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Submitted URL: http://assurance-obseques.info/
Effective URL: https://www.assurance-obseques.info/
Submission: On January 19 via manual from FR — Scanned from FR
Effective URL: https://www.assurance-obseques.info/
Submission: On January 19 via manual from FR — Scanned from FR
Form analysis 1 forms found in the DOM
<form class="form-section" data-error-popup="0" data-insukind="8" data-tunnel="1691">
<div class="form-horizontal affichage_classique">
<div class="zoneTheme col-md-12 margin-bottom-20" data-theme="1">
<div class="themeParentBloc bloc-narrow border-blue radius-bottom-5">
<div class="row">
<div class="zoneBloc col-md-12 padding-bottom-20 blocSouscripteur" data-bloc="1">
<div class="titreBloc">Mes informations</div>
<div class="form-group col-sm-7 QF1_5"><span class="span-has-error" name="errorMessage"><i class="fa fa-exclamation-triangle" aria-hidden="true"></i>Merci d'indiquer la date à laquelle vous souhaitez que votre contrat commence</span>
<label class="control-label col-sm-12">Mon contrat doit commencer le </label>
<div class="col-sm-12">
<div class="input-group"><input autocomplete="on" class="form-control picker__input"
data-condition-reponse="{ 'formatAttendu': 'dd/MM/yyyy', 'reponses_possibles': [ { 'condition': null, 'isCalendar': true, 'dateMin': { 'type': 'DateFixe', 'value': '20/01/2024' }, 'dateMax': { 'type': 'DateFixe', 'value': '19/07/2025' }, 'datePreselection': { 'type': 'DateFixe', 'value': '20/01/2024' }, 'dateDefault': { 'type': 'DateFixe', 'value': '20/01/2024' } } ]}"
data-erreur-msg="Merci d&#39;indiquer la date &#224; laquelle vous souhaitez que votre contrat commence" data-masque-saisie="00/00/0000" data-validation="DateValidateur" id="QF1_5" name="QF1_5" placeholder="__/__/____"
type="text" value="20/01/2024" maxlength="10" readonly="" aria-haspopup="true" aria-readonly="false" aria-owns="QF1_5_root">
<div class="picker" id="QF1_5_root" aria-hidden="true">
<div class="picker__holder" tabindex="-1">
<div class="picker__frame">
<div class="picker__wrap">
<div class="picker__box">
<div class="picker__header"><select class="picker__select--year" disabled="" aria-controls="QF1_5_table" title="Sélectionner une année">
<option value="2024" selected="">2024</option>
<option value="2025">2025</option>
</select><select class="picker__select--month" disabled="" aria-controls="QF1_5_table" title="Sélectionner un mois">
<option value="0" selected="">Janvier</option>
<option value="1">Février</option>
<option value="2">Mars</option>
<option value="3">Avril</option>
<option value="4">Mai</option>
<option value="5">Juin</option>
<option value="6">Juillet</option>
<option value="7">Août</option>
<option value="8">Septembre</option>
<option value="9">Octobre</option>
<option value="10">Novembre</option>
<option value="11">Décembre</option>
</select>
<div class="picker__nav--prev picker__nav--disabled" data-nav="-1" tabindex="0" role="button" aria-controls="QF1_5_table" title="Mois précédent"> </div>
<div class="picker__nav--next" data-nav="1" tabindex="0" role="button" aria-controls="QF1_5_table" title="Mois suivant"> </div>
</div>
<table class="picker__table" id="QF1_5_table" role="grid" aria-controls="QF1_5" aria-readonly="true">
<thead>
<tr>
<th class="picker__weekday" scope="col" title="Lundi">Lun</th>
<th class="picker__weekday" scope="col" title="Mardi">Mar</th>
<th class="picker__weekday" scope="col" title="Mercredi">Mer</th>
<th class="picker__weekday" scope="col" title="Jeudi">Jeu</th>
<th class="picker__weekday" scope="col" title="Vendredi">Ven</th>
<th class="picker__weekday" scope="col" title="Samedi">Sam</th>
<th class="picker__weekday" scope="col" title="Dimanche">Dim</th>
</tr>
</thead>
<tbody>
<tr>
<td>
<div class="picker__day picker__day--infocus picker__day--disabled" data-pick="1704063600000" id="QF1_5_1704063600000" tabindex="0" role="gridcell" aria-label="01/01/2024" aria-disabled="true">1</div>
</td>
<td>
<div class="picker__day picker__day--infocus picker__day--disabled" data-pick="1704150000000" id="QF1_5_1704150000000" tabindex="0" role="gridcell" aria-label="02/01/2024" aria-disabled="true">2</div>
</td>
<td>
<div class="picker__day picker__day--infocus picker__day--disabled" data-pick="1704236400000" id="QF1_5_1704236400000" tabindex="0" role="gridcell" aria-label="03/01/2024" aria-disabled="true">3</div>
</td>
<td>
<div class="picker__day picker__day--infocus picker__day--disabled" data-pick="1704322800000" id="QF1_5_1704322800000" tabindex="0" role="gridcell" aria-label="04/01/2024" aria-disabled="true">4</div>
</td>
<td>
<div class="picker__day picker__day--infocus picker__day--disabled" data-pick="1704409200000" id="QF1_5_1704409200000" tabindex="0" role="gridcell" aria-label="05/01/2024" aria-disabled="true">5</div>
</td>
<td>
<div class="picker__day picker__day--infocus picker__day--disabled" data-pick="1704495600000" id="QF1_5_1704495600000" tabindex="0" role="gridcell" aria-label="06/01/2024" aria-disabled="true">6</div>
</td>
<td>
<div class="picker__day picker__day--infocus picker__day--disabled" data-pick="1704582000000" id="QF1_5_1704582000000" tabindex="0" role="gridcell" aria-label="07/01/2024" aria-disabled="true">7</div>
</td>
</tr>
<tr>
<td>
<div class="picker__day picker__day--infocus picker__day--disabled" data-pick="1704668400000" id="QF1_5_1704668400000" tabindex="0" role="gridcell" aria-label="08/01/2024" aria-disabled="true">8</div>
</td>
<td>
<div class="picker__day picker__day--infocus picker__day--disabled" data-pick="1704754800000" id="QF1_5_1704754800000" tabindex="0" role="gridcell" aria-label="09/01/2024" aria-disabled="true">9</div>
</td>
<td>
<div class="picker__day picker__day--infocus picker__day--disabled" data-pick="1704841200000" id="QF1_5_1704841200000" tabindex="0" role="gridcell" aria-label="10/01/2024" aria-disabled="true">10</div>
</td>
<td>
<div class="picker__day picker__day--infocus picker__day--disabled" data-pick="1704927600000" id="QF1_5_1704927600000" tabindex="0" role="gridcell" aria-label="11/01/2024" aria-disabled="true">11</div>
</td>
<td>
<div class="picker__day picker__day--infocus picker__day--disabled" data-pick="1705014000000" id="QF1_5_1705014000000" tabindex="0" role="gridcell" aria-label="12/01/2024" aria-disabled="true">12</div>
</td>
<td>
<div class="picker__day picker__day--infocus picker__day--disabled" data-pick="1705100400000" id="QF1_5_1705100400000" tabindex="0" role="gridcell" aria-label="13/01/2024" aria-disabled="true">13</div>
</td>
<td>
<div class="picker__day picker__day--infocus picker__day--disabled" data-pick="1705186800000" id="QF1_5_1705186800000" tabindex="0" role="gridcell" aria-label="14/01/2024" aria-disabled="true">14</div>
</td>
</tr>
<tr>
<td>
<div class="picker__day picker__day--infocus picker__day--disabled" data-pick="1705273200000" id="QF1_5_1705273200000" tabindex="0" role="gridcell" aria-label="15/01/2024" aria-disabled="true">15</div>
</td>
<td>
