www.assurancesannulation.be
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91.216.107.200
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https://www.assurancesannulation.be/
Submission: On March 19 via automatic, source certstream-suspicious — Scanned from FR
Submission: On March 19 via automatic, source certstream-suspicious — Scanned from FR
Form analysis 3 forms found in the DOM
POST http://www.cgi4all.org/cgi-bin/formmail.cgi
<form action="http://www.cgi4all.org/cgi-bin/formmail.cgi" method="POST">
<input type="hidden" name="recipient" value="valentino.romano@rgf.be">
<input type="hidden" name="subject" value="[assuranceSannulation] Appelez-moi !">
<input type="hidden" name="redirect" value="http://www.assurancesannulation.be/merci.html">
<p align="center">
<input type="text" name="Telephone" style="width:120px;height:24; color:#003366; background-color:#E6EEF7" value="Numéro" onfocus="if(this.value == this.defaultValue) this.value = '';" onblur="if(this.value == '') this.value = this.defaultValue;"
size="25">
<input type="submit" value="OK" name="submit">
</p>
</form>Name: form-2 — POST http://www.cgi4all.org/cgi-bin/formmail.cgi
<form name="form-2" id="form-2" action="http://www.cgi4all.org/cgi-bin/formmail.cgi" method="POST" onsubmit="return checkrequired(this)">
<input type="hidden" name="recipient" value="valentino.romano@rgf.be">
<input type="hidden" name="subject" value="[assuranceSannulation] Simulation">
<input type="hidden" name="redirect" value="http://www.assurancesannulation.be/merci.html">
<table border="1" width="100%">
<tbody>
<tr>
<td width="291" height="124">
<div class="box" style="width: 289px; height: 197px; background-color:#fcfdfe">
<legend>
<b> Ma couverture annulation</b>
<table cellpadding="0" cellspacing="0" border="0" width="284">
<tbody>
<tr>
<td width="146" align="right"><label>
<font color="#FF0000">*</font>Situation
</label></td>
<td width="5"> </td>
<td width="133">
<select name="SITUATION" style="width:75px; background-color: #E9F0F6; height:21">
<option value=""></option>
<option value="celibataire">célibataire</option>
<option value="couple">couple</option>
<option value="famille">famille</option>
</select>
</td>
</tr>
<tr>
<td width="146" align="right"><label>
<font color="#FF0000">*</font>Formule
</label></td>
<td width="5"></td>
<td align="left" width="133">
<select name="FORMULE" style="width:75px; background-color: #E9F0F6; height:21">
<option value=""></option>
<option value="temporaire">temporaire</option>
<option value="annuelle">annuelle</option>
</select>
</td>
</tr>
<tr>
<td width="146" align="right"><label> Date du prochain voyage ?</label></td>
<td width="5"></td>
<td align="left" width="133">
<input name="DATE" type="text" id="t1" style="width:75px;" size="20">
</td>
</tr>
<tr>
<td width="146" align="right"><label> Options complémentaires</label></td>
<td width="5"></td>
<td align="left" width="133">
<span style="font-size: 75%">
<input class="check" type="checkbox" name="Pack+">Extension</span><img border="0" src="int.gif" class="someClass">
<span style="font-size: 75%"><br>
<input class="check" type="checkbox" name="Chevaux">Bagages</span><img border="0" src="int.gif" class="someClass">
</td>
</tr>
</tbody>
</table>
</legend>
</div>
</td>
<td height="124"> </td>
<td height="124">
<div class="box" style="width: 308px; height: 197px; background-color:#fcfdfe">
<legend><b> Mes Informations</b>
<table cellpadding="0" cellspacing="0" border="0" width="301">
<tbody>
<tr>
<td width="114" align="right"><label>Prénom</label></td>
<td width="6"></td>
<td align="left" width="181">
<input name="PRENOM" type="text" id="t1" style="width:125px;" size="20">
</td>
</tr>
<tr>
<td width="114" align="right"><label>
<font color="#FF0000">*</font>Nom
</label></td>
<td width="6"></td>
<td align="left" width="181">
<input name="required-NOM" type="text" id="t1" style="width:125px;" size="20">
</td>
</tr>
<tr>
<td width="114" align="right"><label>
<font color="#FF0000"> *</font>Sexe
</label></td>
<td width="6"></td>
<td align="left" width="181">
<select name="SEXE" style="width:130px; background-color: #E9F0F6; height:21">
<option value=""></option>
<option value="M"> Homme</option>
<option value="F"> Femme</option>
</select>
</td>
</tr>
<tr>
<td width="114" align="right"><label>
<font color="#FF0000">*</font>Date de naissance
