rctorino.tiassicura.it Open in urlscan Pro
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1 forms found in the DOM

Name: form_240774101385352 — POST https://eu-submit.jotform.com/submit/240774101385352

<form class="jotform-form" onsubmit="return typeof testSubmitFunction !== 'undefined' &amp;&amp; testSubmitFunction();" action="https://eu-submit.jotform.com/submit/240774101385352" method="post" name="form_240774101385352" id="240774101385352"
  accept-charset="utf-8" autocomplete="on" novalidate="true"><input type="hidden" name="formID" value="240774101385352"><input type="hidden" id="JWTContainer" value=""><input type="hidden" id="cardinalOrderNumber" value=""><input type="hidden"
    id="jsExecutionTracker" name="jsExecutionTracker" value="build-date-1712231633233=>init-started:1712495358638=>validator-called:1712495358689=>validator-mounted-true:1712495358689=>init-complete:1712495358693"><input type="hidden"
    id="submitSource" name="submitSource" value="mounted"><input type="hidden" id="buildDate" name="buildDate" value="1712231633233">
  <div role="main" class="form-all">
    <ul class="form-section page-section">
      <li class="form-line jf-required" data-type="control_dropdown" id="id_13"><label class="form-label form-label-right" id="label_13" for="input_13" aria-hidden="false"> Dati Veicolo<span class="form-required">*</span> </label>
        <div id="cid_13" class="form-input jf-required" data-layout="half"> <select class="form-dropdown validate[required]" id="input_13" name="q13_datiVeicolo" style="width:310px" data-component="dropdown" required="" aria-label="Dati Veicolo">
            <option value="">Scegli il veicolo da assicurare</option>
            <option value="Autovettura">Autovettura</option>
            <option value="Autocarro">Autocarro</option>
            <option value="Autotassametro">Autotassametro</option>
            <option value="Ciclomotore">Ciclomotore</option>
            <option value="Motociclo">Motociclo</option>
            <option value="Caravan">Caravan</option>
            <option value="Quad">Quad</option>
            <option value="Microcar">Microcar</option>
            <option value="Quadriciclo Leggero">Quadriciclo Leggero</option>
            <option value="Macchina Agricola">Macchina Agricola</option>
            <option value="Targa Prova">Targa Prova</option>
            <option value="Targa Export">Targa Export</option>
          </select> </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_15"><label class="form-label form-label-right form-label-auto" id="label_15" for="input_15" aria-hidden="false"> Marca </label>
        <div id="cid_15" class="form-input" data-layout="half"> <input type="text" id="input_15" name="q15_marca" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" placeholder="Marca"
            data-component="textbox" aria-labelledby="label_15" value=""> </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_16"><label class="form-label form-label-right form-label-auto" id="label_16" for="input_16" aria-hidden="false"> Modello </label>
        <div id="cid_16" class="form-input" data-layout="half"> <input type="text" id="input_16" name="q16_modello" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" placeholder="Modello"
            data-component="textbox" aria-labelledby="label_16" value=""> </div>
      </li>
      <li class="form-line jf-required" data-type="control_textbox" id="id_17"><label class="form-label form-label-right form-label-auto" id="label_17" for="input_17" aria-hidden="false"> Cilindrata<span class="form-required">*</span> </label>
        <div id="cid_17" class="form-input jf-required" data-layout="half"> <input type="text" id="input_17" name="q17_cilindrata" data-type="input-textbox" class="form-textbox validate[required, AlphaNumeric]" data-defaultvalue=""
            style="width:310px" size="310" placeholder="1992" data-component="textbox" aria-labelledby="label_17" required="" value=""> </div>
      </li>
      <li class="form-line jf-required" data-type="control_dropdown" id="id_27"><label class="form-label form-label-right form-label-auto" id="label_27" for="input_27" aria-hidden="false"> Classe di merito<span class="form-required">*</span> </label>
        <div id="cid_27" class="form-input jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><select class="form-dropdown validate[required] is-active" id="input_27" name="q27_classeDi"
              style="width:310px" data-component="dropdown" required="" aria-label="Classe di merito">
              <option value="">Seleziona</option>
              <option selected="" value="Prima assicurazione dopo voltura">Prima assicurazione dopo voltura</option>
              <option value="1 Classe da oltre un anno">1 Classe da oltre un anno</option>
              <option value="2 Classe di merito">2 Classe di merito</option>
              <option value="3 Classe di merito">3 Classe di merito</option>
              <option value="4 Classe di merito">4 Classe di merito</option>
              <option value="5 Classe di merito">5 Classe di merito</option>
