{"id":371,"date":"2025-03-09T17:39:35","date_gmt":"2025-03-09T17:39:35","guid":{"rendered":"https:\/\/www.mcs.co.mz\/en\/?page_id=371"},"modified":"2025-03-09T17:39:56","modified_gmt":"2025-03-09T17:39:56","slug":"form-acidentes-pessoais","status":"publish","type":"page","link":"https:\/\/www.mcs.co.mz\/en\/form-acidentes-pessoais\/","title":{"rendered":"Form Acidentes Pessoais"},"content":{"rendered":"<div class=\"forminator-ui forminator-custom-form forminator-custom-form-342 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-342\" data-uid=\"69f27f65506f4\"><br\/><\/div><form\r\n\t\t\t\tid=\"forminator-module-342\"\r\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-342 forminator-design--default  forminator_ajax\"\r\n\t\t\t\tmethod=\"post\"\r\n\t\t\t\tdata-forminator-render=\"0\"\r\n\t\t\t\tdata-form-id=\"342\"\r\n\t\t\t\t\r\n\t\t\t\tdata-design=\"default\"\r\n\t\t\t\t\r\n\t\t\t\t\r\n\t\t\t\t\r\n\t\t\t\tdata-grid=\"open\"\r\n\t\t\t\tenctype=\"multipart\/form-data\"\r\n\t\t\t\t\r\n\t\t\t\tstyle=\"display: none;\"\r\n\t\t\t\t\r\n\t\t\t\tdata-uid=\"69f27f65506f4\"\r\n\t\t\t><div role=\"alert\" aria-live=\"polite\" class=\"forminator-response-message forminator-error\" aria-hidden=\"true\"><\/div><div class=\"forminator-row\"><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69f27f65506f4\" id=\"forminator-field-date-1-picker_69f27f65506f4-label\" class=\"forminator-label\">Entry date<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_69f27f65506f4\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd-mm-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-4 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-69f27f65506f4-label\"><span id=\"forminator-checkbox-group-69f27f65506f4-label\" class=\"forminator-label\">Modality\/pruduct<\/span><label id=\"forminator-field-checkbox-1-1-69f27f65506f4-label\" for=\"forminator-field-checkbox-1-1-69f27f65506f4\" class=\"forminator-checkbox\" title=\"Professional risks\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-69f27f65506f4\" aria-labelledby=\"forminator-field-checkbox-1-1-69f27f65506f4-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Professional risks<\/span><\/label><label id=\"forminator-field-checkbox-1-2-69f27f65506f4-label\" for=\"forminator-field-checkbox-1-2-69f27f65506f4\" class=\"forminator-checkbox\" title=\"Extra-prodessional\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"two\" id=\"forminator-field-checkbox-1-2-69f27f65506f4\" aria-labelledby=\"forminator-field-checkbox-1-2-69f27f65506f4-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Extra-prodessional<\/span><\/label><\/div><\/div><div id=\"number-1\" class=\"forminator-field-number forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-1_69f27f65506f4\" id=\"forminator-field-number-1_69f27f65506f4-label\" class=\"forminator-label\">Policy No<\/label><input name=\"number-1\" value=\"\" placeholder=\"E.g. 10\" id=\"forminator-field-number-1_69f27f65506f4\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"150\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"html-1\" class=\"forminator-field-html forminator-col forminator-col-12 \"><div class=\"forminator-field forminator-merge-tags\" data-field=\"html-1\"><p>Personal accident claim<\/p><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69f27f65506f4\" id=\"forminator-field-text-1_69f27f65506f4-label\" class=\"forminator-label\">Broker code<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"E.g. text placeholder\" id=\"forminator-field-text-1_69f27f65506f4\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-6 \"><div class=\"forminator-row\"><div id=\"address-1-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-1-street_address_69f27f65506f4\" id=\"forminator-field-address-1-street_address_69f27f65506f4-label\" class=\"forminator-label\">Branch<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"E.g. 42 Wallaby Way\" id=\"forminator-field-address-1-street_address_69f27f65506f4\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-1\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-1_69f27f65506f4\" id=\"forminator-field-name-1_69f27f65506f4-label\" class=\"forminator-label\">Broker\u2019s name<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"E.g. John Doe\" id=\"forminator-field-name-1_69f27f65506f4\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-2\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">1. Policyholder<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_69f27f65506f4\" id=\"forminator-field-name-2_69f27f65506f4-label\" class=\"forminator-label\">Name<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"E.g. John Doe\" id=\"forminator-field-name-2_69f27f65506f4\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-1\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">2. Injured person details (Insured person)<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_69f27f65506f4\" id=\"forminator-field-name-3_69f27f65506f4-label\" class=\"forminator-label\">Full name<\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"E.g. John Doe\" id=\"forminator-field-name-3_69f27f65506f4\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-2\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-2-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-2-street_address_69f27f65506f4\" id=\"forminator-field-address-2-street_address_69f27f65506f4-label\" class=\"forminator-label\">Street Address<\/label><input type=\"text\" name=\"address-2-street_address\" placeholder=\"E.g. 42 Wallaby Way\" id=\"forminator-field-address-2-street_address_69f27f65506f4\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-3\" class=\"forminator-field-address forminator-col forminator-col-6 \"><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-3-city\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-3-city_69f27f65506f4\" id=\"forminator-field-address-3-city_69f27f65506f4-label\" class=\"forminator-label\">City \/ Town<\/label><input type=\"text\" name=\"address-3-city\" placeholder=\"E.g. Sydney\" id=\"forminator-field-address-3-city_69f27f65506f4\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><\/div><div