funerario.segurosmiranda.com.ve
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190.94.249.173
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URL:
https://funerario.segurosmiranda.com.ve/
Submission: On September 04 via automatic, source certstream-suspicious — Scanned from DE
Submission: On September 04 via automatic, source certstream-suspicious — Scanned from DE
Form analysis 4 forms found in the DOM
<form autocomplete="off" novalidate="" class="">
<div class="d-flex row-gap-4 row">
<div class="col-12">
<div class="p-0 LevelB_card__swwNi card">
<div class="p-2 d-flex justify-content-between align-items-center border-bottom border-gray border-opacity-10 header-bg-child-c LevelB_cardHeader__C0WpT card-header"><span class="fw-semibold text-dark text-opacity-75">Información
personal</span>
<div class="hstack gap-2"></div>
</div>
<div class="bg-light card-body">
<div class="row-gap-4 row">
<div class="col-lg-6 col-md-12">
<div><label class="form-label" for="holder_part_two.first_name" style="cursor: pointer;">Nombre</label>
<div class="input-group"><input placeholder="Ingrese el nombre..." id="holder_part_two.first_name" class="text-uppercase Field_input_placeholder__bP6O6 form-control" type="text" name="holder_part_two.first_name" style="z-index: 0;">
</div>
</div>
</div>
<div class="col-lg-6 col-md-12">
<div><label class="form-label" for="holder_part_two.last_name" style="cursor: pointer;">Apellido</label>
<div class="input-group"><input placeholder="Ingrese el Apellido..." id="holder_part_two.last_name" class="text-uppercase Field_input_placeholder__bP6O6 form-control" type="text" name="holder_part_two.last_name" style="z-index: 0;">
</div>
</div>
</div>
<div class="col-lg-4 col-md-12">
<div><label class="form-label" for="holder_part_two.birthdate" style="cursor: pointer;">Fecha de nacimiento</label>
<div>
<div class="react-datepicker__input-container"><input placeholder="Seleccione la fecha de nacimiento..." class="form-control Field_input_placeholder__bP6O6 undefined" type="text" value="" name="holder_part_two.birthdate"></div>
</div>
</div>
</div>
<div class="col-lg-4 col-md-12">
<div><label class="form-label" for="holder_part_two.ID_holder" style="cursor: pointer;">Número de cédula de identidad</label><input placeholder="Ingrese el número de cédula de identidad..." id="holder_part_two.ID_holder"
class="Field_input_placeholder__bP6O6 undefined form-control" type="text"></div>
</div>
<div class="col-lg-4 col-md-12">
<div><label class="form-label" for="holder_part_two.num_rif" style="cursor: pointer;">Número de RIF<p class="d-inline m-0 fw-light"> (opcional)</p></label>
<div class="input-group"><input placeholder="Ingrese el número de RIF..." id="holder_part_two.num_rif" class="Field_input_placeholder__bP6O6 form-control" type="text" name="holder_part_two.num_rif" style="z-index: 0;"></div>
</div>
</div>
<div class="col-lg-6 col-md-12">
<div style="z-index: 9;"><label class="form-label" for="holder_part_two.sex" style="cursor: pointer;">Sexo</label>
<div class=" css-b62m3t-container" id=":r1:"><span id="react-select-:r1:-live-region" class="css-7pg0cj-a11yText"></span><span aria-live="polite" aria-atomic="false" aria-relevant="additions text" role="log"
class="css-7pg0cj-a11yText"></span>
<div class="Field_input_placeholder__bP6O6 text-uppercase css-1b2lxw6-control">
<div class=" css-hlgwow">
<div class=" css-1jxni03-singleValue">Seleccione el sexo...</div>
<div class=" css-19bb58m" data-value=""><input class="" autocapitalize="none" autocomplete="off" autocorrect="off" id=":r1:" spellcheck="false" tabindex="0" aria-autocomplete="list" aria-expanded="false" aria-haspopup="true"
role="combobox" aria-activedescendant="" type="text" value=""
style="color: inherit; background: 0px center; opacity: 1; width: 100%; grid-area: 1 / 2; font: inherit; min-width: 2px; border: 0px; margin: 0px; outline: 0px; padding: 0px;"></div>
</div>
<div class=" css-1wy0on6">
<div class=" css-1xc3v61-indicatorContainer" aria-hidden="true"><svg height="20" width="20" viewBox="0 0 20 20" aria-hidden="true" focusable="false" class="css-8mmkcg">
<path
d="M14.348 14.849c-0.469 0.469-1.229 0.469-1.697 0l-2.651-3.030-2.651 3.029c-0.469 0.469-1.229 0.469-1.697 0-0.469-0.469-0.469-1.229 0-1.697l2.758-3.15-2.759-3.152c-0.469-0.469-0.469-1.228 0-1.697s1.228-0.469 1.697 0l2.652 3.031 2.651-3.031c0.469-0.469 1.228-0.469 1.697 0s0.469 1.229 0 1.697l-2.758 3.152 2.758 3.15c0.469 0.469 0.469 1.229 0 1.698z">
</path>
</svg></div><span class=" css-1u9des2-indicatorSeparator"></span>
<div class=" css-1xc3v61-indicatorContainer" aria-hidden="true"><svg height="20" width="20" viewBox="0 0 20 20" aria-hidden="true" focusable="false" class="css-8mmkcg">
<path
d="M4.516 7.548c0.436-0.446 1.043-0.481 1.576 0l3.908 3.747 3.908-3.747c0.533-0.481 1.141-0.446 1.574 0 0.436 0.445 0.408 1.197 0 1.615-0.406 0.418-4.695 4.502-4.695 4.502-0.217 0.223-0.502 0.335-0.787 0.335s-0.57-0.112-0.789-0.335c0 0-4.287-4.084-4.695-4.502s-0.436-1.17 0-1.615z">
</path>
</svg></div>
</div>
</div>
</div>
</div>
</div>
<div class="col-lg-6 col-md-12">
<div style="z-index: 9;"><label class="form-label" for="holder_part_two.marital_status" style="cursor: pointer;">Estado civil</label>