              <option value="6 Classe di merito">6 Classe di merito</option>
              <option value="7 Classe di merito">7 Classe di merito</option>
              <option value="8 Classe di merito">8 Classe di merito</option>
              <option value="9 Classe di merito">9 Classe di merito</option>
              <option value="10 Classe di merito">10 Classe di merito</option>
              <option value="11 Classe di merito">11 Classe di merito</option>
              <option value="12 Classe di merito">12 Classe di merito</option>
              <option value="13 Classe di merito">13 Classe di merito</option>
              <option value="14 Classe di merito">14 Classe di merito</option>
              <option value=""></option>
            </select><label class="form-sub-label" for="input_27" id="sublabel_input_27" style="min-height:13px">Indicaci la tua classe di merito</label></span> </div>
      </li>
      <li class="form-line jf-required" data-type="control_datetime" id="id_19"><label class="form-label form-label-right form-label-auto" id="label_19" for="lite_mode_19" aria-hidden="false"> Data inizio copertura della polizza<span
            class="form-required">*</span> </label>
        <div id="cid_19" class="form-input jf-required" data-layout="half">
          <div data-wrapper-react="true">
            <div style="display:none"><span class="form-sub-label-container" style="vertical-align:top"><input type="tel" class="currentDate form-textbox validate[required, disallowPast, limitDate]" id="day_19" name="q19_dataInizio[day]" size="2"
                  data-maxlength="2" data-age="" maxlength="2" value="04" required="" autocomplete="off" aria-labelledby="label_19 sublabel_19_day" inputmode="numeric"><span class="date-separate" aria-hidden="true">&nbsp;/</span><label
                  class="form-sub-label" for="day_19" id="sublabel_19_day" style="min-height:13px">Giorno</label></span><span class="form-sub-label-container" style="vertical-align:top"><input type="tel"
                  class="form-textbox validate[required, disallowPast, limitDate]" id="month_19" name="q19_dataInizio[month]" size="2" data-maxlength="2" data-age="" maxlength="2" value="04" required="" autocomplete="off"
                  aria-labelledby="label_19 sublabel_19_month" inputmode="numeric"><span class="date-separate" aria-hidden="true">&nbsp;/</span><label class="form-sub-label" for="month_19" id="sublabel_19_month"
                  style="min-height:13px">Mese</label></span><span class="form-sub-label-container" style="vertical-align:top"><input type="tel" class="form-textbox validate[required, disallowPast, limitDate]" id="year_19" name="q19_dataInizio[year]"
                  size="4" data-maxlength="4" data-age="" maxlength="4" value="2024" required="" autocomplete="off" aria-labelledby="label_19 sublabel_19_year"><label class="form-sub-label" for="year_19" id="sublabel_19_year"
                  style="min-height:13px">Anno</label></span></div><span class="form-sub-label-container" style="vertical-align:top"><input type="text" class="form-textbox validate[required, disallowPast, limitDate, validateLiteDate]"
                id="lite_mode_19" size="12" data-maxlength="12" data-age="" value="04/04/2024" required="" data-format="ddmmyyyy" data-seperator="/" placeholder="GG/MM/AAAA" data-placeholder="DD/MM/YYYY" autocomplete="off"
                aria-labelledby="label_19 sublabel_19_litemode" inputmode="numeric"><img class=" newDefaultTheme-dateIcon icon-liteMode" alt="Scegli una Data" id="input_19_pick" src="https://cdn.jotfor.ms/images/calendar.png"
                data-component="datetime" aria-hidden="true" data-allow-time="No" data-version="v2"><label class="form-sub-label" for="lite_mode_19" id="sublabel_19_litemode" style="min-height:13px">Data inizio copertura della polizza
                assicurativa.</label></span>
          </div>
        </div>
      </li>
      <li id="cid_74" class="form-input-wide" data-type="control_pagebreak">
        <div class="form-pagebreak" data-component="pagebreak">
          <div class="form-pagebreak-back-container"></div>
          <div class="form-pagebreak-next-container"><button id="form-pagebreak-next_74" type="button" class="form-pagebreak-next  jf-form-buttons" data-component="pagebreak-next">Continua</button></div>
          <div style="clear:both" class="pageInfo form-sub-label" id="pageInfo_74"></div>
        </div>
      </li>
    </ul>
    <ul class="form-section page-section" style="display:none;">
      <li id="cid_91" class="form-input-wide" data-type="control_head">
        <div class="form-header-group  header-default">
          <div class="header-text httac htvam">
            <h2 id="header_91" class="form-header" data-component="header">Pronto a partire?! Inserisci la targa</h2>
          </div>
        </div>
      </li>
      <li class="form-line fixed-width jf-required" data-type="control_textbox" id="id_14"><label class="form-label form-label-right form-label-auto" id="label_14" for="input_14" aria-hidden="false"> Targa<span class="form-required">*</span> </label>