id=\"address-4\" class=\"forminator-field-address forminator-col forminator-col-6 \"><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-4-zip\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-address-4-zip_69f27f65506f4\" id=\"forminator-field-address-4-zip_69f27f65506f4-label\" class=\"forminator-label\">Postal code<\/label><input type=\"text\" name=\"address-4-zip\" placeholder=\"E.g. 2000\" id=\"forminator-field-address-4-zip_69f27f65506f4\" class=\"forminator-input\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69f27f65506f4\" id=\"forminator-field-phone-1_69f27f65506f4-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-1_69f27f65506f4\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><div id=\"phone-2\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-2_69f27f65506f4\" id=\"forminator-field-phone-2_69f27f65506f4-label\" class=\"forminator-label\">Fax<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"E.g. +1 300 400 5000\" id=\"forminator-field-phone-2_69f27f65506f4\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-1\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-1_69f27f65506f4\" id=\"forminator-field-email-1_69f27f65506f4-label\" class=\"forminator-label\">Email<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"E.g. john@doe.com\" id=\"forminator-field-email-1_69f27f65506f4\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69f27f65506f4\" id=\"forminator-field-text-2_69f27f65506f4-label\" class=\"forminator-label\">Identity card \/ Personal ID<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"E.g. text placeholder\" id=\"forminator-field-text-2_69f27f65506f4\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"number-2\" class=\"forminator-field-number forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-2_69f27f65506f4\" id=\"forminator-field-number-2_69f27f65506f4-label\" class=\"forminator-label\">Tax ID (Nuit)<\/label><input name=\"number-2\" value=\"\" placeholder=\"E.g. 10\" id=\"forminator-field-number-2_69f27f65506f4\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"150\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_69f27f65506f4\" id=\"forminator-field-date-2-picker_69f27f65506f4-label\" class=\"forminator-label\">Date of birth<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-2\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-2-picker_69f27f65506f4\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd-mm-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-5\" class=\"forminator-field-number forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-5_69f27f65506f4\" id=\"forminator-field-number-5_69f27f65506f4-label\" class=\"forminator-label\">Bank account number (Nib)<\/label><input name=\"number-5\" value=\"\" placeholder=\"E.g. 10\" id=\"forminator-field-number-5_69f27f65506f4\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"150\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-1\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-1_69f27f65506f4\" id=\"forminator-field-upload-1_69f27f65506f4-label\" class=\"forminator-label\">Proof<\/label><div class=\"forminator-multi-upload \" data-element=\"upload-1_69f27f65506f4\"><input type=\"file\" name=\"upload-1[]\" id=\"forminator-field-upload-1_69f27f65506f4\" class=\"forminator-input-file forminator-field-upload-1_69f27f65506f4-342\" multiple=\"multiple\" data-method=\"ajax\" data-size=\"8000000\" data-size-message=\"Maximum file size allowed is 8 MB. \"><div class=\"forminator-multi-upload-message\" aria-hidden=\"true\"><span class=\"forminator-icon-upload\" aria-hidden=\"true\"><\/span><p>Drag and Drop (or) <a class=\"forminator-upload-file--forminator-field-upload-1_69f27f65506f4\" href=\"#\" onclick=\"return false;\">Choose Files<\/a><\/p><\/div><\/div><ul class=\"forminator-uploaded-files upload-container-upload-1_69f27f65506f4\"><\/ul><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-3\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">3. Accident description<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-3\" class=\"forminator-field-date forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-3-picker_69f27f65506f4\" id=\"forminator-field-date-3-picker_69f27f65506f4-label\" class=\"forminator-label\">Date of accident<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-3\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-3-picker_69f27f65506f4\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd-mm-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><div id=\"time-1\" class=\"forminator-field-time forminator-col forminator-col-4 \"><label for=\"forminator-field-time-1\" id=\"forminator-field-time-1-label\" class=\"forminator-label\">Time<\/label><div class=\"forminator-timepicker\" ><div class=\"forminator-row\" data-multiple=\"true\"><div id=\"time-1-hours\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><select name=\"time-1-hours\" id=\"forminator-field-342__field--time-1-hours_69f27f65506f4\" class=\"forminator-select2 time-hours \" data-field=\"hours\" data-default-value=\"\"><option value=\"\" selected=\"selected\">-<\/option><option value=\"0\" >00<\/option><option value=\"1\" >01<\/option><option value=\"2\" >02<\/option><option value=\"3\" >03<\/option><option value=\"4\" >04<\/option><option value=\"5\" >05<\/option><option value=\"6\" >06<\/option><option value=\"7\" >07<\/option><option value=\"8\" >08<\/option><option value=\"9\" >09<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><\/select><\/div><\/div><div id=\"time-1-minutes\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><select name=\"time-1-minutes\" id=\"forminator-field-342__field--time-1-minutes_69f27f65506f4\" class=\"forminator-select2 time-minutes \" data-field=\"minutes\" data-default-value=\"\"><option value=\"\" selected=\"selected\">-<\/option><option value=\"0\" >00<\/option><option value=\"1\" >01<\/option><option value=\"2\" >02<\/option><option value=\"3\" >03<\/option><option value=\"4\" >04<\/option><option value=\"5\" >05<\/option><option value=\"6\" >06<\/option><option value=\"7\" >07<\/option><option value=\"8\" >08<\/option><option