<div class="picker__day picker__day--infocus picker__day--disabled" data-pick="1705359600000" id="QF1_5_1705359600000" tabindex="0" role="gridcell" aria-label="16/01/2024" aria-disabled="true">16</div>
</td>
<td>
<div class="picker__day picker__day--infocus picker__day--disabled" data-pick="1705446000000" id="QF1_5_1705446000000" tabindex="0" role="gridcell" aria-label="17/01/2024" aria-disabled="true">17</div>
</td>
<td>
<div class="picker__day picker__day--infocus picker__day--disabled" data-pick="1705532400000" id="QF1_5_1705532400000" tabindex="0" role="gridcell" aria-label="18/01/2024" aria-disabled="true">18</div>
</td>
<td>
<div class="picker__day picker__day--infocus picker__day--today picker__day--disabled" data-pick="1705618800000" id="QF1_5_1705618800000" tabindex="0" role="gridcell" aria-label="19/01/2024" aria-disabled="true">19
</div>
</td>
<td>
<div class="picker__day picker__day--infocus picker__day--selected picker__day--highlighted" data-pick="1705705200000" id="QF1_5_1705705200000" tabindex="0" role="gridcell" aria-label="20/01/2024"
aria-selected="true" aria-activedescendant="1705705200000">20</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="1705791600000" id="QF1_5_1705791600000" tabindex="0" role="gridcell" aria-label="21/01/2024">21</div>
</td>
</tr>
<tr>
<td>
<div class="picker__day picker__day--infocus" data-pick="1705878000000" id="QF1_5_1705878000000" tabindex="0" role="gridcell" aria-label="22/01/2024">22</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="1705964400000" id="QF1_5_1705964400000" tabindex="0" role="gridcell" aria-label="23/01/2024">23</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="1706050800000" id="QF1_5_1706050800000" tabindex="0" role="gridcell" aria-label="24/01/2024">24</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="1706137200000" id="QF1_5_1706137200000" tabindex="0" role="gridcell" aria-label="25/01/2024">25</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="1706223600000" id="QF1_5_1706223600000" tabindex="0" role="gridcell" aria-label="26/01/2024">26</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="1706310000000" id="QF1_5_1706310000000" tabindex="0" role="gridcell" aria-label="27/01/2024">27</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="1706396400000" id="QF1_5_1706396400000" tabindex="0" role="gridcell" aria-label="28/01/2024">28</div>
</td>
</tr>
<tr>
<td>
<div class="picker__day picker__day--infocus" data-pick="1706482800000" id="QF1_5_1706482800000" tabindex="0" role="gridcell" aria-label="29/01/2024">29</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="1706569200000" id="QF1_5_1706569200000" tabindex="0" role="gridcell" aria-label="30/01/2024">30</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="1706655600000" id="QF1_5_1706655600000" tabindex="0" role="gridcell" aria-label="31/01/2024">31</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="1706742000000" id="QF1_5_1706742000000" tabindex="0" role="gridcell" aria-label="01/02/2024">1</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="1706828400000" id="QF1_5_1706828400000" tabindex="0" role="gridcell" aria-label="02/02/2024">2</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="1706914800000" id="QF1_5_1706914800000" tabindex="0" role="gridcell" aria-label="03/02/2024">3</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="1707001200000" id="QF1_5_1707001200000" tabindex="0" role="gridcell" aria-label="04/02/2024">4</div>
</td>
</tr>
<tr>
<td>
<div class="picker__day picker__day--outfocus" data-pick="1707087600000" id="QF1_5_1707087600000" tabindex="0" role="gridcell" aria-label="05/02/2024">5</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="1707174000000" id="QF1_5_1707174000000" tabindex="0" role="gridcell" aria-label="06/02/2024">6</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="1707260400000" id="QF1_5_1707260400000" tabindex="0" role="gridcell" aria-label="07/02/2024">7</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="1707346800000" id="QF1_5_1707346800000" tabindex="0" role="gridcell" aria-label="08/02/2024">8</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="1707433200000" id="QF1_5_1707433200000" tabindex="0" role="gridcell" aria-label="09/02/2024">9</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="1707519600000" id="QF1_5_1707519600000" tabindex="0" role="gridcell" aria-label="10/02/2024">10</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="1707606000000" id="QF1_5_1707606000000" tabindex="0" role="gridcell" aria-label="11/02/2024">11</div>
</td>
</tr>
</tbody>
</table>
<div class="picker__footer"><button class="picker__button--today" type="button" data-pick="1705618800000" disabled="" aria-controls="QF1_5">Aujourd'hui</button><button class="picker__button--clear" type="button"
data-clear="1" disabled="" aria-controls="QF1_5">Effacer</button><button class="picker__button--close" type="button" data-close="true" disabled="" aria-controls="QF1_5">Annuler</button></div>
</div>
</div>
</div>
</div>
</div><input type="hidden" name="QF1_5_submit" value="20/01/2024"> <span class="input-group-addon cursor-pointer" data-calendarlink="calendar_QF1_5"><span class="glyphicon glyphicon-calendar"></span></span>
</div>
</div>
</div>
<div class="form-group col-sm-12 Civility"><span class="span-has-error" name="errorMessage"><i class="fa fa-exclamation-triangle" aria-hidden="true"></i>Merci d'indiquer votre civilité</span> <label class="control-label col-sm-2">Civilité
</label>
<div class="col-sm-10">
<div class="radio-inline"><input autocomplete="on" class="form-control radio-inline civility-checkbox" data-erreur-msg="Merci d&#39;indiquer votre civilit&#233;" data-validation="RadioValidateur" id="9187_3" name="Civility"
type="radio" value="3"> <label class="radio" for="9187_3" tabindex="0">M.</label></div>
<div class="radio-inline"><input autocomplete="on" class="form-control radio-inline civility-checkbox" data-erreur-msg="Merci d&#39;indiquer votre civilit&#233;" data-validation="RadioValidateur" id="9187_2" name="Civility"
type="radio" value="2"> <label class="radio" for="9187_2" tabindex="0">Mme</label></div>
<div class="radio-inline"><input autocomplete="on" class="form-control radio-inline civility-checkbox" data-erreur-msg="Merci d&#39;indiquer votre civilit&#233;" data-validation="RadioValidateur" id="9187_1" name="Civility"
type="radio" value="1"> <label class="radio" for="9187_1" tabindex="0">Mlle</label></div>
</div>
</div>
<div class="form-group col-sm-6 LastName"><span class="span-has-error" name="errorMessage"><i class="fa fa-exclamation-triangle" aria-hidden="true"></i>Merci d'indiquer votre nom</span> <label class="control-label col-sm-12">Nom </label>
<div class="col-sm-12"><input autocomplete="on" class="form-control" data-condition-reponse="{ 'type': 'Nom'}" data-erreur-msg="Merci d&#39;indiquer votre nom" data-validation="TexteLibreValidateur" id="LastName" name="LastName"
type="text"></div>
</div>