        <div id="cid_14" class="form-input jf-required" data-layout="half"> <input type="text" id="input_14" name="q14_targa" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" style="width:110px" size="110"
            placeholder="DA123AA" data-component="textbox" aria-labelledby="label_14" required="" value=""> </div>
      </li>
      <li class="form-line jf-required" data-type="control_radio" id="id_97"><label class="form-label form-label-right form-label-auto" id="label_97" aria-hidden="false"> Tipo di Guida<span class="form-required">*</span> </label>
        <div id="cid_97" class="form-input jf-required" data-layout="full">
          <div class="form-single-column" role="group" aria-labelledby="label_97" data-component="radio"><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_97"
                class="form-radio validate[required]" id="input_97_0" name="q97_tipoDi" value="Guida Libera" required=""><label id="label_input_97_0" for="input_97_0">Guida Libera</label></span><span class="form-radio-item" style="clear:left"><span
                class="dragger-item"></span><input type="radio" aria-describedby="label_97" class="form-radio validate[required]" id="input_97_1" name="q97_tipoDi" value="Guida Esperta" required=""><label id="label_input_97_1" for="input_97_1">Guida
                Esperta</label></span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_97" class="form-radio validate[required]" id="input_97_2" name="q97_tipoDi"
                value="Neopatentati" required=""><label id="label_input_97_2" for="input_97_2">Neopatentati</label></span></div>
        </div>
      </li>
      <li id="cid_90" class="form-input-wide" data-type="control_pagebreak">
        <div class="form-pagebreak" data-component="pagebreak">
          <div class="form-pagebreak-back-container"><button id="form-pagebreak-back_90" type="button" class="form-pagebreak-back  jf-form-buttons" data-component="pagebreak-back">Indietro</button></div>
          <div class="form-pagebreak-next-container"><button id="form-pagebreak-next_90" type="button" class="form-pagebreak-next  jf-form-buttons" data-component="pagebreak-next">Continua</button></div>
          <div style="clear:both" class="pageInfo form-sub-label" id="pageInfo_90"></div>
        </div>
      </li>
    </ul>
    <ul class="form-section page-section" style="display:none;">
      <li id="cid_80" class="form-input-wide" data-type="control_head">
        <div class="form-header-group  header-default">
          <div class="header-text httac htvam">
            <h2 id="header_80" class="form-header" data-component="header">Dati Assicurativi</h2>
          </div>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_dropdown" id="id_75"><label class="form-label form-label-right form-label-auto" id="label_75" for="input_75" aria-hidden="false"> Durata:<span class="form-required">*</span> </label>
        <div id="cid_75" class="form-input jf-required" data-layout="half"> <select class="form-dropdown validate[required]" id="input_75" name="q75_durata" style="width:310px" data-component="dropdown" required="" aria-label="Durata:">
            <option value="">Scegli la durata da assicurare </option>
            <option value="1 Giorno">1 Giorno</option>
            <option value="3 Giorni">3 Giorni</option>
            <option value="5 Giorni">5 Giorni</option>
            <option value="7 Giorni">7 Giorni</option>
            <option value="10 Giorni">10 Giorni</option>
            <option value="15 Giorni">15 Giorni</option>
            <option value="21 Giorni">21 Giorni</option>
            <option value="30 Giorni">30 Giorni</option>
            <option value="60 Giorni">60 Giorni</option>
            <option value="90 Giorni">90 Giorni</option>
            <option value="120 Giorni">120 Giorni</option>
            <option value="Semestrale">Semestrale</option>
            <option value="Annuale">Annuale</option>
          </select> </div>
      </li>
      <li class="form-line always-hidden" data-type="control_textbox" id="id_82"><label class="form-label form-label-right form-label-auto" id="label_82" for="input_82" aria-hidden="false"> Costo : </label>
        <div id="cid_82" class="form-input always-hidden" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_82" name="q82_costo" data-type="input-textbox"
              class="form-readonly form-textbox" data-defaultvalue="" style="width:310px" size="310" tabindex="-1" data-component="textbox" aria-labelledby="label_82 sublabel_input_82" readonly="" value=""><label class="form-sub-label" for="input_82"
              id="sublabel_input_82" style="min-height:13px">Le verrà spedito un riepilogo del preventivo via mail.</label></span> </div>
      </li>
      <li class="form-line jf-required" data-type="control_radio" id="id_3"><label class="form-label form-label-right form-label-auto" id="label_3" aria-hidden="false"> Il contraente è :<span class="form-required">*</span> </label>
        <div id="cid_3" class="form-input jf-required" data-layout="full">