value=\"9\" >09<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><option value=\"32\" >32<\/option><option value=\"33\" >33<\/option><option value=\"34\" >34<\/option><option value=\"35\" >35<\/option><option value=\"36\" >36<\/option><option value=\"37\" >37<\/option><option value=\"38\" >38<\/option><option value=\"39\" >39<\/option><option value=\"40\" >40<\/option><option value=\"41\" >41<\/option><option value=\"42\" >42<\/option><option value=\"43\" >43<\/option><option value=\"44\" >44<\/option><option value=\"45\" >45<\/option><option value=\"46\" >46<\/option><option value=\"47\" >47<\/option><option value=\"48\" >48<\/option><option value=\"49\" >49<\/option><option value=\"50\" >50<\/option><option value=\"51\" >51<\/option><option value=\"52\" >52<\/option><option value=\"53\" >53<\/option><option value=\"54\" >54<\/option><option value=\"55\" >55<\/option><option value=\"56\" >56<\/option><option value=\"57\" >57<\/option><option value=\"58\" >58<\/option><option value=\"59\" >59<\/option><\/select><\/div><\/div><\/div><\/div><\/div><div id=\"address-5\" class=\"forminator-field-address forminator-col forminator-col-4 \"><div class=\"forminator-row\"><div id=\"address-5-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-5-street_address_69f27f65506f4\" id=\"forminator-field-address-5-street_address_69f27f65506f4-label\" class=\"forminator-label\">Place of accident<\/label><input type=\"text\" name=\"address-5-street_address\" placeholder=\"E.g. 42 Wallaby Way\" id=\"forminator-field-address-5-street_address_69f27f65506f4\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-1\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-1_69f27f65506f4\" id=\"forminator-field-textarea-1_69f27f65506f4-label\" class=\"forminator-label\">Damages incurred \/ suffered<\/label><textarea name=\"textarea-1\" placeholder=\"E.g. text placeholder\nYou can add new line\" id=\"forminator-field-textarea-1_69f27f65506f4\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-2\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-2_69f27f65506f4\" id=\"forminator-field-textarea-2_69f27f65506f4-label\" class=\"forminator-label\">Detailed description of the accident (if necessary, use page 2)<\/label><textarea name=\"textarea-2\" placeholder=\"E.g. text placeholder\nYou can add new line\" id=\"forminator-field-textarea-2_69f27f65506f4\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f27f65506f4-label\"><span id=\"forminator-radiogroup-69f27f65506f4-label\" class=\"forminator-label\">Is the accident related to your profession?<\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-69f27f65506f4\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-69f27f65506f4\" aria-labelledby=\"forminator-field-radio-1-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-69f27f65506f4\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-69f27f65506f4\" aria-labelledby=\"forminator-field-radio-1-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-2\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f27f65506f4-label\"><span id=\"forminator-radiogroup-69f27f65506f4-label\" class=\"forminator-label\">Is the accident covered by any work accident policy?<\/span><label id=\"forminator-field-radio-2-label-1\" for=\"forminator-field-radio-2-1-69f27f65506f4\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-2\" value=\"one\" id=\"forminator-field-radio-2-1-69f27f65506f4\" aria-labelledby=\"forminator-field-radio-2-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-2-label-2\" for=\"forminator-field-radio-2-2-69f27f65506f4\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-2\" value=\"two\" id=\"forminator-field-radio-2-2-69f27f65506f4\" aria-labelledby=\"forminator-field-radio-2-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69f27f65506f4\" id=\"forminator-field-text-3_69f27f65506f4-label\" class=\"forminator-label\">Which company<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"E.g. text placeholder\" id=\"forminator-field-text-3_69f27f65506f4\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_69f27f65506f4\" id=\"forminator-field-text-4_69f27f65506f4-label\" class=\"forminator-label\">Policy number and\/or employer\u2019s name<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"E.g. text placeholder\" id=\"forminator-field-text-4_69f27f65506f4\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-3\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f27f65506f4-label\"><span id=\"forminator-radiogroup-69f27f65506f4-label\" class=\"forminator-label\">Does the accident have another personal accident insurance covering medical expenses?<\/span><label id=\"forminator-field-radio-3-label-1\" for=\"forminator-field-radio-3-1-69f27f65506f4\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-3\" value=\"one\" id=\"forminator-field-radio-3-1-69f27f65506f4\" aria-labelledby=\"forminator-field-radio-3-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-3-label-2\" for=\"forminator-field-radio-3-2-69f27f65506f4\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-3\" value=\"two\" id=\"forminator-field-radio-3-2-69f27f65506f4\" aria-labelledby=\"forminator-field-radio-3-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><div id=\"text-5\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-5_69f27f65506f4\" id=\"forminator-field-text-5_69f27f65506f4-label\" class=\"forminator-label\">Which company<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"E.g. text placeholder\" id=\"forminator-field-text-5_69f27f65506f4\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_69f27f65506f4\" id=\"forminator-field-text-6_69f27f65506f4-label\" class=\"forminator-label\">Policy number?<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"E.g. text placeholder\" id=\"forminator-field-text-6_69f27f65506f4\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"number-3\" class=\"forminator-field-number forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-3_69f27f65506f4\" id=\"forminator-field-number-3_69f27f65506f4-label\" class=\"forminator-label\">What is the value?