<div class="form-group col-sm-6 FirstName"><span class="span-has-error" name="errorMessage"><i class="fa fa-exclamation-triangle" aria-hidden="true"></i>Merci d'indiquer votre prénom</span> <label class="control-label col-sm-12">Prénom
</label>
<div class="col-sm-12"><input autocomplete="on" class="form-control" data-condition-reponse="{ 'type': 'Nom'}" data-erreur-msg="Merci d&#39;indiquer votre pr&#233;nom" data-validation="TexteLibreValidateur" id="FirstName"
name="FirstName" type="text"></div>
</div>
<div class="form-group col-sm-6 AddressLine1"><span class="span-has-error" name="errorMessage"><i class="fa fa-exclamation-triangle" aria-hidden="true"></i>Merci d'indiquer votre adresse</span> <label
class="control-label col-sm-12">Adresse </label>
<div class="col-sm-12"><input autocomplete="on" class="form-control" data-condition-reponse="{ 'type': 'Texte', 'min': '2', 'max': '500'}" data-erreur-msg="Merci d&#39;indiquer votre adresse"
data-validation="TexteLibreValidateur" id="AddressLine1" name="AddressLine1" type="text"></div>
</div>
<div class="form-group col-sm-6 ZipCode"><span class="span-has-error" name="errorMessage"><i class="fa fa-exclamation-triangle" aria-hidden="true"></i>Merci d'indiquer votre code postal</span> <label class="control-label col-sm-12">Code
postal </label>
<div class="col-sm-12"><input autocomplete="on" class="form-control" data-erreur-msg="Merci d&#39;indiquer votre code postal" data-key-validation="Town" data-masque-saisie="00000" data-validation="CpVilleValidateur"
data-ville="Town" id="ZipCode" name="ZipCode" placeholder="_____" type="number" maxlength="5"></div>
</div>
<div class="form-group col-sm-6 Town"><span class="span-has-error" name="errorMessage"><i class="fa fa-exclamation-triangle" aria-hidden="true"></i>Merci d'indiquer votre ville</span> <label class="control-label col-sm-12">Ville </label>
<div class="select col-sm-12"><select autocomplete="on" class="form-control" data-erreur-msg="Merci d&#39;indiquer votre ville" data-key-validation="Town" data-validation="SelectValidateur" id="Town" name="Town"></select></div>
</div>
<div class="form-group grey fusion Message_CoordonneesV2">Vous recevrez votre recapitulatif de comparaison par email. En renseignant votre numéro de téléphone, vous acceptez d'être appelé par les partenaires d’assurance pour l'étude de
votre projet. <input autocomplete="on" class="form-control" data-optionel="1" data-validation="HiddenValidateur" id="Message_CoordonneesV2" name="Message_CoordonneesV2" type="hidden"></div>
<div class="form-group col-sm-6 PhoneNumber"><span class="span-has-error" name="errorMessage"><i class="fa fa-exclamation-triangle" aria-hidden="true"></i>Merci d'indiquer votre numéro de téléphone</span> <label
class="control-label col-sm-12">Téléphone </label>
<div class="col-sm-12"><input autocomplete="on" class="form-control" data-condition-reponse="{ 'type': 'Telephone'}" data-erreur-msg="Merci d&#39;indiquer votre num&#233;ro de t&#233;l&#233;phone"
data-masque-saisie="00.00.00.00.00" data-validation="TexteLibreValidateur" id="PhoneNumber" name="PhoneNumber" placeholder="__.__.__.__.__" type="tel" maxlength="14"></div>
</div>
<div class="form-group col-sm-6 Email"><span class="span-has-error" name="errorMessage"><i class="fa fa-exclamation-triangle" aria-hidden="true"></i>Merci d'indiquer votre email</span> <label class="control-label col-sm-12">Email </label>
<div class="col-sm-12"><input autocomplete="on" class="form-control" data-condition-reponse="{ 'type': 'Email'}" data-erreur-msg="Merci d&#39;indiquer votre email" data-validation="TexteLibreValidateur" id="Email" name="Email"
type="email"></div>
</div>
<div class="form-group col-sm-6 QF1_2"><span class="span-has-error" name="errorMessage"><i class="fa fa-exclamation-triangle" aria-hidden="true"></i>Merci d'indiquer votre date de naissance</span> <label
class="control-label col-sm-12">Date de naissance </label>
<div class="col-sm-12">
<div class="input-group"><input autocomplete="on" class="form-control picker__input"
data-condition-reponse="{ 'formatAttendu': 'dd/MM/yyyy', 'reponses_possibles': [ { 'condition': null, 'isCalendar': false, 'dateMin': { 'type': 'DateFixe', 'value': '19/01/1904' }, 'dateMax': { 'type': 'DateFixe', 'value': '19/01/2008' }, 'datePreselection': { 'type': 'DateFixe', 'value': '19/01/1969' }, 'dateDefault': null } ]}"
data-erreur-msg="Merci d&#39;indiquer votre date de naissance" data-masque-saisie="00/00/0000" data-validation="DateValidateur" id="QF1_2" name="QF1_2" placeholder="__/__/____" type="tel" maxlength="10" aria-haspopup="true"
aria-readonly="false" aria-owns="QF1_2_root">
<div class="picker" id="QF1_2_root" aria-hidden="true">
<div class="picker__holder" tabindex="-1">
<div class="picker__frame">
<div class="picker__wrap">
<div class="picker__box">
<div class="picker__header"><select class="picker__select--year" disabled="" aria-controls="QF1_2_table" title="Sélectionner une année">
<option value="1904">1904</option>
<option value="1905">1905</option>
<option value="1906">1906</option>
<option value="1907">1907</option>
<option value="1908">1908</option>
<option value="1909">1909</option>
<option value="1910">1910</option>
<option value="1911">1911</option>
<option value="1912">1912</option>
<option value="1913">1913</option>
<option value="1914">1914</option>
<option value="1915">1915</option>
<option value="1916">1916</option>
<option value="1917">1917</option>
<option value="1918">1918</option>
<option value="1919">1919</option>
<option value="1920">1920</option>
<option value="1921">1921</option>
<option value="1922">1922</option>
<option value="1923">1923</option>
<option value="1924">1924</option>
<option value="1925">1925</option>
<option value="1926">1926</option>
<option value="1927">1927</option>
<option value="1928">1928</option>
<option value="1929">1929</option>
<option value="1930">1930</option>
<option value="1931">1931</option>
<option value="1932">1932</option>
<option value="1933">1933</option>
<option value="1934">1934</option>
<option value="1935">1935</option>
<option value="1936">1936</option>
<option value="1937">1937</option>
<option value="1938">1938</option>
<option value="1939">1939</option>
<option value="1940">1940</option>
<option value="1941">1941</option>
<option value="1942">1942</option>
<option value="1943">1943</option>
<option value="1944">1944</option>
<option value="1945">1945</option>
<option value="1946">1946</option>
<option value="1947">1947</option>
<option value="1948">1948</option>
<option value="1949">1949</option>
<option value="1950">1950</option>
<option value="1951">1951</option>
<option value="1952">1952</option>
<option value="1953">1953</option>
<option value="1954">1954</option>
<option value="1955">1955</option>
<option value="1956">1956</option>
<option value="1957">1957</option>
<option value="1958">1958</option>
<option value="1959">1959</option>
<option value="1960">1960</option>
<option value="1961">1961</option>
<option value="1962">1962</option>
<option value="1963">1963</option>
<option value="1964">1964</option>
<option value="1965">1965</option>
