{"id":375,"date":"2025-03-09T17:41:19","date_gmt":"2025-03-09T17:41:19","guid":{"rendered":"https:\/\/www.mcs.co.mz\/en\/?page_id=375"},"modified":"2025-03-24T06:32:46","modified_gmt":"2025-03-24T06:32:46","slug":"acidente-de-trabalho","status":"publish","type":"page","link":"https:\/\/www.mcs.co.mz\/en\/acidente-de-trabalho\/","title":{"rendered":"Form Acidente de Trabalho"},"content":{"rendered":"<div class=\"forminator-ui forminator-custom-form forminator-custom-form-344 forminator-design--default  forminator_ajax\" data-forminator-render=\"0\" data-form=\"forminator-module-344\" data-uid=\"69f27e24a28fd\"><br\/><\/div><form\r\n\t\t\t\tid=\"forminator-module-344\"\r\n\t\t\t\tclass=\"forminator-ui forminator-custom-form forminator-custom-form-344 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=\"344\"\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=\"69f27e24a28fd\"\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=\"text-1\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-1_69f27e24a28fd\" id=\"forminator-field-text-1_69f27e24a28fd-label\" class=\"forminator-label\">Policy number<\/label><input type=\"text\" name=\"text-1\" value=\"\" placeholder=\"\" id=\"forminator-field-text-1_69f27e24a28fd\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-2\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-2_69f27e24a28fd\" id=\"forminator-field-text-2_69f27e24a28fd-label\" class=\"forminator-label\">Branch<\/label><input type=\"text\" name=\"text-2\" value=\"\" placeholder=\"\" id=\"forminator-field-text-2_69f27e24a28fd\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/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\">1. Participant\u2019s Status<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-1\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-69f27e24a28fd-label\"><span id=\"forminator-checkbox-group-69f27e24a28fd-label\" class=\"forminator-label\">Checkbox<\/span><label id=\"forminator-field-checkbox-1-1-69f27e24a28fd-label\" for=\"forminator-field-checkbox-1-1-69f27e24a28fd\" class=\"forminator-checkbox\" title=\"Insured\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"one\" id=\"forminator-field-checkbox-1-1-69f27e24a28fd\" aria-labelledby=\"forminator-field-checkbox-1-1-69f27e24a28fd-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Insured<\/span><\/label><label id=\"forminator-field-checkbox-1-2-69f27e24a28fd-label\" for=\"forminator-field-checkbox-1-2-69f27e24a28fd\" class=\"forminator-checkbox\" title=\"Broker\"><input type=\"checkbox\" name=\"checkbox-1[]\" value=\"two\" id=\"forminator-field-checkbox-1-2-69f27e24a28fd\" aria-labelledby=\"forminator-field-checkbox-1-2-69f27e24a28fd-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Broker<\/span><\/label><\/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_69f27e24a28fd\" id=\"forminator-field-name-1_69f27e24a28fd-label\" class=\"forminator-label\">Name<\/label><input type=\"text\" name=\"name-1\" value=\"\" placeholder=\"E.g. John Doe\" id=\"forminator-field-name-1_69f27e24a28fd\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-3\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-3_69f27e24a28fd\" id=\"forminator-field-text-3_69f27e24a28fd-label\" class=\"forminator-label\">Contact<\/label><input type=\"text\" name=\"text-3\" value=\"\" placeholder=\"\" id=\"forminator-field-text-3_69f27e24a28fd\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/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\">2. Identification of the Policyholder or Employer Entity<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-2\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-2_69f27e24a28fd\" id=\"forminator-field-name-2_69f27e24a28fd-label\" class=\"forminator-label\">Name<\/label><input