<\/label><input name=\"number-3\" value=\"\" placeholder=\"E.g. 10\" id=\"forminator-field-number-3_69f27f65506f4\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"150\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-4\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f27f65506f4-label\"><span id=\"forminator-radiogroup-69f27f65506f4-label\" class=\"forminator-label\">Traffic accident<\/span><label id=\"forminator-field-radio-4-label-1\" for=\"forminator-field-radio-4-1-69f27f65506f4\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-4\" value=\"one\" id=\"forminator-field-radio-4-1-69f27f65506f4\" aria-labelledby=\"forminator-field-radio-4-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-4-label-2\" for=\"forminator-field-radio-4-2-69f27f65506f4\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-4\" value=\"two\" id=\"forminator-field-radio-4-2-69f27f65506f4\" aria-labelledby=\"forminator-field-radio-4-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><div id=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_69f27f65506f4\" id=\"forminator-field-text-7_69f27f65506f4-label\" class=\"forminator-label\">If yes, provide vehicle license plate<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"E.g. text placeholder\" id=\"forminator-field-text-7_69f27f65506f4\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-3\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-3_69f27f65506f4\" id=\"forminator-field-textarea-3_69f27f65506f4-label\" class=\"forminator-label\">Names of passengers<\/label><textarea name=\"textarea-3\" placeholder=\"E.g. text placeholder\nYou can add new line\" id=\"forminator-field-textarea-3_69f27f65506f4\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"textarea-4\" class=\"forminator-field-textarea forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-textarea-4_69f27f65506f4\" id=\"forminator-field-textarea-4_69f27f65506f4-label\" class=\"forminator-label\">Identification of witnesses (if any)<\/label><textarea name=\"textarea-4\" placeholder=\"E.g. text placeholder\nYou can add new line\" id=\"forminator-field-textarea-4_69f27f65506f4\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-5\" class=\"forminator-field-radio forminator-col forminator-col-4 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f27f65506f4-label\"><span id=\"forminator-radiogroup-69f27f65506f4-label\" class=\"forminator-label\">Did the authorities record the occurrence?<\/span><label id=\"forminator-field-radio-5-label-1\" for=\"forminator-field-radio-5-1-69f27f65506f4\" class=\"forminator-radio\" title=\"Yes\"><input type=\"radio\" name=\"radio-5\" value=\"one\" id=\"forminator-field-radio-5-1-69f27f65506f4\" aria-labelledby=\"forminator-field-radio-5-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Yes<\/span><\/label><label id=\"forminator-field-radio-5-label-2\" for=\"forminator-field-radio-5-2-69f27f65506f4\" class=\"forminator-radio\" title=\"No\"><input type=\"radio\" name=\"radio-5\" value=\"two\" id=\"forminator-field-radio-5-2-69f27f65506f4\" aria-labelledby=\"forminator-field-radio-5-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">No<\/span><\/label><\/div><\/div><div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-4 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-69f27f65506f4-label\"><span id=\"forminator-checkbox-group-69f27f65506f4-label\" class=\"forminator-label\">\u200b \u200c \u200d \u1160 \u2060<\/span><label id=\"forminator-field-checkbox-2-1-69f27f65506f4-label\" for=\"forminator-field-checkbox-2-1-69f27f65506f4\" class=\"forminator-checkbox\" title=\"PRM\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"one\" id=\"forminator-field-checkbox-2-1-69f27f65506f4\" aria-labelledby=\"forminator-field-checkbox-2-1-69f27f65506f4-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">PRM<\/span><\/label><\/div><\/div><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-4 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_69f27f65506f4\" id=\"forminator-field-text-8_69f27f65506f4-label\" class=\"forminator-label\">Station \/ Unit \/ Precinct<\/label><input type=\"text\" name=\"text-8\" value=\"\" placeholder=\"E.g. text placeholder\" id=\"forminator-field-text-8_69f27f65506f4\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"number-4\" class=\"forminator-field-number forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-number-4_69f27f65506f4\" id=\"forminator-field-number-4_69f27f65506f4-label\" class=\"forminator-label\">Police report number<\/label><input name=\"number-4\" value=\"\" placeholder=\"E.g. 10\" id=\"forminator-field-number-4_69f27f65506f4\" class=\"forminator-input forminator-number--field\" inputmode=\"decimal\" data-required=\"\" data-decimals=\"0\" aria-required=\"false\" data-inputmask=\"&#039;groupSeparator&#039;: &#039;&#039;, &#039;radixPoint&#039;: &#039;&#039;, &#039;digits&#039;: &#039;0&#039;\" data-hidden-behavior=\"zero\" type=\"number\" step=\"any\" min=\"1\" max=\"150\" \/><\/div><\/div><div id=\"date-4\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-4-picker_69f27f65506f4\" id=\"forminator-field-date-4-picker_69f27f65506f4-label\" class=\"forminator-label\">Date<\/label><div class=\"forminator-input-with-icon\"><span class=\"forminator-icon-calendar\" aria-hidden=\"true\"><\/span><input autocomplete=\"off\" type=\"text\" size=\"1\" name=\"date-4\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-4-picker_69f27f65506f4\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"dd-mm-yy\" data-restrict-type=\"\" data-restrict=\"\" data-start-year=\"1926\" data-end-year=\"2126\" data-past-dates=\"enable\" data-start-of-week=\"1\" data-start-date=\"\" data-end-date=\"\" data-start-field=\"\" data-end-field=\"\" data-start-offset=\"\" data-end-offset=\"\" data-disable-date=\"\" data-disable-range=\"\" \/><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-4\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">4. Required documents depending on main coverages<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"radio-6\" class=\"forminator-field-radio forminator-col forminator-col-12 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f27f65506f4-label\"><span id=\"forminator-radiogroup-69f27f65506f4-label\" class=\"forminator-label\">Select