          <div class="form-multiple-column" data-columncount="3" role="group" aria-labelledby="label_3" data-component="radio"><span class="form-radio-item"><span class="dragger-item"></span><input type="radio" aria-describedby="label_3"
                class="form-radio validate[required]" id="input_3_0" name="q3_ilContraente" value="Maschio" required=""><label id="label_input_3_0" for="input_3_0">Maschio</label></span><span class="form-radio-item"><span
                class="dragger-item"></span><input type="radio" aria-describedby="label_3" class="form-radio validate[required]" id="input_3_1" name="q3_ilContraente" value="Femmina" required=""><label id="label_input_3_1"
                for="input_3_1">Femmina</label></span><span class="form-radio-item"><span class="dragger-item"></span><input type="radio" aria-describedby="label_3" class="form-radio validate[required]" id="input_3_2" name="q3_ilContraente"
                value="Persona Giuridica" required=""><label id="label_input_3_2" for="input_3_2">Persona Giuridica</label></span></div>
        </div>
      </li>
      <li class="form-line fixed-width" data-type="control_dropdown" id="id_11"><label class="form-label form-label-right form-label-auto" id="label_11" for="input_11" aria-hidden="false"> Professione : </label>
        <div id="cid_11" class="form-input" data-layout="half"> <select class="form-dropdown is-active" id="input_11" name="q11_professione" style="width:255px" data-component="dropdown" aria-label="Professione :">
            <option value="">Seleziona</option>
            <option selected="" value="Impiegato">Impiegato</option>
            <option value="Operaio">Operaio</option>
            <option value="Pensionato">Pensionato</option>
            <option value="Casalinga">Casalinga</option>
            <option value="In cerca di occupazione">In cerca di occupazione</option>
            <option value="Casalinga">Casalinga</option>
            <option value="Forze Armate">Forze Armate</option>
            <option value="Artigiano">Artigiano</option>
            <option value="Insegnante">Insegnante</option>
            <option value="Commerciante">Commerciante</option>
            <option value="Imprenditore">Imprenditore</option>
            <option value="Personale Medico">Personale Medico</option>
            <option value="Dirigente">Dirigente</option>
            <option value="Studente">Studente</option>
            <option value="Agente di Commercio - Rappresentante">Agente di Commercio - Rappresentante</option>
            <option value="Libero Professionista">Libero Professionista</option>
            <option value="Ecclesiastico">Ecclesiastico</option>
          </select> </div>
      </li>
      <li class="form-line jf-required" data-type="control_textbox" id="id_92"><label class="form-label form-label-right form-label-auto" id="label_92" for="input_92" aria-hidden="false"> Quanto pagava con la scorsa compagnia?:<span
            class="form-required">*</span> </label>
        <div id="cid_92" class="form-input jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_92" name="q92_quantoPagava" data-type="input-textbox"
              class="form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310" placeholder="1.200€" data-component="textbox" aria-labelledby="label_92 sublabel_input_92" required="" value=""><label class="form-sub-label"
              for="input_92" id="sublabel_input_92" style="min-height:13px">Esempio : Pagavo 1.200€</label></span> </div>
      </li>
      <li class="form-line jf-required" data-type="control_radio" id="id_12"><label class="form-label form-label-right form-label-auto" id="label_12" aria-hidden="false"> Il veicolo è già di tua proprietà?<span class="form-required">*</span> </label>
        <div id="cid_12" class="form-input jf-required" data-layout="full">
          <div class="form-multiple-column" data-columncount="2" role="group" aria-labelledby="label_12" data-component="radio"><span class="form-radio-item"><span class="dragger-item"></span><input type="radio" aria-describedby="label_12"
                class="form-radio validate[required]" id="input_12_0" name="q12_ilVeicolo" value="Si" required=""><label id="label_input_12_0" for="input_12_0">Si</label></span><span class="form-radio-item"><span class="dragger-item"></span><input
                type="radio" aria-describedby="label_12" class="form-radio validate[required]" id="input_12_1" name="q12_ilVeicolo" value="Ancora devo acquistarlo" required=""><label id="label_input_12_1" for="input_12_1">Ancora devo
                acquistarlo</label></span></div>
        </div>
      </li>
      <li id="cid_86" class="form-input-wide" data-type="control_pagebreak">
        <div class="form-pagebreak" data-component="pagebreak">
          <div class="form-pagebreak-back-container"><button id="form-pagebreak-back_86" type="button" class="form-pagebreak-back  jf-form-buttons" data-component="pagebreak-back">Indietro</button></div>
          <div class="form-pagebreak-next-container"><button id="form-pagebreak-next_86" type="button" class="form-pagebreak-next  jf-form-buttons" data-component="pagebreak-next">Continua</button></div>