<option value="1966">1966</option>
<option value="1967">1967</option>
<option value="1968">1968</option>
<option value="1969" selected="">1969</option>
<option value="1970">1970</option>
<option value="1971">1971</option>
<option value="1972">1972</option>
<option value="1973">1973</option>
<option value="1974">1974</option>
<option value="1975">1975</option>
<option value="1976">1976</option>
<option value="1977">1977</option>
<option value="1978">1978</option>
<option value="1979">1979</option>
<option value="1980">1980</option>
<option value="1981">1981</option>
<option value="1982">1982</option>
<option value="1983">1983</option>
<option value="1984">1984</option>
<option value="1985">1985</option>
<option value="1986">1986</option>
<option value="1987">1987</option>
<option value="1988">1988</option>
<option value="1989">1989</option>
<option value="1990">1990</option>
<option value="1991">1991</option>
<option value="1992">1992</option>
<option value="1993">1993</option>
<option value="1994">1994</option>
<option value="1995">1995</option>
<option value="1996">1996</option>
<option value="1997">1997</option>
<option value="1998">1998</option>
<option value="1999">1999</option>
<option value="2000">2000</option>
<option value="2001">2001</option>
<option value="2002">2002</option>
<option value="2003">2003</option>
<option value="2004">2004</option>
<option value="2005">2005</option>
<option value="2006">2006</option>
<option value="2007">2007</option>
<option value="2008">2008</option>
</select><select class="picker__select--month" disabled="" aria-controls="QF1_2_table" title="Sélectionner un mois">
<option value="0" selected="">Janvier</option>
<option value="1">Février</option>
<option value="2">Mars</option>
<option value="3">Avril</option>
<option value="4">Mai</option>
<option value="5">Juin</option>
<option value="6">Juillet</option>
<option value="7">Août</option>
<option value="8">Septembre</option>
<option value="9">Octobre</option>
<option value="10">Novembre</option>
<option value="11">Décembre</option>
</select>
<div class="picker__nav--prev" data-nav="-1" tabindex="0" role="button" aria-controls="QF1_2_table" title="Mois précédent"> </div>
<div class="picker__nav--next" data-nav="1" tabindex="0" role="button" aria-controls="QF1_2_table" title="Mois suivant"> </div>
</div>
<table class="picker__table" id="QF1_2_table" role="grid" aria-controls="QF1_2" aria-readonly="true">
<thead>
<tr>
<th class="picker__weekday" scope="col" title="Lundi">Lun</th>
<th class="picker__weekday" scope="col" title="Mardi">Mar</th>
<th class="picker__weekday" scope="col" title="Mercredi">Mer</th>
<th class="picker__weekday" scope="col" title="Jeudi">Jeu</th>
<th class="picker__weekday" scope="col" title="Vendredi">Ven</th>
<th class="picker__weekday" scope="col" title="Samedi">Sam</th>
<th class="picker__weekday" scope="col" title="Dimanche">Dim</th>
</tr>
</thead>
<tbody>
<tr>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-31712400000" id="QF1_2_-31712400000" tabindex="0" role="gridcell" aria-label="30/12/1968">30</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-31626000000" id="QF1_2_-31626000000" tabindex="0" role="gridcell" aria-label="31/12/1968">31</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-31539600000" id="QF1_2_-31539600000" tabindex="0" role="gridcell" aria-label="01/01/1969">1</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-31453200000" id="QF1_2_-31453200000" tabindex="0" role="gridcell" aria-label="02/01/1969">2</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-31366800000" id="QF1_2_-31366800000" tabindex="0" role="gridcell" aria-label="03/01/1969">3</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-31280400000" id="QF1_2_-31280400000" tabindex="0" role="gridcell" aria-label="04/01/1969">4</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-31194000000" id="QF1_2_-31194000000" tabindex="0" role="gridcell" aria-label="05/01/1969">5</div>
</td>
</tr>
<tr>
<td>
<div class="picker__day picker__day--infocus" data-pick="-31107600000" id="QF1_2_-31107600000" tabindex="0" role="gridcell" aria-label="06/01/1969">6</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-31021200000" id="QF1_2_-31021200000" tabindex="0" role="gridcell" aria-label="07/01/1969">7</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30934800000" id="QF1_2_-30934800000" tabindex="0" role="gridcell" aria-label="08/01/1969">8</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30848400000" id="QF1_2_-30848400000" tabindex="0" role="gridcell" aria-label="09/01/1969">9</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30762000000" id="QF1_2_-30762000000" tabindex="0" role="gridcell" aria-label="10/01/1969">10</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30675600000" id="QF1_2_-30675600000" tabindex="0" role="gridcell" aria-label="11/01/1969">11</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30589200000" id="QF1_2_-30589200000" tabindex="0" role="gridcell" aria-label="12/01/1969">12</div>
</td>
</tr>
<tr>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30502800000" id="QF1_2_-30502800000" tabindex="0" role="gridcell" aria-label="13/01/1969">13</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30416400000" id="QF1_2_-30416400000" tabindex="0" role="gridcell" aria-label="14/01/1969">14</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30330000000" id="QF1_2_-30330000000" tabindex="0" role="gridcell" aria-label="15/01/1969">15</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30243600000" id="QF1_2_-30243600000" tabindex="0" role="gridcell" aria-label="16/01/1969">16</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30157200000" id="QF1_2_-30157200000" tabindex="0" role="gridcell" aria-label="17/01/1969">17</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30070800000" id="QF1_2_-30070800000" tabindex="0" role="gridcell" aria-label="18/01/1969">18</div>
</td>
<td>
<div class="picker__day picker__day--infocus picker__day--selected picker__day--highlighted" data-pick="-29984400000" id="QF1_2_-29984400000" tabindex="0" role="gridcell" aria-label="19/01/1969"
aria-selected="true" aria-activedescendant="-29984400000">19</div>
</td>
</tr>
<tr>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29898000000" id="QF1_2_-29898000000" tabindex="0" role="gridcell" aria-label="20/01/1969">20</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29811600000" id="QF1_2_-29811600000" tabindex="0" role="gridcell" aria-label="21/01/1969">21</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29725200000" id="QF1_2_-29725200000" tabindex="0" role="gridcell" aria-label="22/01/1969">22</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29638800000" id="QF1_2_-29638800000" tabindex="0" role="gridcell" aria-label="23/01/1969">23</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29552400000" id="QF1_2_-29552400000" tabindex="0" role="gridcell" aria-label="24/01/1969">24</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29466000000" id="QF1_2_-29466000000" tabindex="0" role="gridcell" aria-label="25/01/1969">25</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29379600000" id="QF1_2_-29379600000" tabindex="0" role="gridcell" aria-label="26/01/1969">26</div>