type of expenses or compensation:<\/span><label id=\"forminator-field-radio-6-label-1\" for=\"forminator-field-radio-6-1-69f27f65506f4\" class=\"forminator-radio\" title=\"Medical expenses\"><input type=\"radio\" name=\"radio-6\" value=\"one\" id=\"forminator-field-radio-6-1-69f27f65506f4\" aria-labelledby=\"forminator-field-radio-6-label-1\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Medical expenses<\/span><\/label><label id=\"forminator-field-radio-6-label-2\" for=\"forminator-field-radio-6-2-69f27f65506f4\" class=\"forminator-radio\" title=\"Temporary disability\"><input type=\"radio\" name=\"radio-6\" value=\"two\" id=\"forminator-field-radio-6-2-69f27f65506f4\" aria-labelledby=\"forminator-field-radio-6-label-2\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Temporary disability<\/span><\/label><label id=\"forminator-field-radio-6-label-3\" for=\"forminator-field-radio-6-3-69f27f65506f4\" class=\"forminator-radio\" title=\"Hospitalization\"><input type=\"radio\" name=\"radio-6\" value=\"Hospitalization\" id=\"forminator-field-radio-6-3-69f27f65506f4\" aria-labelledby=\"forminator-field-radio-6-label-3\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Hospitalization<\/span><\/label><label id=\"forminator-field-radio-6-label-4\" for=\"forminator-field-radio-6-4-69f27f65506f4\" class=\"forminator-radio\" title=\"Partial permanent disability\"><input type=\"radio\" name=\"radio-6\" value=\"Partial-permanent-disability\" id=\"forminator-field-radio-6-4-69f27f65506f4\" aria-labelledby=\"forminator-field-radio-6-label-4\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Partial permanent disability<\/span><\/label><label id=\"forminator-field-radio-6-label-5\" for=\"forminator-field-radio-6-5-69f27f65506f4\" class=\"forminator-radio\" title=\"Death\"><input type=\"radio\" name=\"radio-6\" value=\"Death\" id=\"forminator-field-radio-6-5-69f27f65506f4\" aria-labelledby=\"forminator-field-radio-6-label-5\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Death<\/span><\/label><label id=\"forminator-field-radio-6-label-6\" for=\"forminator-field-radio-6-6-69f27f65506f4\" class=\"forminator-radio\" title=\"Funeral expenses\"><input type=\"radio\" name=\"radio-6\" value=\"Funeral-expenses\" id=\"forminator-field-radio-6-6-69f27f65506f4\" aria-labelledby=\"forminator-field-radio-6-label-6\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-radio-bullet\" aria-hidden=\"true\"><\/span><span class=\"forminator-radio-label\">Funeral expenses<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-5\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Medical expenses<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-2\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-2_69f27f65506f4\" id=\"forminator-field-upload-2_69f27f65506f4-label\" class=\"forminator-label\">Clinical information<\/label><div class=\"forminator-multi-upload \" data-element=\"upload-2_69f27f65506f4\"><input type=\"file\" name=\"upload-2[]\" id=\"forminator-field-upload-2_69f27f65506f4\" class=\"forminator-input-file forminator-field-upload-2_69f27f65506f4-342\" multiple=\"multiple\" data-method=\"ajax\" data-size=\"8000000\" data-size-message=\"Maximum file size allowed is 8 MB. \"><div class=\"forminator-multi-upload-message\" aria-hidden=\"true\"><span class=\"forminator-icon-upload\" aria-hidden=\"true\"><\/span><p>Drag and Drop (or) <a class=\"forminator-upload-file--forminator-field-upload-2_69f27f65506f4\" href=\"#\" onclick=\"return false;\">Choose Files<\/a><\/p><\/div><\/div><ul class=\"forminator-uploaded-files upload-container-upload-2_69f27f65506f4\"><\/ul><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-5\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-5_69f27f65506f4\" id=\"forminator-field-upload-5_69f27f65506f4-label\" class=\"forminator-label\">Medical prescription (doctor\u2019s note)<\/label><div class=\"forminator-multi-upload \" data-element=\"upload-5_69f27f65506f4\"><input type=\"file\" name=\"upload-5[]\" id=\"forminator-field-upload-5_69f27f65506f4\" class=\"forminator-input-file forminator-field-upload-5_69f27f65506f4-342\" multiple=\"multiple\" data-method=\"ajax\" data-size=\"8000000\" data-size-message=\"Maximum file size allowed is 8 MB. \"><div class=\"forminator-multi-upload-message\" aria-hidden=\"true\"><span class=\"forminator-icon-upload\" aria-hidden=\"true\"><\/span><p>Drag and Drop (or) <a class=\"forminator-upload-file--forminator-field-upload-5_69f27f65506f4\" href=\"#\" onclick=\"return false;\">Choose Files<\/a><\/p><\/div><\/div><ul class=\"forminator-uploaded-files upload-container-upload-5_69f27f65506f4\"><\/ul><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-6\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-6_69f27f65506f4\" id=\"forminator-field-upload-6_69f27f65506f4-label\" class=\"forminator-label\">Original receipts (Pharmacy, Clinic, Hospital, etc.)<\/label><div class=\"forminator-multi-upload \" data-element=\"upload-6_69f27f65506f4\"><input type=\"file\" name=\"upload-6[]\" id=\"forminator-field-upload-6_69f27f65506f4\" class=\"forminator-input-file forminator-field-upload-6_69f27f65506f4-342\" multiple=\"multiple\" data-method=\"ajax\" data-size=\"8000000\" data-size-message=\"Maximum file size allowed is 8 MB. \"><div class=\"forminator-multi-upload-message\" aria-hidden=\"true\"><span class=\"forminator-icon-upload\" aria-hidden=\"true\"><\/span><p>Drag and Drop (or) <a class=\"forminator-upload-file--forminator-field-upload-6_69f27f65506f4\" href=\"#\" onclick=\"return false;\">Choose Files<\/a><\/p><\/div><\/div><ul class=\"forminator-uploaded-files upload-container-upload-6_69f27f65506f4\"><\/ul><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-6\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Temporary disability<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-3\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-3_69f27f65506f4\" id=\"forminator-field-upload-3_69f27f65506f4-label\" class=\"forminator-label\">Medical report<\/label><div class=\"forminator-multi-upload \" data-element=\"upload-3_69f27f65506f4\"><input