          <div style="clear:both" class="pageInfo form-sub-label" id="pageInfo_86"></div>
        </div>
      </li>
    </ul>
    <ul class="form-section page-section" style="display:none;">
      <li id="cid_87" class="form-input-wide" data-type="control_head">
        <div class="form-header-group  header-default">
          <div class="header-text httac htvam">
            <h2 id="header_87" class="form-header" data-component="header">Garanzie</h2>
          </div>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_checkbox" id="id_88"><label class="form-label form-label-right form-label-auto" id="label_88" aria-hidden="false"> Scegli le garanzie da aggiungere :<span class="form-required">*</span>
        </label>
        <div id="cid_88" class="form-input jf-required" data-layout="full">
          <div class="form-single-column" role="group" aria-labelledby="label_88" data-component="checkbox"><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input type="checkbox" aria-describedby="label_88"
                class="form-checkbox validate[required]" id="input_88_0" name="q88_scegliLe[]" value="Assistenza Stradale" required=""><label id="label_input_88_0" for="input_88_0">Assistenza Stradale</label></span><span class="form-checkbox-item"
              style="clear:left"><span class="dragger-item"></span><input type="checkbox" aria-describedby="label_88" class="form-checkbox validate[required]" id="input_88_1" name="q88_scegliLe[]" value="Tutela legale" required=""><label
                id="label_input_88_1" for="input_88_1">Tutela legale</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input type="checkbox" aria-describedby="label_88"
                class="form-checkbox validate[required]" id="input_88_2" name="q88_scegliLe[]" value="Infortuni al conducente" required=""><label id="label_input_88_2" for="input_88_2">Infortuni al conducente</label></span><span
              class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input type="checkbox" aria-describedby="label_88" class="form-checkbox validate[required]" id="input_88_3" name="q88_scegliLe[]"
                value="Incendio &amp; Furto" required=""><label id="label_input_88_3" for="input_88_3">Incendio &amp; Furto</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input type="checkbox"
                aria-describedby="label_88" class="form-checkbox validate[required]" id="input_88_4" name="q88_scegliLe[]" value="Contro veic. non assicurati" required=""><label id="label_input_88_4" for="input_88_4">Contro veic. non
                assicurati</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input type="checkbox" aria-describedby="label_88" class="form-checkbox validate[required]" id="input_88_5"
                name="q88_scegliLe[]" value="Rinuncia alla rivalsa" required=""><label id="label_input_88_5" for="input_88_5">Rinuncia alla rivalsa</label></span><span class="form-checkbox-item" style="clear:left"><span
                class="dragger-item"></span><input type="checkbox" aria-describedby="label_88" class="form-checkbox validate[required]" id="input_88_6" name="q88_scegliLe[]" value="Kasko" required=""><label id="label_input_88_6"
                for="input_88_6">Kasko</label></span><span class="form-checkbox-item" style="clear:left"><span class="dragger-item"></span><input type="checkbox" aria-describedby="label_88" class="form-checkbox validate[required]" id="input_88_7"
                name="q88_scegliLe[]" value="Mini Kasko" required=""><label id="label_input_88_7" for="input_88_7">Mini Kasko</label></span><span class="form-checkbox-item formCheckboxOther" style="clear:left"><input type="checkbox"
                class="form-checkbox-other form-checkbox validate[required]" name="q88_scegliLe[other]" id="other_88" value="other" tabindex="0" aria-label="Altro"><label id="label_other_88" style="text-indent:0" for="other_88">Altro</label><span
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        <div id="cid_89" class="form-input" data-layout="half"> <input type="text" id="input_89" name="q89_valoreDa" data-type="input-textbox" class="form-textbox validate[minCharLimit]" data-defaultvalue="" style="width:230px" size="230"
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        <div id="cid_23" class="form-input jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_23" name="q23_contraente" data-type="input-textbox"
              class="form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310" placeholder="Nome o Denominazione sociale" data-component="textbox" aria-labelledby="label_23 sublabel_input_23" required="" value=""><label
              class="form-sub-label" for="input_23" id="sublabel_input_23" style="min-height:13px">Nome e Cognome o Denominazione sociale</label></span> </div>
      </li>
      <li class="form-line jf-required" data-type="control_datetime" id="id_63"><label class="form-label form-label-right form-label-auto" id="label_63" for="lite_mode_63" aria-hidden="false"> Data di nascita<span class="form-required">*</span>
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        <div id="cid_63" class="form-input jf-required" data-layout="half">