</td>
</tr>
<tr>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29293200000" id="QF1_2_-29293200000" tabindex="0" role="gridcell" aria-label="27/01/1969">27</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29206800000" id="QF1_2_-29206800000" tabindex="0" role="gridcell" aria-label="28/01/1969">28</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29120400000" id="QF1_2_-29120400000" tabindex="0" role="gridcell" aria-label="29/01/1969">29</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29034000000" id="QF1_2_-29034000000" tabindex="0" role="gridcell" aria-label="30/01/1969">30</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-28947600000" id="QF1_2_-28947600000" tabindex="0" role="gridcell" aria-label="31/01/1969">31</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-28861200000" id="QF1_2_-28861200000" tabindex="0" role="gridcell" aria-label="01/02/1969">1</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-28774800000" id="QF1_2_-28774800000" tabindex="0" role="gridcell" aria-label="02/02/1969">2</div>
</td>
</tr>
<tr>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-28688400000" id="QF1_2_-28688400000" tabindex="0" role="gridcell" aria-label="03/02/1969">3</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-28602000000" id="QF1_2_-28602000000" tabindex="0" role="gridcell" aria-label="04/02/1969">4</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-28515600000" id="QF1_2_-28515600000" tabindex="0" role="gridcell" aria-label="05/02/1969">5</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-28429200000" id="QF1_2_-28429200000" tabindex="0" role="gridcell" aria-label="06/02/1969">6</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-28342800000" id="QF1_2_-28342800000" tabindex="0" role="gridcell" aria-label="07/02/1969">7</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-28256400000" id="QF1_2_-28256400000" tabindex="0" role="gridcell" aria-label="08/02/1969">8</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-28170000000" id="QF1_2_-28170000000" tabindex="0" role="gridcell" aria-label="09/02/1969">9</div>
</td>
</tr>
</tbody>
</table>
<div class="picker__footer"><button class="picker__button--today" type="button" data-pick="1705618800000" disabled="" aria-controls="QF1_2">Aujourd'hui</button><button class="picker__button--clear" type="button"
data-clear="1" disabled="" aria-controls="QF1_2">Effacer</button><button class="picker__button--close" type="button" data-close="true" disabled="" aria-controls="QF1_2">Annuler</button></div>
</div>
</div>
</div>
</div>
</div><input type="hidden" name="QF1_2_submit" value="19/01/1969"> <span class="input-group-addon cursor-pointer" data-calendarlink="calendar_QF1_2"><span class="glyphicon glyphicon-calendar"></span></span>
</div>
</div>
</div>
<div class="form-group col-sm-6 QF1_3"><span class="span-has-error" name="errorMessage"><i class="fa fa-exclamation-triangle" aria-hidden="true"></i>Merci d'indiquer votre situation matrimoniale</span> <label
class="control-label col-sm-12">Situation matrimoniale </label>
<div class="select col-sm-12"><select autocomplete="on" class="form-control" data-erreur-msg="Merci d&#39;indiquer votre situation matrimoniale" data-validation="SelectValidateur" id="QF1_3" name="QF1_3">
<option value="1">Célibataire</option>
<option selected="" value="2">Marié(e)</option>
<option value="7">Pacsé(e)</option>
<option value="3">En concubinage</option>
<option value="4">Séparé(e)</option>
<option value="5">Divorcé(e)</option>
<option value="6">Veuf(ve)</option>
</select></div>
</div>
<div class="form-group col-sm-6 QF1_4"><span class="span-has-error" name="errorMessage"><i class="fa fa-exclamation-triangle" aria-hidden="true"></i>Merci d'indiquer le montant pour lequel vous souhaitez être couvert</span> <label
class="control-label col-sm-12">Capital obsèques envisagé </label>
<div class="select col-sm-12"><select autocomplete="on" class="form-control" data-erreur-msg="Merci d&#39;indiquer le montant pour lequel vous souhaitez &#234;tre couvert" data-validation="SelectValidateur" id="QF1_4"
name="QF1_4">
<option value="1">1 000€</option>
<option value="2">2 000€</option>
<option value="3">3 000€</option>
<option selected="" value="4">4 000€</option>
<option value="5">5 000€</option>
<option value="6">6 000€</option>
<option value="7">7 000€</option>
<option value="8">8 000€</option>
<option value="9">9 000€</option>
<option value="10">10 000€</option>
</select></div>
</div>
<div class="form-group col-sm-12 QF1_1"><span class="span-has-error" name="errorMessage"><i class="fa fa-exclamation-triangle" aria-hidden="true"></i>Merci d'indiquer si vous souhaitez couvrir votre conjoint</span> <label
class="control-label col-sm-12">Personne(s) à assurer </label>
<div class="col-sm-12">
<div class="radio-inline"><input autocomplete="on" checked="" class="form-control radio-inline" data-condition-affichage="[[{'key':'QF1_3','value':['2','3','7'],'typeCondition':'Contient'}]]"
data-erreur-msg="Merci d&#39;indiquer si vous souhaitez couvrir votre conjoint" data-validation="RadioValidateur" id="9179_1" name="QF1_1" type="radio" value="1"> <label class="radio" for="9179_1" tabindex="0">Moi</label>
</div>
<div class="radio-inline"><input autocomplete="on" class="form-control radio-inline" data-condition-affichage="[[{'key':'QF1_3','value':['2','3','7'],'typeCondition':'Contient'}]]"
data-erreur-msg="Merci d&#39;indiquer si vous souhaitez couvrir votre conjoint" data-validation="RadioValidateur" id="9179_2" name="QF1_1" type="radio" value="2"> <label class="radio" for="9179_2" tabindex="0">Mon
couple</label></div>
</div>
</div>
</div>
<div class="zoneBloc col-md-12 padding-bottom-20 blocConjoint" data-bloc="1" style="display:none">
<div class="titreBloc">Mon conjoint</div>
<div class="form-group col-sm-6 hiddenInput QF1_2Bis"><span class="span-has-error" name="errorMessage"><i class="fa fa-exclamation-triangle" aria-hidden="true"></i>Merci d'indiquer la date de naissance de votre conjoint</span> <label
class="control-label col-sm-12">Date de naissance </label>
<div class="col-sm-12">
<div class="input-group"><input autocomplete="on" class="form-control picker__input" data-condition-affichage="[[{'key':'QF1_1','value':['2'],'typeCondition':'Contient'}]]"
data-condition-reponse="{ 'formatAttendu': 'dd/MM/yyyy', 'reponses_possibles': [ { 'condition': null, 'isCalendar': false, 'dateMin': { 'type': 'DateFixe', 'value': '19/01/1904' }, 'dateMax': { 'type': 'DateFixe', 'value': '19/01/2008' }, 'datePreselection': { 'type': 'DateFixe', 'value': '19/01/1969' }, 'dateDefault': null } ]}"
data-erreur-msg="Merci d&#39;indiquer la date de naissance de votre conjoint" data-masque-saisie="00/00/0000" data-validation="DateValidateur" id="QF1_2Bis" name="QF1_2Bis" placeholder="__/__/____" type="tel" maxlength="10"
