjoint\/partenaire indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale<\/label><div class='ginput_container ginput_container_select'><select name='input_54' id='input_5_54' class='large gfield_select'     aria-invalid=\"false\" ><option value='Homme' selected='selected'>Homme<\/option><option value='Femme' >Femme<\/option><option value='X' >X<\/option><\/select><\/div><\/div><div id=\"field_5_55\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_55'>Date de naissance du conjoint\/partenaire* (MM\/JJ\/AAAA)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_55' id='input_5_55' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_5_55_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_55_date_format' class='screen-reader-text'>JJ slash MM slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_55' class='gform_hidden' value='https:\/\/pga.ententeinsurance.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_5_59\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nom de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale <\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Nom de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale <\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Genre de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Date de naissance de la personne \u00e0 charge<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Si plus de 21<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Si plus de 21\u202fans \u00c9tudiant(e) or D\u00e9ficience fonctionnelle <\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Si \u00e9tudiant(e), nom de l\u2019institution<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_59_cell1 gform-grid-col' data-label='Nom de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale '><input aria-invalid='false'   aria-label='Nom de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale , Ligne 1' data-aria-label-template='Nom de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale , Ligne {0}' type='text' name='input_59[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_59_cell2 gform-grid-col' data-label='Genre de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale'><input aria-invalid='false'   aria-label='Genre de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale, Ligne 1' data-aria-label-template='Genre de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale, Ligne {0}' type='text' name='input_59[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_59_cell3 gform-grid-col' data-label='Date de naissance de la personne \u00e0 charge'><input aria-invalid='false'   aria-label='Date de naissance de la personne \u00e0 charge, Ligne 1' data-aria-label-template='Date de naissance de la personne \u00e0 charge, Ligne {0}' type='text' name='input_59[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_59_cell4 gform-grid-col' data-label='Si plus de 21'><input aria-invalid='false'   aria-label='Si plus de 21, Ligne 1' data-aria-label-template='Si plus de 21, Ligne {0}' type='text' name='input_59[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_59_cell5 gform-grid-col' data-label='Si plus de 21\u202fans \u00c9tudiant(e) or D\u00e9ficience fonctionnelle '><input aria-invalid='false'   aria-label='Si plus de 21\u202fans \u00c9tudiant(e) or D\u00e9ficience fonctionnelle , Ligne 1' data-aria-label-template='Si plus de 21\u202fans \u00c9tudiant(e) or D\u00e9ficience fonctionnelle , Ligne {0}' type='text' name='input_59[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_59_cell6 gform-grid-col' data-label='Si \u00e9tudiant(e), nom de l\u2019institution'><input aria-invalid='false'   aria-label='Si \u00e9tudiant(e), nom de l\u2019institution, Ligne 1' data-aria-label-template='Si \u00e9tudiant(e), nom de l\u2019institution, Ligne {0}' type='text' name='input_59[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Ajouter une autre ligne' onclick='gformAddListItem(this, 0)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Supprimer la ligne {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Retirer<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_69' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Dos'  \/> <input type='button' id='gform_next_button_5_69' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant - R\u00e9gime de soins dentaires'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_5' class='gform_page' data-js='page-field-id-69' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_5' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_62\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Assurance dentaire<\/h3><div class='gsection_description' id='gfield_description_5_62'>R\u00e9gime d\u2019assurance dentaire (votre conjoint\/partenaire ou vos personnes \u00e0 charge admissibles peuvent b\u00e9n\u00e9ficier d\u2019une couverture individuelle, m\u00eame si vous n\u2019adh\u00e9rez pas \u00e0 ce r\u00e9gime)<\/div><\/div><fieldset id=\"field_5_64\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Participants au r\u00e9gime<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_64'>\n\t\t\t<div class='gchoice gchoice_5_64_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Individuel' checked='checked' id='choice_5_64_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_64_0' id='label_5_64_0' class='gform-field-label gform-field-label--type-inline'>Individuel<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_64_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Couple'  id='choice_5_64_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_64_1' id='label_5_64_1' class='gform-field-label gform-field-label--type-inline'>Couple<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_64_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_64' type='radio' value='Famille'  id='choice_5_64_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_64_2' id='label_5_64_2' class='gform-field-label gform-field-label--type-inline'>Famille<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_75\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.