<div class=" css-b62m3t-container" id=":r2:"><span id="react-select-:r2:-live-region" class="css-7pg0cj-a11yText"></span><span aria-live="polite" aria-atomic="false" aria-relevant="additions text" role="log"
class="css-7pg0cj-a11yText"></span>
<div class="Field_input_placeholder__bP6O6 text-uppercase css-1b2lxw6-control">
<div class=" css-hlgwow">
<div class=" css-1jxni03-singleValue">Seleccione el estado civil...</div>
<div class=" css-19bb58m" data-value=""><input class="" autocapitalize="none" autocomplete="off" autocorrect="off" id=":r2:" spellcheck="false" tabindex="0" aria-autocomplete="list" aria-expanded="false" aria-haspopup="true"
role="combobox" aria-activedescendant="" type="text" value=""
style="color: inherit; background: 0px center; opacity: 1; width: 100%; grid-area: 1 / 2; font: inherit; min-width: 2px; border: 0px; margin: 0px; outline: 0px; padding: 0px;"></div>
</div>
<div class=" css-1wy0on6">
<div class=" css-1xc3v61-indicatorContainer" aria-hidden="true"><svg height="20" width="20" viewBox="0 0 20 20" aria-hidden="true" focusable="false" class="css-8mmkcg">
<path
d="M14.348 14.849c-0.469 0.469-1.229 0.469-1.697 0l-2.651-3.030-2.651 3.029c-0.469 0.469-1.229 0.469-1.697 0-0.469-0.469-0.469-1.229 0-1.697l2.758-3.15-2.759-3.152c-0.469-0.469-0.469-1.228 0-1.697s1.228-0.469 1.697 0l2.652 3.031 2.651-3.031c0.469-0.469 1.228-0.469 1.697 0s0.469 1.229 0 1.697l-2.758 3.152 2.758 3.15c0.469 0.469 0.469 1.229 0 1.698z">
</path>
</svg></div><span class=" css-1u9des2-indicatorSeparator"></span>
<div class=" css-1xc3v61-indicatorContainer" aria-hidden="true"><svg height="20" width="20" viewBox="0 0 20 20" aria-hidden="true" focusable="false" class="css-8mmkcg">
<path
d="M4.516 7.548c0.436-0.446 1.043-0.481 1.576 0l3.908 3.747 3.908-3.747c0.533-0.481 1.141-0.446 1.574 0 0.436 0.445 0.408 1.197 0 1.615-0.406 0.418-4.695 4.502-4.695 4.502-0.217 0.223-0.502 0.335-0.787 0.335s-0.57-0.112-0.789-0.335c0 0-4.287-4.084-4.695-4.502s-0.436-1.17 0-1.615z">
</path>
</svg></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col-12">
<div class="p-0 LevelB_card__swwNi card">
<div class="p-2 d-flex justify-content-between align-items-center border-bottom border-gray border-opacity-10 header-bg-child-c LevelB_cardHeader__C0WpT card-header"><span class="fw-semibold text-dark text-opacity-75">Información de
contacto</span>
<div class="hstack gap-2"></div>
</div>
<div class="bg-light card-body">
<div class="row-gap-4 row">
<div class="col-12"><small class="d-flex flex-row form-text">
<div><svg xmlns="http://www.w3.org/2000/svg" width="14" height="14" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="text-black TextInfo_icon__rE7sU"
style="margin-top: -2px;">
<path d="M3 12a9 9 0 1 0 18 0a9 9 0 0 0 -18 0"></path>
<path d="M12 9h.01"></path>
<path d="M11 12h1v4h1"></path>
</svg></div>
<div>
<p class="m-0 text-black TextInfo_text__ASh8W">Debido a nuevas actualizaciones del sistema, por favor, actualiza tu información de contacto para garantizar que tengamos la información correcta en nuestros registros. Agradecemos
mucho tu colaboración. ¡Gracias!</p>
</div>
</small></div>
<div class="col-lg-6 col-md-6">
<div><label class="form-label" for="holder_part_two.zone_p" style="cursor: pointer;">Zona postal</label><input maxlength="4" placeholder="Ingrese la zona postal..." id="holder_part_two.zone_p"
class="Field_input_placeholder__bP6O6 undefined form-control" type="text"></div>
</div>
<div class="col-lg-6 col-md-6">
<div><label class="form-label" for="holder_part_two.phone" style="cursor: pointer;">Teléfono</label><input placeholder="Ingrese el teléfono..." id="holder_part_two.phone" class="Field_input_placeholder__bP6O6 undefined form-control"
type="text"></div>
</div>
<div class="col-md-12">
<div><label class="form-label" for="holder_part_two.email" style="cursor: pointer;">Correo electrónico</label>
<div class="input-group"><input placeholder="Ingrese el correo electrónico..." id="holder_part_two.email" class="Field_input_placeholder__bP6O6 form-control" type="text" name="holder_part_two.email" style="z-index: 0;"></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col-12">
<div class="p-0 LevelB_card__swwNi card">
<div class="p-2 d-flex justify-content-between align-items-center border-bottom border-gray border-opacity-10 header-bg-child-c LevelB_cardHeader__C0WpT card-header"><span class="fw-semibold text-dark text-opacity-75">Información
Laboral</span>
<div class="hstack gap-2"></div>
</div>
<div class="bg-light card-body">
<div class="row-gap-4 row">
<div class="col-12"><small class="d-flex flex-row form-text">
<div><svg xmlns="http://www.w3.org/2000/svg" width="14" height="14" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="text-black TextInfo_icon__rE7sU"
style="margin-top: -2px;">
<path d="M3 12a9 9 0 1 0 18 0a9 9 0 0 0 -18 0"></path>
<path d="M12 9h.01"></path>
<path d="M11 12h1v4h1"></path>
</svg></div>
<div>
<p class="m-0 text-black TextInfo_text__ASh8W">Debido a nuevas actualizaciones del sistema, por favor, actualiza tu información laboral para garantizar que tengamos la información correcta en nuestros registros. Agradecemos mucho tu