type=\"file\" name=\"upload-3[]\" id=\"forminator-field-upload-3_69f27f65506f4\" class=\"forminator-input-file forminator-field-upload-3_69f27f65506f4-342\" multiple=\"multiple\" data-method=\"ajax\" data-size=\"8000000\" data-size-message=\"Maximum file size allowed is 8 MB. \"><div class=\"forminator-multi-upload-message\" aria-hidden=\"true\"><span class=\"forminator-icon-upload\" aria-hidden=\"true\"><\/span><p>Drag and Drop (or) <a class=\"forminator-upload-file--forminator-field-upload-3_69f27f65506f4\" href=\"#\" onclick=\"return false;\">Choose Files<\/a><\/p><\/div><\/div><ul class=\"forminator-uploaded-files upload-container-upload-3_69f27f65506f4\"><\/ul><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-11\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-11_69f27f65506f4\" id=\"forminator-field-upload-11_69f27f65506f4-label\" class=\"forminator-label\">Diagnostic test results<\/label><div class=\"forminator-multi-upload \" data-element=\"upload-11_69f27f65506f4\"><input type=\"file\" name=\"upload-11[]\" id=\"forminator-field-upload-11_69f27f65506f4\" class=\"forminator-input-file forminator-field-upload-11_69f27f65506f4-342\" multiple=\"multiple\" data-method=\"ajax\" data-size=\"8000000\" data-size-message=\"Maximum file size allowed is 8 MB. \"><div class=\"forminator-multi-upload-message\" aria-hidden=\"true\"><span class=\"forminator-icon-upload\" aria-hidden=\"true\"><\/span><p>Drag and Drop (or) <a class=\"forminator-upload-file--forminator-field-upload-11_69f27f65506f4\" href=\"#\" onclick=\"return false;\">Choose Files<\/a><\/p><\/div><\/div><ul class=\"forminator-uploaded-files upload-container-upload-11_69f27f65506f4\"><\/ul><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-10\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-10_69f27f65506f4\" id=\"forminator-field-upload-10_69f27f65506f4-label\" class=\"forminator-label\">Proof of wage reduction (if partial)<\/label><div class=\"forminator-multi-upload \" data-element=\"upload-10_69f27f65506f4\"><input type=\"file\" name=\"upload-10[]\" id=\"forminator-field-upload-10_69f27f65506f4\" class=\"forminator-input-file forminator-field-upload-10_69f27f65506f4-342\" multiple=\"multiple\" data-method=\"ajax\" data-size=\"8000000\" data-size-message=\"Maximum file size allowed is 8 MB. \"><div class=\"forminator-multi-upload-message\" aria-hidden=\"true\"><span class=\"forminator-icon-upload\" aria-hidden=\"true\"><\/span><p>Drag and Drop (or) <a class=\"forminator-upload-file--forminator-field-upload-10_69f27f65506f4\" href=\"#\" onclick=\"return false;\">Choose Files<\/a><\/p><\/div><\/div><ul class=\"forminator-uploaded-files upload-container-upload-10_69f27f65506f4\"><\/ul><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-9\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-9_69f27f65506f4\" id=\"forminator-field-upload-9_69f27f65506f4-label\" class=\"forminator-label\">Proof of income (if total)<\/label><div class=\"forminator-multi-upload \" data-element=\"upload-9_69f27f65506f4\"><input type=\"file\" name=\"upload-9[]\" id=\"forminator-field-upload-9_69f27f65506f4\" class=\"forminator-input-file forminator-field-upload-9_69f27f65506f4-342\" multiple=\"multiple\" data-method=\"ajax\" data-size=\"8000000\" data-size-message=\"Maximum file size allowed is 8 MB. \"><div class=\"forminator-multi-upload-message\" aria-hidden=\"true\"><span class=\"forminator-icon-upload\" aria-hidden=\"true\"><\/span><p>Drag and Drop (or) <a class=\"forminator-upload-file--forminator-field-upload-9_69f27f65506f4\" href=\"#\" onclick=\"return false;\">Choose Files<\/a><\/p><\/div><\/div><ul class=\"forminator-uploaded-files upload-container-upload-9_69f27f65506f4\"><\/ul><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-7\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Hospitalization<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-4\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-4_69f27f65506f4\" id=\"forminator-field-upload-4_69f27f65506f4-label\" class=\"forminator-label\">Hospital statement (reason + period)<\/label><div class=\"forminator-multi-upload \" data-element=\"upload-4_69f27f65506f4\"><input type=\"file\" name=\"upload-4[]\" id=\"forminator-field-upload-4_69f27f65506f4\" class=\"forminator-input-file forminator-field-upload-4_69f27f65506f4-342\" multiple=\"multiple\" data-method=\"ajax\" data-size=\"8000000\" data-size-message=\"Maximum file size allowed is 8 MB. \"><div class=\"forminator-multi-upload-message\" aria-hidden=\"true\"><span class=\"forminator-icon-upload\" aria-hidden=\"true\"><\/span><p>Drag and Drop (or) <a class=\"forminator-upload-file--forminator-field-upload-4_69f27f65506f4\" href=\"#\" onclick=\"return false;\">Choose Files<\/a><\/p><\/div><\/div><ul class=\"forminator-uploaded-files upload-container-upload-4_69f27f65506f4\"><\/ul><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-8\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Partial permanent disability<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-7\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-7_69f27f65506f4\" id=\"forminator-field-upload-7_69f27f65506f4-label\" class=\"forminator-label\">Medical report (injuries, treatments, sequelae)<\/label><div class=\"forminator-multi-upload \" data-element=\"upload-7_69f27f65506f4\"><input type=\"file\" name=\"upload-7[]\" id=\"forminator-field-upload-7_69f27f65506f4\" class=\"forminator-input-file forminator-field-upload-7_69f27f65506f4-342\" multiple=\"multiple\" data-method=\"ajax\" data-size=\"8000000\" data-size-message=\"Maximum file size allowed is 8 MB. \"><div class=\"forminator-multi-upload-message\" aria-hidden=\"true\"><span class=\"forminator-icon-upload\" aria-hidden=\"true\"><\/span><p>Drag and Drop (or) <a class=\"forminator-upload-file--forminator-field-upload-7_69f27f65506f4\" href=\"#\" onclick=\"return false;\">Choose Files<\/a><\/p><\/div><\/div><ul class=\"forminator-uploaded-files upload-container-upload-7_69f27f65506f4\"><\/ul><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-8\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-8_69f27f65506f4\" id=\"forminator-field-upload-8_69f27f65506f4-label\" class=\"forminator-label\">Diagnostic