aria-haspopup="true" aria-readonly="false" aria-owns="QF1_2Bis_root">
<div class="picker" id="QF1_2Bis_root" aria-hidden="true">
<div class="picker__holder" tabindex="-1">
<div class="picker__frame">
<div class="picker__wrap">
<div class="picker__box">
<div class="picker__header"><select class="picker__select--year" disabled="" aria-controls="QF1_2Bis_table" title="Sélectionner une année">
<option value="1904">1904</option>
<option value="1905">1905</option>
<option value="1906">1906</option>
<option value="1907">1907</option>
<option value="1908">1908</option>
<option value="1909">1909</option>
<option value="1910">1910</option>
<option value="1911">1911</option>
<option value="1912">1912</option>
<option value="1913">1913</option>
<option value="1914">1914</option>
<option value="1915">1915</option>
<option value="1916">1916</option>
<option value="1917">1917</option>
<option value="1918">1918</option>
<option value="1919">1919</option>
<option value="1920">1920</option>
<option value="1921">1921</option>
<option value="1922">1922</option>
<option value="1923">1923</option>
<option value="1924">1924</option>
<option value="1925">1925</option>
<option value="1926">1926</option>
<option value="1927">1927</option>
<option value="1928">1928</option>
<option value="1929">1929</option>
<option value="1930">1930</option>
<option value="1931">1931</option>
<option value="1932">1932</option>
<option value="1933">1933</option>
<option value="1934">1934</option>
<option value="1935">1935</option>
<option value="1936">1936</option>
<option value="1937">1937</option>
<option value="1938">1938</option>
<option value="1939">1939</option>
<option value="1940">1940</option>
<option value="1941">1941</option>
<option value="1942">1942</option>
<option value="1943">1943</option>
<option value="1944">1944</option>
<option value="1945">1945</option>
<option value="1946">1946</option>
<option value="1947">1947</option>
<option value="1948">1948</option>
<option value="1949">1949</option>
<option value="1950">1950</option>
<option value="1951">1951</option>
<option value="1952">1952</option>
<option value="1953">1953</option>
<option value="1954">1954</option>
<option value="1955">1955</option>
<option value="1956">1956</option>
<option value="1957">1957</option>
<option value="1958">1958</option>
<option value="1959">1959</option>
<option value="1960">1960</option>
<option value="1961">1961</option>
<option value="1962">1962</option>
<option value="1963">1963</option>
<option value="1964">1964</option>
<option value="1965">1965</option>
<option value="1966">1966</option>
<option value="1967">1967</option>
<option value="1968">1968</option>
<option value="1969" selected="">1969</option>
<option value="1970">1970</option>
<option value="1971">1971</option>
<option value="1972">1972</option>
<option value="1973">1973</option>
<option value="1974">1974</option>
<option value="1975">1975</option>
<option value="1976">1976</option>
<option value="1977">1977</option>
<option value="1978">1978</option>
<option value="1979">1979</option>
<option value="1980">1980</option>
<option value="1981">1981</option>
<option value="1982">1982</option>
<option value="1983">1983</option>
<option value="1984">1984</option>
<option value="1985">1985</option>
<option value="1986">1986</option>
<option value="1987">1987</option>
<option value="1988">1988</option>
<option value="1989">1989</option>
<option value="1990">1990</option>
<option value="1991">1991</option>
<option value="1992">1992</option>
<option value="1993">1993</option>
<option value="1994">1994</option>
<option value="1995">1995</option>
<option value="1996">1996</option>
<option value="1997">1997</option>
<option value="1998">1998</option>
<option value="1999">1999</option>
<option value="2000">2000</option>
<option value="2001">2001</option>
<option value="2002">2002</option>
<option value="2003">2003</option>
<option value="2004">2004</option>
<option value="2005">2005</option>
<option value="2006">2006</option>
<option value="2007">2007</option>
<option value="2008">2008</option>
</select><select class="picker__select--month" disabled="" aria-controls="QF1_2Bis_table" title="Sélectionner un mois">
<option value="0" selected="">Janvier</option>
<option value="1">Février</option>
<option value="2">Mars</option>
<option value="3">Avril</option>
<option value="4">Mai</option>
<option value="5">Juin</option>
<option value="6">Juillet</option>
<option value="7">Août</option>
<option value="8">Septembre</option>
<option value="9">Octobre</option>
<option value="10">Novembre</option>
<option value="11">Décembre</option>
</select>
<div class="picker__nav--prev" data-nav="-1" tabindex="0" role="button" aria-controls="QF1_2Bis_table" title="Mois précédent"> </div>
<div class="picker__nav--next" data-nav="1" tabindex="0" role="button" aria-controls="QF1_2Bis_table" title="Mois suivant"> </div>
</div>
<table class="picker__table" id="QF1_2Bis_table" role="grid" aria-controls="QF1_2Bis" aria-readonly="true">
<thead>
<tr>
<th class="picker__weekday" scope="col" title="Lundi">Lun</th>
<th class="picker__weekday" scope="col" title="Mardi">Mar</th>
<th class="picker__weekday" scope="col" title="Mercredi">Mer</th>
<th class="picker__weekday" scope="col" title="Jeudi">Jeu</th>
<th class="picker__weekday" scope="col" title="Vendredi">Ven</th>
<th class="picker__weekday" scope="col" title="Samedi">Sam</th>
<th class="picker__weekday" scope="col" title="Dimanche">Dim</th>
</tr>
</thead>
<tbody>
<tr>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-31712400000" id="QF1_2Bis_-31712400000" tabindex="0" role="gridcell" aria-label="30/12/1968">30</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-31626000000" id="QF1_2Bis_-31626000000" tabindex="0" role="gridcell" aria-label="31/12/1968">31</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-31539600000" id="QF1_2Bis_-31539600000" tabindex="0" role="gridcell" aria-label="01/01/1969">1</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-31453200000" id="QF1_2Bis_-31453200000" tabindex="0" role="gridcell" aria-label="02/01/1969">2</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-31366800000" id="QF1_2Bis_-31366800000" tabindex="0" role="gridcell" aria-label="03/01/1969">3</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-31280400000" id="QF1_2Bis_-31280400000" tabindex="0" role="gridcell" aria-label="04/01/1969">4</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-31194000000" id="QF1_2Bis_-31194000000" tabindex="0" role="gridcell" aria-label="05/01/1969">5</div>
</td>
</tr>
<tr>
<td>