colaboración. ¡Gracias!</p>
</div>
</small></div>
<div class="col-lg-6 col-md-12">
<div><label class="form-label" for="holder_part_two.act_eco" style="cursor: pointer;">Actividad económica</label>
<div class="input-group"><input placeholder="Ingrese la actividad económica..." id="holder_part_two.act_eco" class="text-uppercase Field_input_placeholder__bP6O6 form-control" type="text" name="holder_part_two.act_eco"
style="z-index: 0;"></div>
</div>
</div>
<div class="col-lg-6 col-md-12">
<div><label class="form-label" for="holder_part_two.prof" style="cursor: pointer;">Profesión</label>
<div class="input-group"><input placeholder="Ingrese la profesión..." id="holder_part_two.prof" class="text-uppercase Field_input_placeholder__bP6O6 form-control" type="text" name="holder_part_two.prof" style="z-index: 0;"></div>
</div>
</div>
<div class="col-lg-6 col-md-12">
<div><label class="form-label" for="holder_part_two.occupies" style="cursor: pointer;">Ocupación</label>
<div class="input-group"><input placeholder="Ingrese la ocupación..." id="holder_part_two.occupies" class="text-uppercase Field_input_placeholder__bP6O6 form-control" type="text" name="holder_part_two.occupies" style="z-index: 0;">
</div>
</div>
</div>
<div class="col-lg-6 col-md-12">
<div><label class="form-label" for="holder_part_two.ing_annual" style="cursor: pointer;">Ingreso anual</label><input placeholder="Ingrese el ingreso anual..." id="holder_part_two.ing_annual"
class="Field_input_placeholder__bP6O6 undefined form-control" type="text" name="holder_part_two.ing_annual"></div>
</div>
</div>
</div>
</div>
</div>
<div class="col-12">
<div class="p-0 LevelB_card__swwNi card">
<div class="p-2 d-flex justify-content-between align-items-center border-bottom border-gray border-opacity-10 header-bg-child-c LevelB_cardHeader__C0WpT card-header"><span class="fw-semibold text-dark text-opacity-75">Ubicación</span>
<div class="hstack gap-2"></div>
</div>
<div class="bg-light card-body">
<div class="row-gap-4 row">
<div class="col-12"><small class="d-flex flex-row form-text">
<div><svg xmlns="http://www.w3.org/2000/svg" width="14" height="14" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="text-black TextInfo_icon__rE7sU"
style="margin-top: -2px;">
<path d="M3 12a9 9 0 1 0 18 0a9 9 0 0 0 -18 0"></path>
<path d="M12 9h.01"></path>
<path d="M11 12h1v4h1"></path>
</svg></div>
<div>
<p class="m-0 text-black TextInfo_text__ASh8W">Debido a nuevas actualizaciones del sistema, por favor, actualiza tu dirección para garantizar que tengamos la información correcta en nuestros registros. Agradecemos mucho tu
colaboración. ¡Gracias!</p>
</div>
</small></div>
<div class="col-md-12">
<div><label class="form-label" for="holder_part_two.country" style="cursor: pointer;">País</label>
<div class="input-group"><input disabled="" placeholder="Seleccione el país..." id="holder_part_two.country" class="text-uppercase Field_input_placeholder__bP6O6 form-control" type="text" value="Venezuela"
name="holder_part_two.country" style="z-index: 0;"></div>
</div>
</div>
<div class="z-3 col-lg-4 col-md-12">
<div style="z-index: 9;"><label class="form-label" for="holder_part_two.state" style="cursor: pointer;">Estado</label>
<div class=" css-b62m3t-container" id=":r3:"><span id="react-select-:r3:-live-region" class="css-7pg0cj-a11yText"></span><span aria-live="polite" aria-atomic="false" aria-relevant="additions text" role="log"
class="css-7pg0cj-a11yText"></span>
<div class="Field_input_placeholder__bP6O6 text-uppercase css-1b2lxw6-control">
<div class=" css-hlgwow">
<div class=" css-1jxni03-singleValue">Seleccione el estado...</div>
<div class=" css-19bb58m" data-value=""><input class="" autocapitalize="none" autocomplete="off" autocorrect="off" id=":r3:" spellcheck="false" tabindex="0" aria-autocomplete="list" aria-expanded="false" aria-haspopup="true"
role="combobox" aria-activedescendant="" type="text" value=""
style="color: inherit; background: 0px center; opacity: 1; width: 100%; grid-area: 1 / 2; font: inherit; min-width: 2px; border: 0px; margin: 0px; outline: 0px; padding: 0px;"></div>
</div>
<div class=" css-1wy0on6">
<div class=" css-1xc3v61-indicatorContainer" aria-hidden="true"><svg height="20" width="20" viewBox="0 0 20 20" aria-hidden="true" focusable="false" class="css-8mmkcg">
<path
d="M14.348 14.849c-0.469 0.469-1.229 0.469-1.697 0l-2.651-3.030-2.651 3.029c-0.469 0.469-1.229 0.469-1.697 0-0.469-0.469-0.469-1.229 0-1.697l2.758-3.15-2.759-3.152c-0.469-0.469-0.469-1.228 0-1.697s1.228-0.469 1.697 0l2.652 3.031 2.651-3.031c0.469-0.469 1.228-0.469 1.697 0s0.469 1.229 0 1.697l-2.758 3.152 2.758 3.15c0.469 0.469 0.469 1.229 0 1.698z">
</path>
</svg></div><span class=" css-1u9des2-indicatorSeparator"></span>
<div class=" css-1xc3v61-indicatorContainer" aria-hidden="true"><svg height="20" width="20" viewBox="0 0 20 20" aria-hidden="true" focusable="false" class="css-8mmkcg">
<path
d="M4.516 7.548c0.436-0.446 1.043-0.481 1.576 0l3.908 3.747 3.908-3.747c0.533-0.481 1.141-0.446 1.574 0 0.436 0.445 0.408 1.197 0 1.615-0.406 0.418-4.695 4.502-4.695 4.502-0.217 0.223-0.502 0.335-0.787 0.335s-0.57-0.112-0.789-0.335c0 0-4.287-4.084-4.695-4.502s-0.436-1.17 0-1.615z">