type=\"text\" name=\"name-2\" value=\"\" placeholder=\"E.g. John Doe\" id=\"forminator-field-name-2_69f27e24a28fd\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><div id=\"phone-1\" class=\"forminator-field-phone forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-phone-1_69f27e24a28fd\" id=\"forminator-field-phone-1_69f27e24a28fd-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-1\" value=\"\" placeholder=\"E.g. +258 848191186\" id=\"forminator-field-phone-1_69f27e24a28fd\" 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_69f27e24a28fd\" id=\"forminator-field-email-1_69f27e24a28fd-label\" class=\"forminator-label\">Email<\/label><input type=\"email\" name=\"email-1\" value=\"\" placeholder=\"E.g. gervasiochavane798@gmail.com\" id=\"forminator-field-email-1_69f27e24a28fd\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-4\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-4_69f27e24a28fd\" id=\"forminator-field-text-4_69f27e24a28fd-label\" class=\"forminator-label\">Nuit<\/label><input type=\"text\" name=\"text-4\" value=\"\" placeholder=\"Tax Identification Number\" id=\"forminator-field-text-4_69f27e24a28fd\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/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_69f27e24a28fd\" id=\"forminator-field-text-5_69f27e24a28fd-label\" class=\"forminator-label\">Employee of the Employer Entity<\/label><input type=\"text\" name=\"text-5\" value=\"\" placeholder=\"\" id=\"forminator-field-text-5_69f27e24a28fd\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-1\" class=\"forminator-field-address forminator-col forminator-col-12 \"><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_69f27e24a28fd\" id=\"forminator-field-address-1-street_address_69f27e24a28fd-label\" class=\"forminator-label\">Business Address<\/label><input type=\"text\" name=\"address-1-street_address\" placeholder=\"E.g. 42 Wallaby Way\" id=\"forminator-field-address-1-street_address_69f27e24a28fd\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-6\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-6_69f27e24a28fd\" id=\"forminator-field-text-6_69f27e24a28fd-label\" class=\"forminator-label\">Main Activity of the Establishment<\/label><input type=\"text\" name=\"text-6\" value=\"\" placeholder=\"\" id=\"forminator-field-text-6_69f27e24a28fd\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/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. Identification of the Injured Person<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"name-3\" class=\"forminator-field-name forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-name-3_69f27e24a28fd\" id=\"forminator-field-name-3_69f27e24a28fd-label\" class=\"forminator-label\">Name<\/label><input type=\"text\" name=\"name-3\" value=\"\" placeholder=\"E.g. John Doe\" id=\"forminator-field-name-3_69f27e24a28fd\" class=\"forminator-input forminator-name--field\" aria-required=\"false\" \/><\/div><\/div><div id=\"date-1\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-1-picker_69f27e24a28fd\" id=\"forminator-field-date-1-picker_69f27e24a28fd-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-1\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-1-picker_69f27e24a28fd\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"yy\/mm\/dd\" 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=\"text-7\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-7_69f27e24a28fd\" id=\"forminator-field-text-7_69f27e24a28fd-label\" class=\"forminator-label\">Identity Card<\/label><input type=\"text\" name=\"text-7\" value=\"\" placeholder=\"E.g. text placeholder\" id=\"forminator-field-text-7_69f27e24a28fd\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><div id=\"radio-1\" class=\"forminator-field-radio