\"><\/i><span>Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.<\/span><\/div><h3 class=\"gsection_title\">Volet couple\/famille<\/h3><\/div><fieldset id=\"field_5_74\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Votre conjoint\/partenaire poss\u00e8de-t-il une carte Sant\u00e9 provinciale\/territoriale valide?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_74'>\n\t\t\t<div class='gchoice gchoice_5_74_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Oui'  id='choice_5_74_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_74_0' id='label_5_74_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_74_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_74' type='radio' value='Non'  id='choice_5_74_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_74_1' id='label_5_74_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_71\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_71'>Nom du conjoint\/partenaire indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_5_71' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_72\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_72'>Genre du conjoint\/partenaire indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale<\/label><div class='ginput_container ginput_container_select'><select name='input_72' id='input_5_72' class='large gfield_select'     aria-invalid=\"false\" ><option value='Homme' selected='selected'>Homme<\/option><option value='Femme' >Femme<\/option><option value='X' >X<\/option><\/select><\/div><\/div><div id=\"field_5_73\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_73'>Date de naissance du conjoint\/partenaire* (MM\/JJ\/AAAA)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_73' id='input_5_73' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_5_73_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_73_date_format' class='screen-reader-text'>JJ slash MM slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_73' class='gform_hidden' value='https:\/\/pga.ententeinsurance.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_5_76\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nom de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale <\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Nom de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale <\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Genre de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Date de naissance de la personne \u00e0 charge<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Si plus de 21<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Si plus de 21\u202fans :  \u00e9tudiant(e) ou handicap fonctionnel <\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Si \u00e9tudiant(e), nom de l\u2019institution<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_76_cell1 gform-grid-col' data-label='Nom de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale '><input aria-invalid='false'   aria-label='Nom de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale , Ligne 1' data-aria-label-template='Nom de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale , Ligne {0}' type='text' name='input_76[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_76_cell2 gform-grid-col' data-label='Genre de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale'><input aria-invalid='false'   aria-label='Genre de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale, Ligne 1' data-aria-label-template='Genre de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale, Ligne {0}' type='text' name='input_76[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_76_cell3 gform-grid-col' data-label='Date de naissance de la personne \u00e0 charge'><input aria-invalid='false'   aria-label='Date de naissance de la personne \u00e0 charge, Ligne 1' data-aria-label-template='Date de naissance de la personne \u00e0 charge, Ligne {0}' type='text' name='input_76[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_76_cell4 gform-grid-col' data-label='Si plus de 21'><input aria-invalid='false'   aria-label='Si plus de 21, Ligne 1' data-aria-label-template='Si plus de 21, Ligne {0}' type='text' name='input_76[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_76_cell5 gform-grid-col' data-label='Si plus de 21\u202fans :  \u00e9tudiant(e) ou handicap fonctionnel '><input aria-invalid='false'   aria-label='Si plus de 21\u202fans :  \u00e9tudiant(e) ou handicap fonctionnel , Ligne 1' data-aria-label-template='Si plus de 21\u202fans :  \u00e9tudiant(e) ou handicap fonctionnel , Ligne {0}' type='text' name='input_76[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_76_cell6 gform-grid-col' data-label='Si \u00e9tudiant(e), nom de l\u2019institution'><input aria-invalid='false'   aria-label='Si \u00e9tudiant(e), nom de l\u2019institution, Ligne 1' data-aria-label-template='Si \u00e9tudiant(e), nom de l\u2019institution, Ligne {0}' type='text' name='input_76[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Ajouter une autre ligne' onclick='gformAddListItem(this, 0)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Supprimer la ligne {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Retirer<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_78' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Dos'  \/> <input type='button' id='gform_next_button_5_78' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_6' class='gform_page' data-js='page-field-id-78' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_6' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_79\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">R\u00e9gime Frais hospitaliers et soins de convalescence <\/h3><div class='gsection_description' id='gfield_description_5_79'>Type de r\u00e9gime hospitalier (Votre conjoint(e)\/partenaire ou vos personnes \u00e0 charge admissibles peuvent d\u00e9tenir une protection individuelle, m\u00eame si vous n\u2019adh\u00e9rez pas \u00e0 ce r\u00e9gime.) <\/div><\/div><fieldset id=\"field_5_80\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Participants au r\u00e9gime<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_80'>\n\t\t\t<div class='gchoice gchoice_5_80_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Individuel' checked='checked' id='choice_5_80_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_80_0' id='label_5_80_0' class='gform-field-label gform-field-label--type-inline'>Individuel<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_80_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Couple'  id='choice_5_80_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_80_1' id='label_5_80_1' class='gform-field-label gform-field-label--type-inline'>Couple<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_80_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_80' type='radio' value='Famille'  id='choice_5_80_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_80_2' id='label_5_80_2' class='gform-field-label gform-field-label--type-inline'>Famille<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_81\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.\"><\/i><span>Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.<\/span><\/div><h3 class=\"gsection_title\">Volet couple\/famille<\/h3><\/div><fieldset id=\"field_5_82\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Votre conjoint(e)\/partenaire poss\u00e8de-t-il(elle) une carte sant\u00e9 provinciale\/territoriale valide?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_82'>\n\t\t\t<div class='gchoice gchoice_5_82_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Oui'  id='choice_5_82_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_82_0' id='label_5_82_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_82_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_82' type='radio' value='Non'  id='choice_5_82_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_82_1' id='label_5_82_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_83\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_83'>Nom du conjoint(e)\/partenaire indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale<\/label><div class='ginput_container ginput_container_text'><input name='input_83' id='input_5_83' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_84\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_84'>Genre du conjoint(e)\/partenaire indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale<\/label><div class='ginput_container ginput_container_select'><select name='input_84' id='input_5_84' class='large gfield_select'     aria-invalid=\"false\" ><option value='Homme' selected='selected'>Homme<\/option><option value='Femme' >Femme<\/option><option value='X' >X<\/option><\/select><\/div><\/div><div id=\"field_5_85\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_85'>Date de naissance du conjoint(e)\/partenaire* (MM\/JJ\/AAAA)<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_85' id='input_5_85' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='jj\/mm\/aaaa' aria-describedby=\"input_5_85_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_5_85_date_format' class='screen-reader-text'>JJ slash MM slash AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_5_85' class='gform_hidden' value='https:\/\/pga.ententeinsurance.ca\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><fieldset id=\"field_5_86\" class=\"gfield gfield--type-list gfield--input-type-list gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Personne \u00e0 charge<\/legend><div class='ginput_container ginput_container_list ginput_list ginput_container_list--columns'><div class='gfield_list gfield_list_container'><div class=\"gfield_list_header gform-grid-row\"><div class=\"gform-field-label gfield_header_item gform-grid-col\">Nom de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale <\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Genre de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Date de naissance de la personne \u00e0 