</path>
</svg></div>
</div>
</div>
</div>
</div>
</div>
<div class="z-2 col-lg-4 col-md-12">
<div style="z-index: 9;"><label class="form-label" for="holder_part_two.city_h" style="cursor: pointer;">Ciudad</label>
<div class=" css-b62m3t-container" id=":r4:"><span id="react-select-:r4:-live-region" class="css-7pg0cj-a11yText"></span><span aria-live="polite" aria-atomic="false" aria-relevant="additions text" role="log"
class="css-7pg0cj-a11yText"></span>
<div class="Field_input_placeholder__bP6O6 text-uppercase css-1b2lxw6-control">
<div class=" css-hlgwow">
<div class=" css-1jxni03-singleValue">Ingrese la ciudad...</div>
<div class=" css-19bb58m" data-value=""><input class="" autocapitalize="none" autocomplete="off" autocorrect="off" id=":r4:" spellcheck="false" tabindex="0" aria-autocomplete="list" aria-expanded="false" aria-haspopup="true"
role="combobox" aria-activedescendant="" type="text" value=""
style="color: inherit; background: 0px center; opacity: 1; width: 100%; grid-area: 1 / 2; font: inherit; min-width: 2px; border: 0px; margin: 0px; outline: 0px; padding: 0px;"></div>
</div>
<div class=" css-1wy0on6">
<div class=" css-1xc3v61-indicatorContainer" aria-hidden="true"><svg height="20" width="20" viewBox="0 0 20 20" aria-hidden="true" focusable="false" class="css-8mmkcg">
<path
d="M14.348 14.849c-0.469 0.469-1.229 0.469-1.697 0l-2.651-3.030-2.651 3.029c-0.469 0.469-1.229 0.469-1.697 0-0.469-0.469-0.469-1.229 0-1.697l2.758-3.15-2.759-3.152c-0.469-0.469-0.469-1.228 0-1.697s1.228-0.469 1.697 0l2.652 3.031 2.651-3.031c0.469-0.469 1.228-0.469 1.697 0s0.469 1.229 0 1.697l-2.758 3.152 2.758 3.15c0.469 0.469 0.469 1.229 0 1.698z">
</path>
</svg></div><span class=" css-1u9des2-indicatorSeparator"></span>
<div class=" css-1xc3v61-indicatorContainer" aria-hidden="true"><svg height="20" width="20" viewBox="0 0 20 20" aria-hidden="true" focusable="false" class="css-8mmkcg">
<path
d="M4.516 7.548c0.436-0.446 1.043-0.481 1.576 0l3.908 3.747 3.908-3.747c0.533-0.481 1.141-0.446 1.574 0 0.436 0.445 0.408 1.197 0 1.615-0.406 0.418-4.695 4.502-4.695 4.502-0.217 0.223-0.502 0.335-0.787 0.335s-0.57-0.112-0.789-0.335c0 0-4.287-4.084-4.695-4.502s-0.436-1.17 0-1.615z">
</path>
</svg></div>
</div>
</div>
</div>
</div>
</div>
<div class="z-1 col-lg-4 col-md-12">
<div style="z-index: 9;"><label class="form-label" for="holder_part_two.municipality_h" style="cursor: pointer;">Municipio</label>
<div class=" css-b62m3t-container" id=":r5:"><span id="react-select-:r5:-live-region" class="css-7pg0cj-a11yText"></span><span aria-live="polite" aria-atomic="false" aria-relevant="additions text" role="log"
class="css-7pg0cj-a11yText"></span>
<div class="Field_input_placeholder__bP6O6 text-uppercase css-1b2lxw6-control">
<div class=" css-hlgwow">
<div class=" css-1jxni03-singleValue">Ingrese el municipio...</div>
<div class=" css-19bb58m" data-value=""><input class="" autocapitalize="none" autocomplete="off" autocorrect="off" id=":r5:" spellcheck="false" tabindex="0" aria-autocomplete="list" aria-expanded="false" aria-haspopup="true"
role="combobox" aria-activedescendant="" type="text" value=""
style="color: inherit; background: 0px center; opacity: 1; width: 100%; grid-area: 1 / 2; font: inherit; min-width: 2px; border: 0px; margin: 0px; outline: 0px; padding: 0px;"></div>
</div>
<div class=" css-1wy0on6">
<div class=" css-1xc3v61-indicatorContainer" aria-hidden="true"><svg height="20" width="20" viewBox="0 0 20 20" aria-hidden="true" focusable="false" class="css-8mmkcg">
<path
d="M14.348 14.849c-0.469 0.469-1.229 0.469-1.697 0l-2.651-3.030-2.651 3.029c-0.469 0.469-1.229 0.469-1.697 0-0.469-0.469-0.469-1.229 0-1.697l2.758-3.15-2.759-3.152c-0.469-0.469-0.469-1.228 0-1.697s1.228-0.469 1.697 0l2.652 3.031 2.651-3.031c0.469-0.469 1.228-0.469 1.697 0s0.469 1.229 0 1.697l-2.758 3.152 2.758 3.15c0.469 0.469 0.469 1.229 0 1.698z">
</path>
</svg></div><span class=" css-1u9des2-indicatorSeparator"></span>
<div class=" css-1xc3v61-indicatorContainer" aria-hidden="true"><svg height="20" width="20" viewBox="0 0 20 20" aria-hidden="true" focusable="false" class="css-8mmkcg">
<path
d="M4.516 7.548c0.436-0.446 1.043-0.481 1.576 0l3.908 3.747 3.908-3.747c0.533-0.481 1.141-0.446 1.574 0 0.436 0.445 0.408 1.197 0 1.615-0.406 0.418-4.695 4.502-4.695 4.502-0.217 0.223-0.502 0.335-0.787 0.335s-0.57-0.112-0.789-0.335c0 0-4.287-4.084-4.695-4.502s-0.436-1.17 0-1.615z">
</path>
</svg></div>
</div>
</div>
</div>
</div>
</div>
<div class="col-lg-6 col-md-12">
<div><label class="form-label" for="holder_part_two.urb_sec_h" style="cursor: pointer;">Urbanización / Sector</label>
<div class="input-group"><input placeholder="Ingrese la urbanización/sector..." id="holder_part_two.urb_sec_h" class="text-uppercase Field_input_placeholder__bP6O6 form-control" type="text" name="holder_part_two.urb_sec_h"
style="z-index: 0;"></div>
</div>
</div>
<div class="col-lg-6 col-md-12">
<div><label class="form-label" for="holder_part_two.street_h" style="cursor: pointer;">Av. / Calle / Transversal</label>
<div class="input-group"><input placeholder="Ingrese la Av. / Calle / Transversal..." id="holder_part_two.street_h" class="text-uppercase Field_input_placeholder__bP6O6 form-control" type="text" name="holder_part_two.street_h"