</label></td>
<td width="6"></td>
<td align="left" width="181">
<select name="NAISSANCE-jour" style="width:52px; background-color: #E9F0F6; height:21">
<option value="">Jour</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
<option value="13">13</option>
<option value="14">14</option>
<option value="15">15</option>
<option value="16">16</option>
<option value="17">17</option>
<option value="18">18</option>
<option value="19">19</option>
<option value="20">20</option>
<option value="21">21</option>
<option value="22">22</option>
<option value="23">23</option>
<option value="24">24</option>
<option value="25">25</option>
<option value="26">26</option>
<option value="27">27</option>
<option value="28">28</option>
<option value="29">29</option>
<option value="30">30</option>
<option value="30">31</option>
</select>
<select name="NAISSANCE-mois" style="width:52px; background-color: #E9F0F6">
<option value="">Mois</option>
<option value="1">1</option>
<option value="2">2</option>
<option value="3">3</option>
<option value="4">4</option>
<option value="5">5</option>
<option value="6">6</option>
<option value="7">7</option>
<option value="8">8</option>
<option value="9">9</option>
<option value="10">10</option>
<option value="11">11</option>
<option value="12">12</option>
</select>
<select name="NAISSANCE-annee" style="width:62px; background-color: #E9F0F6">
<option value="">Année</option>
<option value="2000">2000</option>
<option value="1999">1999</option>
<option value="1998">1998</option>
<option value="1997">1997</option>
<option value="1996">1996</option>
<option value="1995">1995</option>
<option value="1994">1994</option>
<option value="1993">1993</option>
<option value="1992">1992</option>
<option value="1991">1991</option>
<option value="1990">1990</option>
<option value="1989">1989</option>
<option value="1988">1988</option>
<option value="1987">1987</option>
<option value="1986">1986</option>
<option value="1985">1985</option>
<option value="1984">1984</option>
<option value="1983">1983</option>
<option value="1982">1982</option>
<option value="1981">1981</option>
<option value="1980">1980</option>
<option value="1979">1979</option>
<option value="1978">1978</option>
<option value="1977">1977</option>
<option value="1976">1976</option>
<option value="1975">1975</option>
<option value="1974">1974</option>
<option value="1973">1973</option>
<option value="1972">1972</option>
<option value="1971">1971</option>
<option value="1970">1970</option>
<option value="1969">1969</option>
<option value="1968">1968</option>
<option value="1967">1967</option>
<option value="1966">1966</option>
<option value="1965">1965</option>
<option value="1964">1964</option>
<option value="1963">1963</option>
<option value="1962">1962</option>
<option value="1961">1961</option>
<option value="1960">1960</option>
<option value="1959">1959</option>
<option value="1958">1958</option>
<option value="1957">1957</option>
<option value="1956">1956</option>
<option value="1955">1955</option>
<option value="1954">1954</option>
<option value="1953">1953</option>
<option value="1952">1952</option>
<option value="1951">1951</option>
<option value="1950">1950</option>
</select>
</td>
</tr>
</tbody>
</table>
</legend>
</div>
</td>
</tr>
<tr>
<td width="291"></td>
<td> </td>
<td> </td>
</tr>
</tbody>
</table>
<table border="1" width="100%">
<tbody>
<tr>
<td width="611">
<div class="box" style="width: 604px; height: 142px; background-color:#fcfdfe">
<legend>
<b> Mes coordonnées</b>
</legend>
<table cellpadding="0" cellspacing="0" border="0" width="600" style="border-style: solid; border-width: 0">
<tbody>
<tr>
<td width="140" align="right"><label>
<font color="#FF0000"></font> Rue et N°
</label></td>
<td width="13"></td>
<td align="left" width="159">
<input name="ADRESSE" type="text" id="t1" style="width:150px;" size="20">
</td>
<td align="right" width="87">
<label>
<font color="#FF0000">*</font>Téléphone
</label>
</td>
<td align="left"> </td>
<td align="left" width="189">
<input name="required-TELEPHONE" type="text" id="t1" style="width:150px;" size="20">
</td>
<td align="left" width="1">
<br>
</td>
</tr>
<tr>
<td width="140" align="right"><label>
<font color="#FF0000"> *</font>Code Postal
</label></td>
<td width="13"></td>
<td align="left" width="159">