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                  maxlength="2" value="" required="" autocomplete="off" aria-labelledby="label_63 sublabel_63_day" inputmode="numeric"><span class="date-separate" aria-hidden="true">&nbsp;/</span><label class="form-sub-label" for="day_63"
                  id="sublabel_63_day" style="min-height:13px">Giorno</label></span><span class="form-sub-label-container" style="vertical-align:top"><input type="tel" class="form-textbox validate[required, limitDate]" id="month_63"
                  name="q63_dataDi63[month]" size="2" data-maxlength="2" data-age="" maxlength="2" value="" required="" autocomplete="off" aria-labelledby="label_63 sublabel_63_month" inputmode="numeric"><span class="date-separate"
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            class="form-required">*</span> </label>
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      </li>
      <li class="form-line jf-required" data-type="control_email" id="id_25"><label class="form-label form-label-right form-label-auto" id="label_25" for="input_25" aria-hidden="false"> Email<span class="form-required">*</span> </label>
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              class="form-sub-label" for="input_25" id="sublabel_input_25" style="min-height:13px">esempio@esempio.com</label></span> </div>
      </li>
      <li class="form-line jf-required" data-type="control_address" id="id_79" data-compound-hint="Viale Innocenzo XI,,Roma,,00100,"><label class="form-label form-label-top" id="label_79" for="input_79_addr_line1" aria-hidden="false"> Residenza o
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                    id="input_79_addr_line1" name="q79_residenzaO[addr_line1]" class="form-textbox validate[required] form-address-line" data-defaultvalue="" autocomplete="section-input_79 address-line1" placeholder="Viale Innocenzo XI"
                    data-component="address_line_1" aria-labelledby="label_79 sublabel_79_addr_line1" required="" value="" maxlength="100"><label class="form-sub-label" for="input_79_addr_line1" id="sublabel_79_addr_line1"
                    style="min-height:13px">Indirizzo e civico</label></span></span></div>
            <div class="form-address-line-wrapper jsTest-address-line-wrapperField" style="display:none"><span class="form-address-line form-address-street-line jsTest-address-lineField"><span class="form-sub-label-container"
                  style="vertical-align:top"><input type="text" id="input_79_addr_line2" name="q79_residenzaO[addr_line2]" class="form-textbox form-address-line" data-defaultvalue="" autocomplete="section-input_79 off" data-component="address_line_2"
                    aria-labelledby="label_79 sublabel_79_addr_line2" required="" value="" maxlength="100"><label class="form-sub-label" for="input_79_addr_line2" id="sublabel_79_addr_line2" style="min-height:13px">Indirizzo Riga
                    2</label></span></span></div>
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                    aria-labelledby="label_79 sublabel_79_postal" required="" value="" maxlength="20"><label class="form-sub-label" for="input_79_postal" id="sublabel_79_postal" style="min-height:13px">Codice Postale</label></span></span></div>
          </div>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_phone" id="id_26" data-compound-hint="328 000 0000"><label class="form-label form-label-right form-label-auto" id="label_26" for="input_26_full"> Numero Cellulare<span
            class="form-required">*</span> </label>
        <div id="cid_26" class="form-input jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="tel" id="input_26_full" name="q26_numeroCellulare[full]" data-type="mask-number"
              class="mask-phone-number form-textbox validate[required, Fill Mask]" data-defaultvalue="" autocomplete="section-input_26 tel-national" style="width:310px" data-masked="true" placeholder="328 000 0000" data-component="phone"
              aria-labelledby="label_26 sublabel_26_masked" required="" value="" inputmode="text" maskvalue="##########"><label class="form-sub-label" for="input_26_full" id="sublabel_26_masked" style="min-height:13px">Si prega di inserire un numero
              di telefono valido.</label></span> </div>
      </li>
      <li class="form-line" data-type="control_divider" id="id_72">
        <div id="cid_72" class="form-input-wide" data-layout="full">
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            <div class="form-pagebreak-back-container"><button id="form-pagebreak-back_74" type="button" class="form-pagebreak-back jf-form-buttons" data-component="pagebreak-back">Indietro</button></div><button id="input_81" type="submit"
              class="form-submit-button submit-button jf-form-buttons jsTest-submitField" data-component="button" data-content="" aria-live="polite" disabled="">Richiedi preventivo</button>
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      </li>
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Text Content