style="z-index: 0;"></div>
</div>
</div>
<div class="col-lg-8 col-md-12">
<div><label class="form-label" for="holder_part_two.house_h" style="cursor: pointer;">Inmueble<b style="padding-left: 4px;"><sub>CASA / QUINTA / LOCAL / TORRE / CC / APARTAMENTO / OFICINA</sub></b></label>
<div class="input-group"><input placeholder="Ingrese casa / quinta / local / torre / cc / apartamento / oficina..." id="holder_part_two.house_h" class="text-uppercase Field_input_placeholder__bP6O6 form-control" type="text"
name="holder_part_two.house_h" style="z-index: 0;"></div>
</div>
</div>
<div class="col-lg-4 col-md-12">
<div><label class="form-label" for="holder_part_two.floor_h" style="cursor: pointer;">Piso / Nivel</label>
<div class="input-group"><input placeholder="Ingrese el piso / nivel..." id="holder_part_two.floor_h" class="text-uppercase Field_input_placeholder__bP6O6 form-control" type="text" name="holder_part_two.floor_h" style="z-index: 0;">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="d-flex justify-content-end column-gap-3 col-12"><button type="button" class="shadow-sm btn btn-secondary">
<div class="hstack gap-2"><svg xmlns="http://www.w3.org/2000/svg" width="24" height="24" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round"
class="tabler-icon tabler-icon-arrow-narrow-left">
<path d="M5 12l14 0"></path>
<path d="M5 12l4 4"></path>
<path d="M5 12l4 -4"></path>
</svg>
<p class="m-0">Regresar</p>
</div>
</button><button type="submit" class="shadow-sm btn btn-secondary">
<div class="hstack gap-2"><span hidden="" class="spinner-border spinner-border-sm"></span>Continuar<svg xmlns="http://www.w3.org/2000/svg" width="24" height="24" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2"
stroke-linecap="round" stroke-linejoin="round" class="tabler-icon tabler-icon-arrow-narrow-right">
<path d="M5 12l14 0"></path>
<path d="M15 16l4 -4"></path>
<path d="M15 8l4 4"></path>
</svg></div>
</button></div>
</div>
</form><form autocomplete="off" novalidate="" class="">
<div class="row-gap-3 row">
<div class="col-12">
<div class="vstack gap-1">
<div class="d-flex gap-3 flex-wrap" style="padding-bottom: 16px; z-index: 1;">
<div class="d-flex flex-grow-1">
<div class="shadow-sm input-group"><input placeholder="Buscar en todas las columnas..." class="Toolbar_inputPlaceholderItalic__9YK56 Toolbar_inputPlaceholderUppercase__Uvu2F form-control form-control-sm" type="search"><span
class="border-secondary border-opacity-50 input-group-text"><i class="bi bi-search text-secondary"></i></span></div>
</div>
</div>
</div>
<div class="table-responsive">
<table class="table-white table table-hover" style="margin-bottom: 16px; margin-top: 16px;">
<thead>
<tr>
<th class="TableHeaderComp-thead text-nowrap" scope="col">
<div class="col" style="display: flex; cursor: pointer; align-items: flex-start; width: auto;"><span
style="padding-right: 8px; text-overflow: ellipsis;">Parentesco</span><i class="bi bi-sort-alpha-down-alt" style="font-size: 16px; opacity: 0;"></i></div>
</th>
<th class="TableHeaderComp-thead text-nowrap" scope="col">
<div class="col" style="display: flex; cursor: pointer; align-items: flex-start; width: auto;"><span
style="padding-right: 8px; text-overflow: ellipsis;">Nombre</span><i class="bi bi-sort-alpha-down-alt" style="font-size: 16px; opacity: 0;"></i></div>
</th>
<th class="TableHeaderComp-thead text-nowrap" scope="col">
<div class="col" style="display: flex; cursor: pointer; align-items: flex-start; width: auto;"><span
style="padding-right: 8px; text-overflow: ellipsis;">Apellido</span><i class="bi bi-sort-alpha-down-alt" style="font-size: 16px; opacity: 0;"></i></div>
</th>
<th class="TableHeaderComp-thead text-nowrap" scope="col">
<div class="col" style="display: flex; cursor: pointer; align-items: flex-start; width: auto;"><span style="padding-right: 8px; text-overflow: ellipsis;">Cédula de
identidad</span><i class="bi bi-sort-alpha-down-alt" style="font-size: 16px; opacity: 0;"></i></div>
</th>
<th class="TableHeaderComp-thead text-nowrap" scope="col">
<div class="col" style="display: flex; cursor: pointer; align-items: flex-start; width: auto;"><span style="padding-right: 8px; text-overflow: ellipsis;">Fecha de
nacimiento</span><i class="bi bi-sort-alpha-down-alt" style="font-size: 16px; opacity: 0;"></i></div>
</th>
<th class="TableHeaderComp-thead text-nowrap" scope="col">
<div class="text-nowrap">
<div class="col" style="display: flex; cursor: pointer; align-items: flex-start; width: auto;"><span
style="padding-right: 8px; text-overflow: ellipsis;">Sexo</span><i class="bi bi-sort-alpha-down-alt" style="font-size: 16px; opacity: 0;"></i></div>
</div>
</th>
<th class="TableHeaderComp-thead text-nowrap" scope="col">
<div class="text-nowrap">
<div class="col" style="display: flex; cursor: pointer; align-items: flex-start; width: auto;"><span style="padding-right: 8px; text-overflow: ellipsis;">Estatura
(m)</span><i class="bi bi-sort-alpha-down-alt" style="font-size: 16px; opacity: 0;"></i></div>
</div>
</th>
<th class="TableHeaderComp-thead text-nowrap" scope="col">