forminator-col forminator-col-6 \"><div role=\"radiogroup\" class=\"forminator-field\" aria-labelledby=\"forminator-radiogroup-69f27e24a28fd-label\"><span id=\"forminator-radiogroup-69f27e24a28fd-label\" class=\"forminator-label\">Sex<\/span><label id=\"forminator-field-radio-1-label-1\" for=\"forminator-field-radio-1-1-69f27e24a28fd\" class=\"forminator-radio forminator-radio-inline\" title=\"F\"><input type=\"radio\" name=\"radio-1\" value=\"one\" id=\"forminator-field-radio-1-1-69f27e24a28fd\" 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\">F<\/span><\/label><label id=\"forminator-field-radio-1-label-2\" for=\"forminator-field-radio-1-2-69f27e24a28fd\" class=\"forminator-radio forminator-radio-inline\" title=\"M\"><input type=\"radio\" name=\"radio-1\" value=\"two\" id=\"forminator-field-radio-1-2-69f27e24a28fd\" 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\">M<\/span><\/label><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-2\" class=\"forminator-field-address forminator-col forminator-col-6 \"><div class=\"forminator-row\" data-multiple=\"false\"><div id=\"address-2-country\" class=\"forminator-col forminator-col-12\"><div class=\"forminator-field\"><label for=\"forminator-field-344__field--address-2-country_69f27e24a28fd\" id=\"forminator-field-344__field--address-2-country_69f27e24a28fd-label\" class=\"forminator-label\">Nationality<\/label><select name=\"address-2-country\" id=\"forminator-field-344__field--address-2-country_69f27e24a28fd\" class=\"forminator-select2\" data-search=\"true\" data-placeholder=\"Select country\" data-default-value=\"\"><option value=\"\" data-country-code=\"\" selected=\"selected\"><\/option><option value=\"Afghanistan\" data-country-code=\"AF\" >Afghanistan<\/option><option value=\"Albania\" data-country-code=\"AL\" >Albania<\/option><option value=\"Algeria\" data-country-code=\"DZ\" >Algeria<\/option><option value=\"American Samoa\" data-country-code=\"AS\" >American Samoa<\/option><option value=\"Andorra\" data-country-code=\"AD\" >Andorra<\/option><option value=\"Angola\" data-country-code=\"AO\" >Angola<\/option><option value=\"Anguilla\" data-country-code=\"AI\" >Anguilla<\/option><option value=\"Antarctica\" data-country-code=\"AQ\" >Antarctica<\/option><option value=\"Antigua and Barbuda\" data-country-code=\"AG\" >Antigua and Barbuda<\/option><option value=\"Argentina\" data-country-code=\"AR\" >Argentina<\/option><option value=\"Armenia\" data-country-code=\"AM\" >Armenia<\/option><option value=\"Aruba\" data-country-code=\"AW\" >Aruba<\/option><option value=\"Australia\" data-country-code=\"AU\" >Australia<\/option><option value=\"Austria\" data-country-code=\"AT\" >Austria<\/option><option value=\"Azerbaijan\" data-country-code=\"AZ\" >Azerbaijan<\/option><option value=\"Bahamas\" data-country-code=\"BS\" >Bahamas<\/option><option value=\"Bahrain\" data-country-code=\"BH\" >Bahrain<\/option><option value=\"Bangladesh\" data-country-code=\"BD\" >Bangladesh<\/option><option value=\"Barbados\" data-country-code=\"BB\" >Barbados<\/option><option value=\"Belarus\" data-country-code=\"BY\" >Belarus<\/option><option value=\"Belgium\" data-country-code=\"BE\" >Belgium<\/option><option value=\"Belize\" data-country-code=\"BZ\" >Belize<\/option><option value=\"Benin\" data-country-code=\"BJ\" >Benin<\/option><option value=\"Bermuda\" data-country-code=\"BM\" >Bermuda<\/option><option value=\"Bhutan\" data-country-code=\"BT\" >Bhutan<\/option><option value=\"Bolivia\" data-country-code=\"BO\" >Bolivia<\/option><option value=\"Bosnia and Herzegovina\" data-country-code=\"BA\" >Bosnia and Herzegovina<\/option><option value=\"Botswana\" data-country-code=\"BW\" >Botswana<\/option><option value=\"Bouvet Island\" data-country-code=\"BV\" >Bouvet