test results<\/label><div class=\"forminator-multi-upload \" data-element=\"upload-8_69f27f65506f4\"><input type=\"file\" name=\"upload-8[]\" id=\"forminator-field-upload-8_69f27f65506f4\" class=\"forminator-input-file forminator-field-upload-8_69f27f65506f4-342\" multiple=\"multiple\" data-method=\"ajax\" data-size=\"8000000\" data-size-message=\"Maximum file size allowed is 8 MB. \"><div class=\"forminator-multi-upload-message\" aria-hidden=\"true\"><span class=\"forminator-icon-upload\" aria-hidden=\"true\"><\/span><p>Drag and Drop (or) <a class=\"forminator-upload-file--forminator-field-upload-8_69f27f65506f4\" href=\"#\" onclick=\"return false;\">Choose Files<\/a><\/p><\/div><\/div><ul class=\"forminator-uploaded-files upload-container-upload-8_69f27f65506f4\"><\/ul><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-9\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Death<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-12\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-12_69f27f65506f4\" id=\"forminator-field-upload-12_69f27f65506f4-label\" class=\"forminator-label\">Certificate of heirs entitlement<\/label><div class=\"forminator-file-upload \" data-element=\"upload-12_69f27f65506f4\"><input type=\"file\" name=\"upload-12\" id=\"forminator-field-upload-12_69f27f65506f4\" class=\"forminator-input-file\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.webp,.avif,.ico,.heic,.heif,.heics,.heifs,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.flv,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.vtt,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.x-wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.pdf,.class,.tar,.zip,.gz,.gzip,.rar,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mdb,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onetmp,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages,.svgz\"><button id=\"forminator-field-upload-12_69f27f65506f4_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-12_69f27f65506f4\">Choose File<\/button><span data-empty-text=\"No file chosen\">No file chosen<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Delete uploaded file<\/span><\/button><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-13\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-13_69f27f65506f4\" id=\"forminator-field-upload-13_69f27f65506f4-label\" class=\"forminator-label\">Birth certificate (in case of minors)<\/label><div class=\"forminator-file-upload \" data-element=\"upload-13_69f27f65506f4\"><input type=\"file\" name=\"upload-13\" id=\"forminator-field-upload-13_69f27f65506f4\" class=\"forminator-input-file\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.webp,.avif,.ico,.heic,.heif,.heics,.heifs,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.flv,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.vtt,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.x-wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.pdf,.class,.tar,.zip,.gz,.gzip,.rar,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mdb,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onetmp,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages,.svgz\"><button id=\"forminator-field-upload-13_69f27f65506f4_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-13_69f27f65506f4\">Choose File<\/button><span data-empty-text=\"No file chosen\">No file chosen<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Delete uploaded file<\/span><\/button><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-14\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-14_69f27f65506f4\" id=\"forminator-field-upload-14_69f27f65506f4-label\" class=\"forminator-label\">Autopsy + toxicology report<\/label><div class=\"forminator-file-upload \" data-element=\"upload-14_69f27f65506f4\"><input type=\"file\" name=\"upload-14\" id=\"forminator-field-upload-14_69f27f65506f4\" class=\"forminator-input-file\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.webp,.avif,.ico,.heic,.heif,.heics,.heifs,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.flv,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.vtt,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.x-wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.pdf,.class,.tar,.zip,.gz,.gzip,.rar,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mdb,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onetmp,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages,.svgz\"><button id=\"forminator-field-upload-14_69f27f65506f4_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-14_69f27f65506f4\">Choose File<\/button><span data-empty-text=\"No file chosen\">No file chosen<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Delete uploaded file<\/span><\/button><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-15\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-15_69f27f65506f4\" id=\"forminator-field-upload-15_69f27f65506f4-label\" class=\"forminator-label\">Police report<\/label><div class=\"forminator-file-upload \" data-element=\"upload-15_69f27f65506f4\"><input type=\"file\" name=\"upload-15\" id=\"forminator-field-upload-15_69f27f65506f4\" class=\"forminator-input-file\" accept=\".jpg,.jpeg,.jpe,.gif,.png,.bmp,.tiff,.tif,.webp,.avif,.ico,.heic,.heif,.heics,.heifs,.asf,.asx,.wmv,.wmx,.wm,.avi,.divx,.flv,.mov,.qt,.mpeg,.mpg,.mpe,.mp4,.m4v,.ogv,.webm,.mkv,.3gp,.3gpp,.3g2,.3gp2,.txt,.asc,.c,.cc,.h,.srt,.csv,.tsv,.ics,.rtx,.vtt,.mp3,.m4a,.m4b,.aac,.ra,.ram,.wav,.x-wav,.ogg,.oga,.flac,.mid,.midi,.wma,.wax,.mka,.rtf,.pdf,.class,.tar,.zip,.gz,.gzip,.rar,.7z,.psd,.xcf,.doc,.pot,.pps,.ppt,.wri,.xla,.xls,.xlt,.xlw,.mdb,.mpp,.docx,.docm,.dotx,.dotm,.xlsx,.xlsm,.xlsb,.xltx,.xltm,.xlam,.pptx,.pptm,.ppsx,.ppsm,.potx,.potm,.ppam,.sldx,.sldm,.onetoc,.onetoc2,.onetmp,.onepkg,.oxps,.xps,.odt,.odp,.ods,.odg,.odc,.odb,.odf,.wp,.wpd,.key,.numbers,.pages,.svgz\"><button id=\"forminator-field-upload-15_69f27f65506f4_button\" class=\"forminator-button forminator-button-upload\" data-id=\"forminator-field-upload-15_69f27f65506f4\">Choose File<\/button><span data-empty-text=\"No file chosen\">No file