<div class="picker__day picker__day--infocus" data-pick="-31107600000" id="QF1_2Bis_-31107600000" tabindex="0" role="gridcell" aria-label="06/01/1969">6</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-31021200000" id="QF1_2Bis_-31021200000" tabindex="0" role="gridcell" aria-label="07/01/1969">7</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30934800000" id="QF1_2Bis_-30934800000" tabindex="0" role="gridcell" aria-label="08/01/1969">8</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30848400000" id="QF1_2Bis_-30848400000" tabindex="0" role="gridcell" aria-label="09/01/1969">9</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30762000000" id="QF1_2Bis_-30762000000" tabindex="0" role="gridcell" aria-label="10/01/1969">10</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30675600000" id="QF1_2Bis_-30675600000" tabindex="0" role="gridcell" aria-label="11/01/1969">11</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30589200000" id="QF1_2Bis_-30589200000" tabindex="0" role="gridcell" aria-label="12/01/1969">12</div>
</td>
</tr>
<tr>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30502800000" id="QF1_2Bis_-30502800000" tabindex="0" role="gridcell" aria-label="13/01/1969">13</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30416400000" id="QF1_2Bis_-30416400000" tabindex="0" role="gridcell" aria-label="14/01/1969">14</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30330000000" id="QF1_2Bis_-30330000000" tabindex="0" role="gridcell" aria-label="15/01/1969">15</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30243600000" id="QF1_2Bis_-30243600000" tabindex="0" role="gridcell" aria-label="16/01/1969">16</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30157200000" id="QF1_2Bis_-30157200000" tabindex="0" role="gridcell" aria-label="17/01/1969">17</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-30070800000" id="QF1_2Bis_-30070800000" tabindex="0" role="gridcell" aria-label="18/01/1969">18</div>
</td>
<td>
<div class="picker__day picker__day--infocus picker__day--selected picker__day--highlighted" data-pick="-29984400000" id="QF1_2Bis_-29984400000" tabindex="0" role="gridcell" aria-label="19/01/1969"
aria-selected="true" aria-activedescendant="-29984400000">19</div>
</td>
</tr>
<tr>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29898000000" id="QF1_2Bis_-29898000000" tabindex="0" role="gridcell" aria-label="20/01/1969">20</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29811600000" id="QF1_2Bis_-29811600000" tabindex="0" role="gridcell" aria-label="21/01/1969">21</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29725200000" id="QF1_2Bis_-29725200000" tabindex="0" role="gridcell" aria-label="22/01/1969">22</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29638800000" id="QF1_2Bis_-29638800000" tabindex="0" role="gridcell" aria-label="23/01/1969">23</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29552400000" id="QF1_2Bis_-29552400000" tabindex="0" role="gridcell" aria-label="24/01/1969">24</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29466000000" id="QF1_2Bis_-29466000000" tabindex="0" role="gridcell" aria-label="25/01/1969">25</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29379600000" id="QF1_2Bis_-29379600000" tabindex="0" role="gridcell" aria-label="26/01/1969">26</div>
</td>
</tr>
<tr>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29293200000" id="QF1_2Bis_-29293200000" tabindex="0" role="gridcell" aria-label="27/01/1969">27</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29206800000" id="QF1_2Bis_-29206800000" tabindex="0" role="gridcell" aria-label="28/01/1969">28</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29120400000" id="QF1_2Bis_-29120400000" tabindex="0" role="gridcell" aria-label="29/01/1969">29</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-29034000000" id="QF1_2Bis_-29034000000" tabindex="0" role="gridcell" aria-label="30/01/1969">30</div>
</td>
<td>
<div class="picker__day picker__day--infocus" data-pick="-28947600000" id="QF1_2Bis_-28947600000" tabindex="0" role="gridcell" aria-label="31/01/1969">31</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-28861200000" id="QF1_2Bis_-28861200000" tabindex="0" role="gridcell" aria-label="01/02/1969">1</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-28774800000" id="QF1_2Bis_-28774800000" tabindex="0" role="gridcell" aria-label="02/02/1969">2</div>
</td>
</tr>
<tr>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-28688400000" id="QF1_2Bis_-28688400000" tabindex="0" role="gridcell" aria-label="03/02/1969">3</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-28602000000" id="QF1_2Bis_-28602000000" tabindex="0" role="gridcell" aria-label="04/02/1969">4</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-28515600000" id="QF1_2Bis_-28515600000" tabindex="0" role="gridcell" aria-label="05/02/1969">5</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-28429200000" id="QF1_2Bis_-28429200000" tabindex="0" role="gridcell" aria-label="06/02/1969">6</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-28342800000" id="QF1_2Bis_-28342800000" tabindex="0" role="gridcell" aria-label="07/02/1969">7</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-28256400000" id="QF1_2Bis_-28256400000" tabindex="0" role="gridcell" aria-label="08/02/1969">8</div>
</td>
<td>
<div class="picker__day picker__day--outfocus" data-pick="-28170000000" id="QF1_2Bis_-28170000000" tabindex="0" role="gridcell" aria-label="09/02/1969">9</div>
</td>
</tr>
</tbody>
</table>
<div class="picker__footer"><button class="picker__button--today" type="button" data-pick="1705618800000" disabled="" aria-controls="QF1_2Bis">Aujourd'hui</button><button class="picker__button--clear" type="button"
data-clear="1" disabled="" aria-controls="QF1_2Bis">Effacer</button><button class="picker__button--close" type="button" data-close="true" disabled="" aria-controls="QF1_2Bis">Annuler</button></div>
</div>
</div>
</div>
</div>
</div><input type="hidden" name="QF1_2Bis_submit" value="19/01/1969"> <span class="input-group-addon cursor-pointer" data-calendarlink="calendar_QF1_2Bis"><span class="glyphicon glyphicon-calendar"></span></span>
</div>
</div>
</div>
<div class="form-group col-sm-6 hiddenInput QF1_4Bis"><span class="span-has-error" name="errorMessage"><i class="fa fa-exclamation-triangle" aria-hidden="true"></i>Merci d'indiquer le montant pour lequel votre conjoint souhaite être
couvert</span> <label class="control-label col-sm-12">Montant du capital souscrit </label>
<div class="select col-sm-12"><select autocomplete="on" class="form-control" data-condition-affichage="[[{'key':'QF1_1','value':['2'],'typeCondition':'Contient'}]]"
data-erreur-msg="Merci d&#39;indiquer le montant pour lequel votre conjoint souhaite &#234;tre couvert" data-validation="SelectValidateur" id="QF1_4Bis" name="QF1_4Bis">
<option value="1">1 000€</option>
<option value="2">2 000€</option>
<option value="3">3 000€</option>
<option value="4">4 000€</option>
<option selected="" value="5">5 000€</option>
<option value="6">6 000€</option>
<option value="7">7 000€</option>
<option value="8">8 000€</option>
<option value="9">9 000€</option>
<option value="10">10 000€</option>
</select></div>
</div>
</div>
<div class="zoneBloc col-md-12 padding-bottom-20" data-bloc="1">