charge<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Si plus de 21<\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Si plus de 21\u202fans :  \u00e9tudiant(e) ou handicap fonctionnel <\/div><div class=\"gform-field-label gfield_header_item gform-grid-col\">Si \u00e9tudiant(e), nom de l\u2019institution<\/div><div class=\"gfield_header_item gfield_header_item--icons gform-grid-col\">&nbsp;<\/div><\/div><div class=\"gfield_list_groups\"><div class='gfield_list_row_odd gfield_list_group gform-grid-row'><div class='gfield_list_group_item gfield_list_cell gfield_list_86_cell1 gform-grid-col' data-label='Nom de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale '><input aria-invalid='false'   aria-label='Nom de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale , Ligne 1' data-aria-label-template='Nom de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale , Ligne {0}' type='text' name='input_86[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_86_cell2 gform-grid-col' data-label='Genre de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale'><input aria-invalid='false'   aria-label='Genre de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale, Ligne 1' data-aria-label-template='Genre de la personne \u00e0 charge indiqu\u00e9 sur la carte Sant\u00e9 provinciale\/territoriale, Ligne {0}' type='text' name='input_86[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_86_cell3 gform-grid-col' data-label='Date de naissance de la personne \u00e0 charge'><input aria-invalid='false'   aria-label='Date de naissance de la personne \u00e0 charge, Ligne 1' data-aria-label-template='Date de naissance de la personne \u00e0 charge, Ligne {0}' type='text' name='input_86[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_86_cell4 gform-grid-col' data-label='Si plus de 21'><input aria-invalid='false'   aria-label='Si plus de 21, Ligne 1' data-aria-label-template='Si plus de 21, Ligne {0}' type='text' name='input_86[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_86_cell5 gform-grid-col' data-label='Si plus de 21\u202fans :  \u00e9tudiant(e) ou handicap fonctionnel '><input aria-invalid='false'   aria-label='Si plus de 21\u202fans :  \u00e9tudiant(e) ou handicap fonctionnel , Ligne 1' data-aria-label-template='Si plus de 21\u202fans :  \u00e9tudiant(e) ou handicap fonctionnel , Ligne {0}' type='text' name='input_86[]' value=''   \/><\/div><div class='gfield_list_group_item gfield_list_cell gfield_list_86_cell6 gform-grid-col' data-label='Si \u00e9tudiant(e), nom de l\u2019institution'><input aria-invalid='false'   aria-label='Si \u00e9tudiant(e), nom de l\u2019institution, Ligne 1' data-aria-label-template='Si \u00e9tudiant(e), nom de l\u2019institution, Ligne {0}' type='text' name='input_86[]' value=''   \/><\/div><div class='gfield_list_icons gform-grid-col'>   <button type='button'  class='add_list_item ' aria-label='Ajouter une autre ligne' onclick='gformAddListItem(this, 0)'>Ajouter<\/button>   <button type='button'  class='delete_list_item' aria-label='Supprimer la ligne 1' data-aria-label-template='Supprimer la ligne {0}' onclick='gformDeleteListItem(this, 0)' style=\"visibility:hidden;\">Retirer<\/button><\/div><\/div><\/div><\/div><\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_87' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_5_87' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_7' class='gform_page' data-js='page-field-id-87' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_7' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_88\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Informations bancaires<\/h3><div class='gsection_description' id='gfield_description_5_88'>Pour autoriser le pr\u00e9l\u00e8vement des primes et le d\u00e9p\u00f4t direct<\/div><\/div><div id=\"field_5_89\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_89'>Nom de l\u2019institution financi\u00e8re<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_89' id='input_5_89' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_5_90\" class=\"gfield gfield--type-address gfield--input-type-address gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Adresse de la succursale<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_state has_zip ginput_container_address gform-grid-row' id='input_5_90' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_5_90_1_container' >\n                                        <input type='text' name='input_90.1' id='input_5_90_1' value=''    aria-required='true'    \/>\n                                        <label for='input_5_90_1' id='input_5_90_1_label' class='gform-field-label gform-field-label--type-sub '>Adresse postale<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_5_90_2_container' >\n                                        <input type='text' name='input_90.2' id='input_5_90_2' value=''     aria-required='false'   \/>\n                                        <label for='input_5_90_2' id='input_5_90_2_label' class='gform-field-label gform-field-label--type-sub '>Adresse ligne 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_5_90_3_container' >\n                                    <input type='text' name='input_90.3' id='input_5_90_3' value=''    aria-required='true'    \/>\n                                    <label for='input_5_90_3' id='input_5_90_3_label' class='gform-field-label gform-field-label--type-sub '>Ville<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_5_90_4_container' >\n                                        <select name='input_90.4' id='input_5_90_4'     aria-required='true'    ><option value='' selected='selected'><\/option><option value='Alberta' >Alberta<\/option><option value='Colombie-Britannique' >Colombie-Britannique<\/option><option value='Manitoba' >Manitoba<\/option><option value='Nouveau-Brunswick' >Nouveau-Brunswick<\/option><option value='Terre-Neuve-et-Labrador' >Terre-Neuve-et-Labrador<\/option><option value='Territoires du Nord-Ouest' >Territoires du Nord-Ouest<\/option><option value='Nouvelle-\u00c9cosse' >Nouvelle-\u00c9cosse<\/option><option value='Nunavut' >Nunavut<\/option><option value='Ontario' >Ontario<\/option><option value='\u00cele du Prince-\u00c9douard' >\u00cele du Prince-\u00c9douard<\/option><option value='Qu\u00e9bec' >Qu\u00e9bec<\/option><option value='Saskatchewan' >Saskatchewan<\/option><option value='Yukon' >Yukon<\/option><\/select>\n                                        <label for='input_5_90_4' id='input_5_90_4_label' class='gform-field-label gform-field-label--type-sub '>Province<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_5_90_5_container' >\n                                    <input type='text' name='input_90.5' id='input_5_90_5' value=''    aria-required='true'    \/>\n                                    <label for='input_5_90_5' id='input_5_90_5_label' class='gform-field-label gform-field-label--type-sub '>Code postal<\/label>\n                                <\/span><input type='hidden' class='gform_hidden' name='input_90.6' id='input_5_90_6' value='Canada' \/>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><input type=\"hidden\" name=\"gpaa_place_90\" class=\"gform_hidden\" value=\"\"><\/fieldset><div id=\"field_5_91\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_91'>Num\u00e9ro de l\u2019institution (3 chiffres)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_91' id='input_5_91' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_5_92\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_92'>Num\u00e9ro d\u2019identification de la banque (5 chiffres)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_92' id='input_5_92' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_5_93\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_93'>Num\u00e9ro de compte<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_93' id='input_5_93' type='number' step='any'   value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_5_94\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nom complet figurant sur votre compte bancaire<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(N\u00e9cessaire)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_5_94'>\n                            \n                            <span id='input_5_94_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_94.3' id='input_5_94_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_94_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            <span id='input_5_94_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_94.4' id='input_5_94_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_94_4' class='gform-field-label gform-field-label--type-sub '>2\u00e8me pr\u00e9nom<\/label>\n                                                <\/span>\n                            <span id='input_5_94_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_94.6' id='input_5_94_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_5_94_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_5_95' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='button' id='gform_next_button_5_95' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Suivant '  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_5_8' class='gform_page' data-js='page-field-id-95' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_5_8' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_5_97\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Coordination des prestations<\/h3><div class='gsection_description' id='gfield_description_5_97'>La coordination des prestations peut vous permettre d\u2019obtenir un remboursement allant jusqu\u2019\u00e0 100\u202f% de vos d\u00e9penses admissibles.<\/div><\/div><fieldset id=\"field_5_96\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Est-ce que vous-m\u00eame, ou tout autre membre de votre famille, avez droit \u00e0 des prestations m\u00e9dicales en vertu d\u2019un autre r\u00e9gime d&#039;assurance?<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_96'>\n\t\t\t<div class='gchoice gchoice_5_96_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='Oui'  id='choice_5_96_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_96_0' id='label_5_96_0' class='gform-field-label gform-field-label--type-inline'>Oui<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_96_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_96' type='radio' value='Non'  id='choice_5_96_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_96_1' id='label_5_96_1' class='gform-field-label gform-field-label--type-inline'>Non<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_105\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.\"><\/i><span>Ce champ est masqu\u00e9 lorsque l\u2018on voit le formulaire.