chosen<\/span><button class=\"forminator-button-delete\" style=\"display: none;\"><i class=\"forminator-icon-close\" aria-hidden=\"true\"><\/i><span class=\"forminator-screen-reader-only\">Delete uploaded file<\/span><\/button><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-10\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">Funeral expenses<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"upload-16\" class=\"forminator-field-upload forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-upload-16_69f27f65506f4\" id=\"forminator-field-upload-16_69f27f65506f4-label\" class=\"forminator-label\">Original funeral expense receipt<\/label><div class=\"forminator-multi-upload \" data-element=\"upload-16_69f27f65506f4\"><input type=\"file\" name=\"upload-16[]\" id=\"forminator-field-upload-16_69f27f65506f4\" class=\"forminator-input-file forminator-field-upload-16_69f27f65506f4-342\" multiple=\"multiple\" data-method=\"ajax\" data-size=\"8000000\" data-size-message=\"Maximum file size allowed is 8 MB. \"><div class=\"forminator-multi-upload-message\" aria-hidden=\"true\"><span class=\"forminator-icon-upload\" aria-hidden=\"true\"><\/span><p>Drag and Drop (or) <a class=\"forminator-upload-file--forminator-field-upload-16_69f27f65506f4\" href=\"#\" onclick=\"return false;\">Choose Files<\/a><\/p><\/div><\/div><ul class=\"forminator-uploaded-files upload-container-upload-16_69f27f65506f4\"><\/ul><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"section-11\" class=\"forminator-field-section forminator-col forminator-col-12 \"><div class=\"forminator-field\"><h2 class=\"forminator-title\">5. Declaration<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-3\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-69f27f65506f4-label\"><label id=\"forminator-field-checkbox-3-1-69f27f65506f4-label\" for=\"forminator-field-checkbox-3-1-69f27f65506f4\" class=\"forminator-checkbox\" title=\"1. I hereby declare, for all due purposes, that the information provided by me is true and complete. I assume full responsibility for the accuracy of the information provided, being aware that any false or omitted information may have legal or administrative consequences, as applicable.\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"one\" id=\"forminator-field-checkbox-3-1-69f27f65506f4\" aria-labelledby=\"forminator-field-checkbox-3-1-69f27f65506f4-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">1. I hereby declare, for all due purposes, that the information provided by me is true and complete. I assume full responsibility for the accuracy of the information provided, being aware that any false or omitted information may have legal or administrative consequences, as applicable.<\/span><\/label><label id=\"forminator-field-checkbox-3-2-69f27f65506f4-label\" for=\"forminator-field-checkbox-3-2-69f27f65506f4\" class=\"forminator-checkbox\" title=\"2. I authorize the Insurance Company to collect additional personal data from public bodies, specialized companies, and other economic entities, with the purpose of confirming or complementing the information collected, necessary for the management of the contractual relationship. Omissions, inaccuracies, and falsehoods in the provision of information are my responsibility. Access to the provided personal data is granted under strict confidentiality, provided that it is compatible with the purpose for which the data was collected.\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"two\" id=\"forminator-field-checkbox-3-2-69f27f65506f4\" aria-labelledby=\"forminator-field-checkbox-3-2-69f27f65506f4-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">2. I authorize the Insurance Company to collect additional personal data from public bodies, specialized companies, and other economic entities, with the purpose of confirming or complementing the information collected, necessary for the management of the contractual relationship. Omissions, inaccuracies, and falsehoods in the provision of information are my responsibility. Access to the provided personal data is granted under strict confidentiality, provided that it is compatible with the purpose for which the data was collected.<\/span><\/label><\/div><\/div><\/div><input type=\"hidden\" name=\"referer_url\" value=\"\" \/><div class=\"forminator-row forminator-row-last\"><div class=\"forminator-col\"><div class=\"forminator-field\"><button class=\"forminator-button forminator-button-submit\">Submit Claim Report<\/button><\/div><\/div><\/div><input type=\"hidden\" id=\"forminator_nonce\" name=\"forminator_nonce\" value=\"78eb635243\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/371\" \/><input type=\"hidden\" name=\"form_id\" value=\"342\"><input type=\"hidden\" name=\"page_id\" value=\"371\"><input type=\"hidden\" name=\"form_type\" value=\"default\"><input type=\"hidden\" name=\"current_url\" value=\"https:\/\/www.mcs.co.mz\/en\/form-acidentes-pessoais\/\"><input type=\"hidden\" name=\"render_id\" value=\"0\"><input type=\"hidden\" name=\"forminator-multifile-hidden\" class=\"forminator-multifile-hidden\"><input type=\"hidden\" name=\"action\" value=\"forminator_submit_form_custom-forms\"><\/form>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-formularios.php","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":""},"class_list":["post-371","page","type-page","status-publish","hentry"],"acf":[],"_links":{"self":[{"href":"https:\/\/www.mcs.co.mz\/en\/wp-json\/wp\/v2\/pages\/371","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.mcs.co.mz\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.mcs.co.mz\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.mcs.co.mz\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.mcs.co.mz\/en\/wp-json\/wp\/v2\/comments?post=371"}],"version-history":[{"count":1,"href":"https:\/\/www.mcs.co.mz\/en\/wp-json\/wp\/v2\/pages\/371\/revisions"}],"predecessor-version":[{"id":372,"href":"https:\/\/www.mcs.co.mz\/en\/wp-json\/wp\/v2\/pages\/371\/revisions\/372"}],"wp:attachment":[{"href":"https:\/\/www.mcs.co.mz\/en\/wp-json\/wp\/v2\/media?parent=371"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}