Island<\/option><option value=\"Brazil\" data-country-code=\"BR\" >Brazil<\/option><option value=\"British Indian Ocean Territory\" data-country-code=\"IO\" >British Indian Ocean Territory<\/option><option value=\"Brunei\" data-country-code=\"BN\" >Brunei<\/option><option value=\"Bulgaria\" data-country-code=\"BG\" >Bulgaria<\/option><option value=\"Burkina Faso\" data-country-code=\"BF\" >Burkina Faso<\/option><option value=\"Burundi\" data-country-code=\"BI\" >Burundi<\/option><option value=\"Cabo Verde\" data-country-code=\"CV\" >Cabo Verde<\/option><option value=\"Cambodia\" data-country-code=\"KH\" >Cambodia<\/option><option value=\"Cameroon\" data-country-code=\"CM\" >Cameroon<\/option><option value=\"Canada\" data-country-code=\"CA\" >Canada<\/option><option value=\"Cayman Islands\" data-country-code=\"KY\" >Cayman Islands<\/option><option value=\"Central African Republic\" data-country-code=\"CF\" >Central African Republic<\/option><option value=\"Chad\" data-country-code=\"TD\" >Chad<\/option><option value=\"Chile\" data-country-code=\"CL\" >Chile<\/option><option value=\"China, People's Republic of\" data-country-code=\"CN\" >China, People's Republic of<\/option><option value=\"Christmas Island\" data-country-code=\"CX\" >Christmas Island<\/option><option value=\"Cocos Islands\" data-country-code=\"CC\" >Cocos Islands<\/option><option value=\"Colombia\" data-country-code=\"CO\" >Colombia<\/option><option value=\"Comoros\" data-country-code=\"KM\" >Comoros<\/option><option value=\"Congo, Democratic Republic of the\" data-country-code=\"CD\" >Congo, Democratic Republic of the<\/option><option value=\"Congo, Republic of the\" data-country-code=\"CG\" >Congo, Republic of the<\/option><option value=\"Cook Islands\" data-country-code=\"CK\" >Cook Islands<\/option><option value=\"Costa Rica\" data-country-code=\"CR\" >Costa Rica<\/option><option value=\"Croatia\" data-country-code=\"HR\" >Croatia<\/option><option value=\"Cuba\" data-country-code=\"CU\" >Cuba<\/option><option value=\"Cura\u00e7ao\" data-country-code=\"CW\" >Cura\u00e7ao<\/option><option value=\"Cyprus\" data-country-code=\"CY\" >Cyprus<\/option><option value=\"Czech Republic\" data-country-code=\"CZ\" >Czech Republic<\/option><option value=\"C\u00f4te d'Ivoire\" data-country-code=\"CI\" >C\u00f4te d'Ivoire<\/option><option value=\"Denmark\" data-country-code=\"DK\" >Denmark<\/option><option value=\"Djibouti\" data-country-code=\"DJ\" >Djibouti<\/option><option value=\"Dominica\" data-country-code=\"DM\" >Dominica<\/option><option value=\"Dominican Republic\" data-country-code=\"DO\" >Dominican Republic<\/option><option value=\"East Timor\" data-country-code=\"TL\" >East Timor<\/option><option value=\"Ecuador\" data-country-code=\"EC\" >Ecuador<\/option><option value=\"Egypt\" data-country-code=\"EG\" >Egypt<\/option><option value=\"El Salvador\" data-country-code=\"SV\" >El Salvador<\/option><option value=\"Equatorial Guinea\" data-country-code=\"GQ\" >Equatorial Guinea<\/option><option value=\"Eritrea\" data-country-code=\"ER\" >Eritrea<\/option><option value=\"Estonia\" data-country-code=\"EE\" >Estonia<\/option><option value=\"Ethiopia\" data-country-code=\"ET\" >Ethiopia<\/option><option value=\"Falkland Islands\" data-country-code=\"FK\" >Falkland Islands<\/option><option value=\"Faroe Islands\" data-country-code=\"FO\" >Faroe Islands<\/option><option value=\"Fiji\" data-country-code=\"FJ\" >Fiji<\/option><option value=\"Finland\" data-country-code=\"FI\" >Finland<\/option><option value=\"France\" data-country-code=\"FR\" >France<\/option><option value=\"France, Metropolitan\" data-country-code=\"FX\" >France, Metropolitan<\/option><option value=\"French Guiana\" data-country-code=\"GF\" >French