<div class="col" style="display: flex; cursor: pointer; align-items: flex-start; width: auto;"><span style="padding-right: 8px; text-overflow: ellipsis;">Peso
(kg)</span><i class="bi bi-sort-alpha-down-alt" style="font-size: 16px; opacity: 0;"></i></div>
</th>
<th class="TableHeaderComp-thead text-nowrap" scope="col"></th>
</tr>
</thead>
<tbody></tbody>
<tfoot>
<tr class="border-white">
<th class="p-2 m-0 fw-normal" colspan="42"><svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round"
class="tabler-icon tabler-icon-alert-triangle" style="padding-right: 8px;">
<path d="M12 9v4"></path>
<path d="M10.363 3.591l-8.106 13.534a1.914 1.914 0 0 0 1.636 2.871h16.214a1.914 1.914 0 0 0 1.636 -2.87l-8.106 -13.536a1.914 1.914 0 0 0 -3.274 0z"></path>
<path d="M12 16h.01"></path>
</svg>Lamentablemente, no existen registros de <span class="text-decoration-underline"> asegurados </span>en este momento. Por favor, cree uno nuevo para poder visualizarlo en pantalla.</th>
</tr>
</tfoot>
</table>
</div>
</div>
<div class="col-lg col-md-12">
<div class="gap-3 row">
<div class="col-lg col-md-12"><button type="button" class="w-100 border-success btn btn-outline-success btn-sm" style="border-style: dotted;">
<div class="justify-content-center fw-semibold hstack gap-2">Agregar Familiares<div style="scale: 0.8;"><svg xmlns="http://www.w3.org/2000/svg" width="24" height="24" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2"
stroke-linecap="round" stroke-linejoin="round" class="tabler-icon tabler-icon-circle-plus">
<path d="M3 12a9 9 0 1 0 18 0a9 9 0 0 0 -18 0"></path>
<path d="M9 12h6"></path>
<path d="M12 9v6"></path>
</svg></div>
</div>
</button></div>
</div>
</div>
<div class="d-flex justify-content-end column-gap-3 col-12"><button type="button" class="shadow-sm btn btn-secondary">
<div class="hstack gap-2"><svg xmlns="http://www.w3.org/2000/svg" width="24" height="24" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round"
class="tabler-icon tabler-icon-arrow-narrow-left">
<path d="M5 12l14 0"></path>
<path d="M5 12l4 4"></path>
<path d="M5 12l4 -4"></path>
</svg>
<p class="m-0">Regresar</p>
</div>
</button><button type="submit" class="shadow-sm btn btn-secondary">
<div class="hstack gap-2"><span hidden="" class="spinner-border spinner-border-sm"></span>Continuar<svg xmlns="http://www.w3.org/2000/svg" width="24" height="24" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2"
stroke-linecap="round" stroke-linejoin="round" class="tabler-icon tabler-icon-arrow-narrow-right">
<path d="M5 12l14 0"></path>
<path d="M15 16l4 -4"></path>
<path d="M15 8l4 4"></path>
</svg></div>
</button></div>
</div>
</form><form autocomplete="off" novalidate="" class="">
<div class="row-gap-4 row">
<div class="col-12">
<div class="shadow-sm border border-secondary border-opacity-25 card">
<div class="d-flex justify-content-between align-items-center border-bottom border-gray border-opacity-10 LevelA_card__mnM_U card-header"><span class="fw-semibold text-dark text-opacity-75">Declaraciones y cláusula</span>
<div class="hstack gap-2"></div>
</div>
<div class="collapse show">
<div class="card-body">
<div class="row-gap-4 row">
<div class="col-12">
<div class="col-12">
<div class="p-0 LevelB_card__swwNi card">
<div class="p-2 d-flex justify-content-between align-items-center border-bottom border-gray border-opacity-10 header-bg-child-c LevelB_cardHeader__C0WpT card-header"><span class="fw-semibold text-dark text-opacity-75">Declaración
de fe</span>
<div class="hstack gap-2"></div>
</div>
<div class="bg-light card-body">
<div class="row-gap-4 row">
<div class="row-gap-4 row">
<div class="col-md-12">
<div class="d-flex justify-content-center col-md-12">
<div class="border-secondary border-opacity-50 py-2" style="width: 90%; border-top: 1px dashed;"></div>
</div>
<p>Yo, <b> , C.I. , </b> en mi carácter de Tomador Propuesto de la Presente Póliza, declaro: Doy fe de que el dinero utilizado para el pago de la Prima de la presente Póliza, proviene de una fuente lícita, por lo tanto no
tiene relación alguna con capitales, bienes, haberes o beneficios derivados de las actividades ilícitas o del delito de legitimación de capitales u otras conductas tipificadas en la Ley Orgánica Contra la Delincuencia
Organizada y Financiamiento al Terrorismo en la Legislación Venezolana.</p>
<div class="d-flex justify-content-center col-md-12">
<div class="border-secondary border-opacity-50 py-2" style="width: 90%; border-top: 1px dashed;"></div>
</div>
<div style="z-index: 9;"><label class="form-label" for="declaration_of_faith" style="cursor: pointer;">¿Aceptas la declaración de fe?</label>
<div class=" css-b62m3t-container" id=":r8:"><span id="react-select-:r8:-live-region" class="css-7pg0cj-a11yText"></span><span aria-live="polite" aria-atomic="false" aria-relevant="additions text" role="log"
class="css-7pg0cj-a11yText"></span>
<div class="Field_input_placeholder__bP6O6 undefined css-1b2lxw6-control">
<div class=" css-hlgwow">
<div class=" css-1jxni03-singleValue">Seleccione una opción...</div>
<div class=" css-19bb58m" data-value=""><input class="" autocapitalize="none" autocomplete="off" autocorrect="off" id=":r8:" spellcheck="false" tabindex="0" aria-autocomplete="list" aria-expanded="false"