<input name="required-CP" type="text" id="t1" style="width:75px;" size="20">
</td>
<td align="right" width="87">
<label>
<font color="#FF0000"> *</font>E-mail
</label>
</td>
<td align="left"> </td>
<td align="left" width="189">
<input name="required-EMAIL" type="text" id="t1" style="width:150px;" size="20">
</td>
<td align="left" width="1">
<br>
</td>
</tr>
<tr>
<td width="140" align="right" height="31"><label>
<font color="#FF0000"></font> Commune
</label></td>
<td width="13" height="31"></td>
<td align="left" width="159" height="31">
<input name="COMMUNE" type="text" id="t1" style="width:150px;" size="20">
</td>
<td align="right" width="87" height="31">
<label> Profession</label>
</td>
<td align="left" height="31"> </td>
<td align="left" width="189" height="31">
<select name="PROFESSION" style="width:150px; background-color: #E9F0F6">
<option value=""></option>
<option value="Ouvier"> Ouvrier</option>
<option value="Employé"> Employé</option>
<option value="Fonctionnaire"> Fonctionnaire</option>
<option value="Independant"> Indépendant</option>
<option value="Profession Liberale"> Profession Libérale</option>
<option value="Autre"> Autre</option> >
</select>
</td>
<td align="left" width="1" height="31">
<br>
</td>
</tr>
</tbody>
</table>
</div>
</td>
<td> </td>
</tr>
</tbody>
</table>
<div style="width: 595px;height:68px"><br>
<p style="text-align: center">
<font color="#FFFFFF">
<input type="submit" name="Recevoir la simulation" style="background-color: #B5C1CE" value="RECEVOIR LA SIMULATION">
</font>
</p>
</div>
</form>POST http://www.cgi4all.org/cgi-bin/formmail.cgi
<form id="form-1" action="http://www.cgi4all.org/cgi-bin/formmail.cgi" method="POST" onsubmit="return check();">
<input type="hidden" name="recipient" value="valentino.romano@rgf.be">
<input type="hidden" name="subject" value="[assuranceSannulation] Newsletter">
<input type="hidden" name="redirect" value="http://www.assurancesannulation.be/merci.html">
<fieldset>
<div class="form-1">
<a class="button" href="#" onclick="document.getElementById('form-1').submit()"><strong><strong><cufon class="cufon cufon-canvas" alt=" " style="width: 4px; height: 18px;"><canvas width="17" height="18" style="width: 17px; height: 18px; top: 0px; left: -1px;"></canvas><cufontext> </cufontext></cufon><cufon class="cufon cufon-canvas" alt="inscription" style="width: 80px; height: 18px;"><canvas width="87" height="18" style="width: 87px; height: 18px; top: 0px; left: -1px;"></canvas><cufontext>inscription</cufontext></cufon></strong></strong></a>
<label><span class="input"><input name="Email" type="text"></span></label>
<h3 class="title">
<cufon class="cufon cufon-canvas" alt="newsletter" style="width: 100px; height: 18px;"><canvas width="107" height="18" style="width: 107px; height: 18px; top: 0px; left: -1px;"></canvas>
<cufontext>newsletter</cufontext>
</cufon>
</h3>
</div>
</fieldset>
</form>Text Content
SERVICE | SECURITE | SATISFACTION MIEUX QUE LE DIRECT, LE SERVICE EN PLUS ! * Accueil * Annulation * Exemples * F.A.Q. * Simulation * Les 3 S * Contact Vous avez des questions ? Cliquez ici NOS PARTENAIRES Nous travaillons avec plus de 30 compagnies afin de vous proposer les meilleurs produits du marché ! Plus d'infos ASSURANCE ANNULATION L’assurance annulation vous protège financièrement contre les imprévus qui pourraient vous empêcher de partir en vacances. Que vous soyez un globe trotter assidu ou un voyageur occasionnel, il y a toujours une formule pour vous ! L’assurance annulation annuelle ou temporaire est bien plus avantageuse que les assurances proposées par votre voyagiste. Plus d’infos SIMULATION RAPIDE Ma couverture annulation *Situation célibataire couple famille *Formule temporaire annuelle Date du prochain voyage ? Options complémentaires Extension Bagages Mes Informations Prénom *Nom *Sexe Homme Femme *Date de naissance Jour 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Mois 1 2 3 4 5 6 7 8 9 10 11 12 Année 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 Mes coordonnées Rue et N° *Téléphone *Code Postal *E-mail Commune Profession Ouvrier Employé Fonctionnaire Indépendant Profession Libérale Autre > * champs obligatoires assuranceSannulation© 2012 | Member of RGF Group | Privacy policy * Accueil * Annulation * Exemples * F.A.Q. * Simulation * Les 3 S * Contact inscription NEWSLETTER