Guiana<\/option><option value=\"French Polynesia\" data-country-code=\"PF\" >French Polynesia<\/option><option value=\"French South Territories\" data-country-code=\"TF\" >French South Territories<\/option><option value=\"Gabon\" data-country-code=\"GA\" >Gabon<\/option><option value=\"Gambia\" data-country-code=\"GM\" >Gambia<\/option><option value=\"Georgia\" data-country-code=\"GE\" >Georgia<\/option><option value=\"Germany\" data-country-code=\"DE\" >Germany<\/option><option value=\"Ghana\" data-country-code=\"GH\" >Ghana<\/option><option value=\"Gibraltar\" data-country-code=\"GI\" >Gibraltar<\/option><option value=\"Greece\" data-country-code=\"GR\" >Greece<\/option><option value=\"Greenland\" data-country-code=\"GL\" >Greenland<\/option><option value=\"Grenada\" data-country-code=\"GD\" >Grenada<\/option><option value=\"Guadeloupe\" data-country-code=\"GP\" >Guadeloupe<\/option><option value=\"Guam\" data-country-code=\"GU\" >Guam<\/option><option value=\"Guatemala\" data-country-code=\"GT\" >Guatemala<\/option><option value=\"Guernsey\" data-country-code=\"GG\" >Guernsey<\/option><option value=\"Guinea\" data-country-code=\"GN\" >Guinea<\/option><option value=\"Guinea-Bissau\" data-country-code=\"GW\" >Guinea-Bissau<\/option><option value=\"Guyana\" data-country-code=\"GY\" >Guyana<\/option><option value=\"Haiti\" data-country-code=\"HT\" >Haiti<\/option><option value=\"Heard Island And Mcdonald Island\" data-country-code=\"HM\" >Heard Island And Mcdonald Island<\/option><option value=\"Honduras\" data-country-code=\"HN\" >Honduras<\/option><option value=\"Hong Kong\" data-country-code=\"HK\" >Hong Kong<\/option><option value=\"Hungary\" data-country-code=\"HU\" >Hungary<\/option><option value=\"Iceland\" data-country-code=\"IS\" >Iceland<\/option><option value=\"India\" data-country-code=\"IN\" >India<\/option><option value=\"Indonesia\" data-country-code=\"ID\" >Indonesia<\/option><option value=\"Iran\" data-country-code=\"IR\" >Iran<\/option><option value=\"Iraq\" data-country-code=\"IQ\" >Iraq<\/option><option value=\"Ireland\" data-country-code=\"IE\" >Ireland<\/option><option value=\"Israel\" data-country-code=\"IL\" >Israel<\/option><option value=\"Italy\" data-country-code=\"IT\" >Italy<\/option><option value=\"Jamaica\" data-country-code=\"JM\" >Jamaica<\/option><option value=\"Japan\" data-country-code=\"JP\" >Japan<\/option><option value=\"Jersey\" data-country-code=\"JE\" >Jersey<\/option><option value=\"Johnston Island\" data-country-code=\"JT\" >Johnston Island<\/option><option value=\"Jordan\" data-country-code=\"JO\" >Jordan<\/option><option value=\"Kazakhstan\" data-country-code=\"KZ\" >Kazakhstan<\/option><option value=\"Kenya\" data-country-code=\"KE\" >Kenya<\/option><option value=\"Kiribati\" data-country-code=\"KI\" >Kiribati<\/option><option value=\"Korea, Democratic People's Republic of\" data-country-code=\"KP\" >Korea, Democratic People's Republic of<\/option><option value=\"Korea, Republic of\" data-country-code=\"KR\" >Korea, Republic of<\/option><option value=\"Kosovo\" data-country-code=\"XK\" >Kosovo<\/option><option value=\"Kuwait\" data-country-code=\"KW\" >Kuwait<\/option><option value=\"Kyrgyzstan\" data-country-code=\"KG\" >Kyrgyzstan<\/option><option value=\"Lao People's Democratic Republic\" data-country-code=\"LA\" >Lao People's Democratic Republic<\/option><option value=\"Latvia\" data-country-code=\"LV\" >Latvia<\/option><option value=\"Lebanon\" data-country-code=\"LB\" >Lebanon<\/option><option value=\"Lesotho\" data-country-code=\"LS\" >Lesotho<\/option><option value=\"Liberia\" data-country-code=\"LR\" >Liberia<\/option><option value=\"Libya\" data-country-code=\"LY\" >Libya<\/option><option value=\"Liechtenstein\" data-country-code=\"LI\" >Liechtenstein<\/option><option