 * Dati Veicolo*
   Scegli il veicolo da assicurare Autovettura Autocarro Autotassametro
   Ciclomotore Motociclo Caravan Quad Microcar Quadriciclo Leggero Macchina
   Agricola Targa Prova Targa Export
 * Marca
   
 * Modello
   
 * Cilindrata*
   
 * Classe di merito*
   Seleziona Prima assicurazione dopo voltura 1 Classe da oltre un anno 2 Classe
   di merito 3 Classe di merito 4 Classe di merito 5 Classe di merito 6 Classe
   di merito 7 Classe di merito 8 Classe di merito 9 Classe di merito 10 Classe
   di merito 11 Classe di merito 12 Classe di merito 13 Classe di merito 14
   Classe di merito Indicaci la tua classe di merito
 * Data inizio copertura della polizza*
    /Giorno /MeseAnno
   Data inizio copertura della polizza assicurativa.
 * Continua
   


 * PRONTO A PARTIRE?! INSERISCI LA TARGA

 * Targa*
   
 * Tipo di Guida*
   Guida LiberaGuida EspertaNeopatentati
 * Indietro
   Continua
   


 * DATI ASSICURATIVI

 * Durata:*
   Scegli la durata da assicurare 1 Giorno 3 Giorni 5 Giorni 7 Giorni 10 Giorni
   15 Giorni 21 Giorni 30 Giorni 60 Giorni 90 Giorni 120 Giorni Semestrale
   Annuale
 * Costo :
   Le verrà spedito un riepilogo del preventivo via mail.
 * Il contraente è :*
   MaschioFemminaPersona Giuridica
 * Professione :
   Seleziona Impiegato Operaio Pensionato Casalinga In cerca di occupazione
   Casalinga Forze Armate Artigiano Insegnante Commerciante Imprenditore
   Personale Medico Dirigente Studente Agente di Commercio - Rappresentante
   Libero Professionista Ecclesiastico
 * Quanto pagava con la scorsa compagnia?:*
   Esempio : Pagavo 1.200€
 * Il veicolo è già di tua proprietà?*
   SiAncora devo acquistarlo
 * Indietro
   Continua
   


 * GARANZIE

 * Scegli le garanzie da aggiungere :*
   Assistenza StradaleTutela legaleInfortuni al conducenteIncendio & FurtoContro
   veic. non assicuratiRinuncia alla rivalsaKaskoMini KaskoAltro
 * Valore da assicurare :
   
 * Indietro
   Continua
   


 * DATI CONTRAENTE

 * Contraente :*
   Nome e Cognome o Denominazione sociale
 * Data di nascita*
    /Giorno /MeseAnno
   Data
 * Codice fiscale / Partita Iva*
   
 * Email*
   esempio@esempio.com
 * Residenza o Sede Legale :*
   Indirizzo e civico
   Indirizzo Riga 2
   ComuneNazione / Provincia
   Codice Postale
 * Numero Cellulare*
   Si prega di inserire un numero di telefono valido.
 * 
 * Indietro
   Richiedi preventivo
 * Should be Empty:

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