<div class="form-group OptIn1"><span class="span-has-error" name="errorMessage"><i class="fa fa-exclamation-triangle" aria-hidden="true"></i>Vous devez accepter pour accéder à votre comparatif personnalisé</span> <label
class="control-label col-sm-12"> </label>
<div class="col-sm-12">
<div><input autocomplete="on" class="form-control" data-erreur-msg="Vous devez accepter pour acc&#233;der &#224; votre comparatif personnalis&#233;" data-validation="CheckBoxValidateur" id="9195_1" name="OptIn1"
type="checkbox" value="1"> <label class="checkbox" for="9195_1" tabindex="0">J'accepte de transmettre mes données aux <a class="popupAssureurs lienCGU" style="cursor:pointer">partenaires d'assurance</a> afin qu'ils me contactent
pour étudier mon projet</label></div>
<div style="display:none"><input autocomplete="on" class="form-control" data-erreur-msg="Vous devez accepter pour acc&#233;der &#224; votre comparatif personnalis&#233;" data-validation="CheckBoxValidateur" id="9195_0"
name="OptIn1" type="checkbox" value="0"> <label class="checkbox" for="9195_0" tabindex="0">Non</label></div>
</div>
</div><input data-validation="HiddenValidateur" id="Device" name="Device" type="hidden" value="Desktop"> <input data-validation="HiddenValidateur" id="Channel" name="Channel" type="hidden" value="0"> <input
data-validation="HiddenValidateur" id="AFF_referrer" name="AFF_referrer" type="hidden"> <input data-validation="HiddenValidateur" id="AFF_utm_campaign" name="AFF_utm_campaign" type="hidden"> <input data-validation="HiddenValidateur"
id="AFF_utm_content" name="AFF_utm_content" type="hidden"> <input data-validation="HiddenValidateur" id="AFF_utm_medium" name="AFF_utm_medium" type="hidden"> <input data-validation="HiddenValidateur" id="AFF_utm_source"
name="AFF_utm_source" type="hidden"> <input data-validation="HiddenValidateur" id="AFF_utm_term" name="AFF_utm_term" type="hidden"> <input data-validation="HiddenValidateur" id="UserAgent" name="UserAgent" type="hidden"
value="Mozilla/5.0 (Windows NT 10.0; Win64; x64) AppleWebKit/537.36 (KHTML, like Gecko) Chrome/120.0.6099.224 Safari/537.36"> <input data-validation="HiddenValidateur" id="AFF_Query" name="AFF_Query" type="hidden"> <input
data-validation="HiddenValidateur" id="Optin1Label" name="Optin1Label" type="hidden"> <input data-validation="HiddenValidateur" id="OptoutLabel" name="OptoutLabel" type="hidden">
</div>
<div class="col-md-12">
<div class="zoneButton cta margin-top-30 text-right">
<div class="mentions-RGPD-landing text-center small margin-bottom-20" id="mentions-FormGen">En cliquant sur le bouton, je crée un compte client Meilleurtaux et accepte de recevoir des emails, conformément aux
<a data-popup-mentions="CGU" class="popupMentions lienCGU blue" style="cursor:pointer">conditions générales</a> et la
<a data-popup-mentions="DonneesPerso" data-popup-type="assurance" class="lienCGU blue" style="cursor:pointer">politique de données personnelles</a> des sociétés du groupe Meilleurtaux.</div><button type="button"
class="pixeoLogValidateForm btn btn-valider btn-lg" data-btn-validation="1" data-page-exception=""> <span>Je compare <br> les assurances <i class="glyphicon glyphicon-triangle-right"></i></span> </button>
</div>
</div>
</div>
<div class="clear"></div>
</div>
</div><input id="idWebPage" name="idWebPage" type="hidden" value="2234"> <input id="form-insukind" name="form-insukind" type="hidden" value="8"> <input id="declinaisonTechnique" name="declinaisonTechnique" type="hidden" value="113"> <input
data-val="true" data-val-required="Le champ website est requis." id="website" name="website" type="hidden" value="1">
</div>
</form>Text Content
Assurez l'avenir de vos proches
en comparant les assurances obsèques
Aucun questionnaire médical
Tarification en temps réel
Capital obsèques compris
entre 1 000€ et 10 000€
Nos assureurs partenaires
Devis sans engagement en 2 min
Mes informations
Merci d'indiquer la date à laquelle vous souhaitez que votre contrat commence
Mon contrat doit commencer le
20242025JanvierFévrierMarsAvrilMaiJuinJuilletAoûtSeptembreOctobreNovembreDécembre
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Aujourd'huiEffacerAnnuler
Merci d'indiquer votre civilité Civilité
M.
Mme
Mlle
Merci d'indiquer votre nom Nom
Merci d'indiquer votre prénom Prénom
Merci d'indiquer votre adresse Adresse
Merci d'indiquer votre code postal Code postal
Merci d'indiquer votre ville Ville
Vous recevrez votre recapitulatif de comparaison par email. En renseignant votre
numéro de téléphone, vous acceptez d'être appelé par les partenaires d’assurance
pour l'étude de votre projet.
Merci d'indiquer votre numéro de téléphone Téléphone
Merci d'indiquer votre email Email
Merci d'indiquer votre date de naissance Date de naissance
190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008JanvierFévrierMarsAvrilMaiJuinJuilletAoûtSeptembreOctobreNovembreDécembre
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Aujourd'huiEffacerAnnuler
Merci d'indiquer votre situation matrimoniale Situation matrimoniale
CélibataireMarié(e)Pacsé(e)En concubinageSéparé(e)Divorcé(e)Veuf(ve)
Merci d'indiquer le montant pour lequel vous souhaitez être couvert Capital
obsèques envisagé
1 000€2 000€3 000€4 000€5 000€6 000€7 000€8 000€9 000€10 000€
Merci d'indiquer si vous souhaitez couvrir votre conjoint Personne(s) à assurer
Moi
Mon couple
Mon conjoint
Merci d'indiquer la date de naissance de votre conjoint Date de naissance
190419051906190719081909191019111912191319141915191619171918191919201921192219231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008JanvierFévrierMarsAvrilMaiJuinJuilletAoûtSeptembreOctobreNovembreDécembre
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Aujourd'huiEffacerAnnuler
Merci d'indiquer le montant pour lequel votre conjoint souhaite être couvert
Montant du capital souscrit
1 000€2 000€3 000€4 000€5 000€6 000€7 000€8 000€9 000€10 000€
Vous devez accepter pour accéder à votre comparatif personnalisé
J'accepte de transmettre mes données aux partenaires d'assurance afin qu'ils me
contactent pour étudier mon projet
Non
En cliquant sur le bouton, je crée un compte client Meilleurtaux et accepte de
recevoir des emails, conformément aux conditions générales et la politique de
données personnelles des sociétés du groupe Meilleurtaux.
Je compare
les assurances
Fermer
Mentions légales Conditions générales d'utilisation Mentions comparateur
Protection des données personnelles Politique cookies
Fermer
Oui Non
Nos partenaires assureurs :
Voir la liste des partenaires courtiers
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Pour des raisons de confidentialité, votre session a expiré.
Mais pas de panique, cliquez simplement sur le bouton ci-contre pour accéder à
vos tarifs personnalisés !
Retrouvez mes offres
*Tarif constaté sur assurance-obsèques.info 04/11/2020 pour une célibataire de
48 ans habitant les Yvelines pour un capital souhaité de 1000€.
Contact - Mentions légales - Mentions comparateur - Politique Données
Personnelles - CGU - Partenaires d'assurance - Cookies
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