<\/span><\/div><h3 class=\"gsection_title\"><\/h3><\/div><fieldset id=\"field_5_98\" class=\"gfield gfield--type-name gfield--input-type-name gfield--width-full field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nom du membre de la famille assur\u00e9<\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name has_middle_name has_last_name no_suffix gf_name_has_3 ginput_container_name gform-grid-row' id='input_5_98'>\n                            \n                            <span id='input_5_98_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_98.3' id='input_5_98_3' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_98_3' class='gform-field-label gform-field-label--type-sub '>Pr\u00e9nom<\/label>\n                                                <\/span>\n                            <span id='input_5_98_4_container' class='name_middle gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_98.4' id='input_5_98_4' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_98_4' class='gform-field-label gform-field-label--type-sub '>2\u00e8me pr\u00e9nom<\/label>\n                                                <\/span>\n                            <span id='input_5_98_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_98.6' id='input_5_98_6' value=''   aria-required='false'     \/>\n                                                    <label for='input_5_98_6' class='gform-field-label gform-field-label--type-sub '>Nom<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_5_99\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Couverture<\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_5_99'>\n\t\t\t<div class='gchoice gchoice_5_99_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='Individuel'  id='choice_5_99_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_99_0' id='label_5_99_0' class='gform-field-label gform-field-label--type-inline'>Individuel<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_99_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='Couple'  id='choice_5_99_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_99_1' id='label_5_99_1' class='gform-field-label gform-field-label--type-inline'>Couple<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_5_99_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_99' type='radio' value='Famille'  id='choice_5_99_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_5_99_2' id='label_5_99_2' class='gform-field-label gform-field-label--type-inline'>Famille<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_5_100\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Type de couverture<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox gfield_choice--select_all_enabled' id='input_5_100'><div class='gchoice gchoice_5_100_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_100.1' type='checkbox'  value='Sant\u00e9'  id='choice_5_100_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_100_1' id='label_5_100_1' class='gform-field-label gform-field-label--type-inline'>Sant\u00e9<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_100_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_100.2' type='checkbox'  value='Dentaire'  id='choice_5_100_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_100_2' id='label_5_100_2' class='gform-field-label gform-field-label--type-inline'>Dentaire<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_100_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_100.3' type='checkbox'  value='Hospitalisation'  id='choice_5_100_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_100_3' id='label_5_100_3' class='gform-field-label gform-field-label--type-inline'>Hospitalisation<\/label>\n\t\t\t\t\t\t\t<\/div><div class=\"gfield-choice-toggle-all\"><button type=\"button\" id=\"button_100_select_all\" class=\"gfield_choice_all_toggle gform-theme-button--size-sm\" onclick=\"gformToggleCheckboxes( this )\" data-checked=\"0\" data-label-select=\"Tout s\u00e9lectionner\" data-label-deselect=\"Tout d\u00e9s\u00e9lectionner\">Tout s\u00e9lectionner<\/button><\/div><\/div><\/div><\/fieldset><div id=\"field_5_102\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_102'>Nom de la compagnie d\u2019assurance<\/label><div class='ginput_container ginput_container_text'><input name='input_102' id='input_5_102' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_103\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_103'>Num\u00e9ro de police<\/label><div class='ginput_container ginput_container_number'><input name='input_103' id='input_5_103' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_5_104\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-third field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_104'>Num\u00e9ro d\u2019identification<\/label><div class='ginput_container ginput_container_number'><input name='input_104' id='input_5_104' type='number' step='any'   value='' class='large'      aria-invalid=\"false\"  \/><\/div><\/div><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_5' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Pr\u00e9c\u00e9dent'  \/> <input type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Accus\u00e9 de r\u00e9ception et consentement'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_5' value='postback' \/>\n            <input type='hidden' 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