aria-haspopup="true" role="combobox" aria-activedescendant="" type="text" value=""
style="color: inherit; background: 0px center; opacity: 1; width: 100%; grid-area: 1 / 2; font: inherit; min-width: 2px; border: 0px; margin: 0px; outline: 0px; padding: 0px;"></div>
</div>
<div class=" css-1wy0on6">
<div class=" css-1xc3v61-indicatorContainer" aria-hidden="true"><svg height="20" width="20" viewBox="0 0 20 20" aria-hidden="true" focusable="false" class="css-8mmkcg">
<path
d="M14.348 14.849c-0.469 0.469-1.229 0.469-1.697 0l-2.651-3.030-2.651 3.029c-0.469 0.469-1.229 0.469-1.697 0-0.469-0.469-0.469-1.229 0-1.697l2.758-3.15-2.759-3.152c-0.469-0.469-0.469-1.228 0-1.697s1.228-0.469 1.697 0l2.652 3.031 2.651-3.031c0.469-0.469 1.228-0.469 1.697 0s0.469 1.229 0 1.697l-2.758 3.152 2.758 3.15c0.469 0.469 0.469 1.229 0 1.698z">
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<div class=" css-1xc3v61-indicatorContainer" aria-hidden="true"><svg height="20" width="20" viewBox="0 0 20 20" aria-hidden="true" focusable="false" class="css-8mmkcg">
<path
d="M4.516 7.548c0.436-0.446 1.043-0.481 1.576 0l3.908 3.747 3.908-3.747c0.533-0.481 1.141-0.446 1.574 0 0.436 0.445 0.408 1.197 0 1.615-0.406 0.418-4.695 4.502-4.695 4.502-0.217 0.223-0.502 0.335-0.787 0.335s-0.57-0.112-0.789-0.335c0 0-4.287-4.084-4.695-4.502s-0.436-1.17 0-1.615z">
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</svg></div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col-12">
<div class="col-12">
<div class="p-0 LevelB_card__swwNi card">
<div class="p-2 d-flex justify-content-between align-items-center border-bottom border-gray border-opacity-10 header-bg-child-c LevelB_cardHeader__C0WpT card-header"><span class="fw-semibold text-dark text-opacity-75">Cláusula
falsedades y reticencias de mala fe</span>
<div class="hstack gap-2"></div>
</div>
<div class="bg-light card-body">
<div class="row-gap-4 row">
<div class="row">
<div class="col-md-12">
<div class="d-flex justify-content-center col-md-12">
<div class="border-secondary border-opacity-50 py-2" style="width: 90%; border-top: 1px dashed;"></div>
</div>
<p>Las falsedades y reticencias de mala fe por parte del tomador, asegurado o del beneficiario, debidamente probadas, serán causa de nulidad absoluta del contrato de tal naturaleza que el Asegurador de haberlas conocido no
hubiese contratado o lo hubiese hecho en otras condiciones.</p>
<div class="d-flex justify-content-center col-md-12">
<div class="border-secondary border-opacity-50 py-2" style="width: 90%; border-top: 1px dashed;"></div>
</div>
<div style="z-index: 9;"><label class="form-label" for="clause" style="cursor: pointer;">¿Aceptas la cláusula falsedades y reticencias de mala fe?</label>
<div class=" css-b62m3t-container" id=":r9:"><span id="react-select-:r9:-live-region" class="css-7pg0cj-a11yText"></span><span aria-live="polite" aria-atomic="false" aria-relevant="additions text" role="log"
class="css-7pg0cj-a11yText"></span>
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<div class=" css-19bb58m" data-value=""><input class="" autocapitalize="none" autocomplete="off" autocorrect="off" id=":r9:" spellcheck="false" tabindex="0" aria-autocomplete="list" aria-expanded="false"
aria-haspopup="true" role="combobox" aria-activedescendant="" type="text" value=""
style="color: inherit; background: 0px center; opacity: 1; width: 100%; grid-area: 1 / 2; font: inherit; min-width: 2px; border: 0px; margin: 0px; outline: 0px; padding: 0px;"></div>
</div>
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</svg></div>
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</div>
</div>
</div>
</div>
</div>
<div class="d-flex justify-content-end column-gap-3 col-12"><button type="button" class="shadow-sm btn btn-secondary">
<div class="hstack gap-2"><svg xmlns="http://www.w3.org/2000/svg" width="24" height="24" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round"
class="tabler-icon tabler-icon-arrow-narrow-left">
<path d="M5 12l14 0"></path>
<path d="M5 12l4 4"></path>
<path d="M5 12l4 -4"></path>
</svg>
<p class="m-0">Regresar</p>
</div>
</button><button type="submit" class="shadow-sm btn btn-secondary">
<div class="hstack gap-2"><span hidden="" class="spinner-border spinner-border-sm"></span>Continuar<svg xmlns="http://www.w3.org/2000/svg" width="24" height="24" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2"
stroke-linecap="round" stroke-linejoin="round" class="tabler-icon tabler-icon-arrow-narrow-right">
<path d="M5 12l14 0"></path>
<path d="M15 16l4 -4"></path>
<path d="M15 8l4 4"></path>
</svg></div>
</button></div>
</div>
</div>
</div>
</div>
</div>
</div>
</form><form autocomplete="off" novalidate="" class="">
<div class="d-flex row-gap-3 row">
<div class="col-12">
<div class="col-12">
<div class="shadow-sm border-0 card">
<div class="undefined card-body">
<div class="col-md-12">
<div role="alert" class="fade m-0 shadow-sm alert alert-secondary show">
<div class="d-flex alert-heading h4">
<div style="scale: 1.3;"><svg xmlns="http://www.w3.org/2000/svg" width="24" height="24" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round"
class="tabler-icon tabler-icon-alert-triangle">
<path d="M12 9v4"></path>
<path d="M10.363 3.591l-8.106 13.534a1.914 1.914 0 0 0 1.636 2.871h16.214a1.914 1.914 0 0 0 1.636 -2.87l-8.106 -13.536a1.914 1.914 0 0 0 -3.274 0z"></path>
<path d="M12 16h.01"></path>
</svg></div><span class="fs-4" style="margin-top: 3px; margin-left: 8px;">¡Atención!</span>
</div>
<p class="m-0">Para completar tu <span class="fw-semibold bg-dark bg-opacity-10 border border-dark border-opacity-10 rounded px-1">solicitud de registro,</span> A continuación, sigue estos pasos: Primero: tómate un momento para añadir
tu firma y huella. Segundo, cuando hayas terminado, simplemente haz clic en el botón 'Subir firma y huella' que encontrarás en la página correspondiente. Tercero: Después de cargar tu firma y huella, el botón para registrar todos
los datos se desbloqueará y luego podrás descargar en la planilla adjunta.</p><br><small class="d-flex flex-row form-text">
<div><svg xmlns="http://www.w3.org/2000/svg" width="14" height="14" viewBox="0 0 24 24" fill="none" stroke="currentColor" stroke-width="2" stroke-linecap="round" stroke-linejoin="round" class="text-black TextInfo_icon__rE7sU"
style="margin-top: -2px;">
<path d="M3 12a9 9 0 1 0 18 0a9 9 0 0 0 -18 0"></path>
<path d="M12 9h.01"></path>
<path d="M11 12h1v4h1"></path>
</svg></div>
<div>
<p class="m-0 text-black TextInfo_text__ASh8W">Una vez registrado sus datos no podra ser modificado</p>
</div>
</small>
<div class="pt-3 row">
<div class="d-flex justify-content-center column-gap-4 row-gap-2 flex-wrap text-nowrap col-12"><button type="button" class="btn btn-dark" style="opacity: 0.9;">
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Datos del titular Asegurados Declaración Aceptación Datos del titular Información personal Nombre Apellido Fecha de nacimiento Número de cédula de identidad Número de RIF (opcional) Sexo Seleccione el sexo... Estado civil Seleccione el estado civil... Información de contacto Debido a nuevas actualizaciones del sistema, por favor, actualiza tu información de contacto para garantizar que tengamos la información correcta en nuestros registros. Agradecemos mucho tu colaboración. ¡Gracias! Zona postal Teléfono Correo electrónico Información Laboral Debido a nuevas actualizaciones del sistema, por favor, actualiza tu información laboral para garantizar que tengamos la información correcta en nuestros registros. Agradecemos mucho tu colaboración. ¡Gracias! Actividad económica Profesión Ocupación Ingreso anual Ubicación Debido a nuevas actualizaciones del sistema, por favor, actualiza tu dirección para garantizar que tengamos la información correcta en nuestros registros. Agradecemos mucho tu colaboración. ¡Gracias! País Estado Seleccione el estado... Ciudad Ingrese la ciudad... Municipio Ingrese el municipio... Urbanización / Sector Av. / Calle / Transversal InmuebleCASA / QUINTA / LOCAL / TORRE / CC / APARTAMENTO / OFICINA Piso / Nivel Regresar Continuar Consulta de asegurados Parentesco Nombre Apellido Cédula de identidad Fecha de nacimiento Sexo Estatura (m) Peso (kg) Lamentablemente, no existen registros de asegurados en este momento. Por favor, cree uno nuevo para poder visualizarlo en pantalla. Agregar Familiares Regresar Continuar Declaraciones y cláusula Declaración de fe Yo, , C.I. , en mi carácter de Tomador Propuesto de la Presente Póliza, declaro: Doy fe de que el dinero utilizado para el pago de la Prima de la presente Póliza, proviene de una fuente lícita, por lo tanto no tiene relación alguna con capitales, bienes, haberes o beneficios derivados de las actividades ilícitas o del delito de legitimación de capitales u otras conductas tipificadas en la Ley Orgánica Contra la Delincuencia Organizada y Financiamiento al Terrorismo en la Legislación Venezolana. ¿Aceptas la declaración de fe? Seleccione una opción... Cláusula falsedades y reticencias de mala fe Las falsedades y reticencias de mala fe por parte del tomador, asegurado o del beneficiario, debidamente probadas, serán causa de nulidad absoluta del contrato de tal naturaleza que el Asegurador de haberlas conocido no hubiese contratado o lo hubiese hecho en otras condiciones. ¿Aceptas la cláusula falsedades y reticencias de mala fe? Seleccione una opción... Regresar Continuar Aceptación ¡Atención! Para completar tu solicitud de registro, A continuación, sigue estos pasos: Primero: tómate un momento para añadir tu firma y huella. Segundo, cuando hayas terminado, simplemente haz clic en el botón 'Subir firma y huella' que encontrarás en la página correspondiente. Tercero: Después de cargar tu firma y huella, el botón para registrar todos los datos se desbloqueará y luego podrás descargar en la planilla adjunta. Una vez registrado sus datos no podra ser modificado Subir firma y huella Regresar ¡Registro completado! Su solicitud ha sido recibida y se ha añadido a la lista de espera. Recibirá un correo electrónico cuando su solicitud haya sido aprobada. Beneficiarios Parentesco Nombre Appellido Cédula de identidad Fecha de nacimiento Sexo Estatura Peso Lamentablemente, no existen registros de asegurados en este momento. Por favor, cree uno nuevo para poder visualizarlo en pantalla.