value=\"Lithuania\" data-country-code=\"LT\" >Lithuania<\/option><option value=\"Luxembourg\" data-country-code=\"LU\" >Luxembourg<\/option><option value=\"Macau\" data-country-code=\"MO\" >Macau<\/option><option value=\"Madagascar\" data-country-code=\"MG\" >Madagascar<\/option><option value=\"Malawi\" data-country-code=\"MW\" >Malawi<\/option><option value=\"Malaysia\" data-country-code=\"MY\" >Malaysia<\/option><option value=\"Maldives\" data-country-code=\"MV\" >Maldives<\/option><option value=\"Mali\" data-country-code=\"ML\" >Mali<\/option><option value=\"Malta\" data-country-code=\"MT\" >Malta<\/option><option value=\"Marshall Islands\" data-country-code=\"MH\" >Marshall Islands<\/option><option value=\"Martinique\" data-country-code=\"MQ\" >Martinique<\/option><option value=\"Mauritania\" data-country-code=\"MR\" >Mauritania<\/option><option value=\"Mauritius\" data-country-code=\"MU\" >Mauritius<\/option><option value=\"Mayotte\" data-country-code=\"YT\" >Mayotte<\/option><option value=\"Mexico\" data-country-code=\"MX\" >Mexico<\/option><option value=\"Micronesia\" data-country-code=\"FM\" >Micronesia<\/option><option value=\"Moldova\" data-country-code=\"MD\" >Moldova<\/option><option value=\"Monaco\" data-country-code=\"MC\" >Monaco<\/option><option value=\"Mongolia\" data-country-code=\"MN\" >Mongolia<\/option><option value=\"Montenegro\" data-country-code=\"ME\" >Montenegro<\/option><option value=\"Montserrat\" data-country-code=\"MS\" >Montserrat<\/option><option value=\"Morocco\" data-country-code=\"MA\" >Morocco<\/option><option value=\"Mozambique\" data-country-code=\"MZ\" >Mozambique<\/option><option value=\"Myanmar\" data-country-code=\"MM\" >Myanmar<\/option><option value=\"Namibia\" data-country-code=\"NA\" >Namibia<\/option><option value=\"Nauru\" data-country-code=\"NR\" >Nauru<\/option><option value=\"Nepal\" data-country-code=\"NP\" >Nepal<\/option><option value=\"Netherlands\" data-country-code=\"NL\" >Netherlands<\/option><option value=\"Netherlands Antilles\" data-country-code=\"AN\" >Netherlands Antilles<\/option><option value=\"New Caledonia\" data-country-code=\"NC\" >New Caledonia<\/option><option value=\"New Zealand\" data-country-code=\"NZ\" >New Zealand<\/option><option value=\"Nicaragua\" data-country-code=\"NI\" >Nicaragua<\/option><option value=\"Niger\" data-country-code=\"NE\" >Niger<\/option><option value=\"Nigeria\" data-country-code=\"NG\" >Nigeria<\/option><option value=\"Niue\" data-country-code=\"NU\" >Niue<\/option><option value=\"Norfolk Island\" data-country-code=\"NF\" >Norfolk Island<\/option><option value=\"North Macedonia\" data-country-code=\"MK\" >North Macedonia<\/option><option value=\"Northern Mariana Islands\" data-country-code=\"MP\" >Northern Mariana Islands<\/option><option value=\"Norway\" data-country-code=\"NO\" >Norway<\/option><option value=\"Oman\" data-country-code=\"OM\" >Oman<\/option><option value=\"Pakistan\" data-country-code=\"PK\" >Pakistan<\/option><option value=\"Palau\" data-country-code=\"PW\" >Palau<\/option><option value=\"Palestine, State of\" data-country-code=\"PS\" >Palestine, State of<\/option><option value=\"Panama\" data-country-code=\"PA\" >Panama<\/option><option value=\"Papua New Guinea\" data-country-code=\"PG\" >Papua New Guinea<\/option><option value=\"Paraguay\" data-country-code=\"PY\" >Paraguay<\/option><option value=\"Peru\" data-country-code=\"PE\" >Peru<\/option><option value=\"Philippines\" data-country-code=\"PH\" >Philippines<\/option><option value=\"Pitcairn Islands\" data-country-code=\"PN\" >Pitcairn Islands<\/option><option value=\"Poland\" data-country-code=\"PL\" >Poland<\/option><option value=\"Portugal\" data-country-code=\"PT\" >Portugal<\/option><option value=\"Puerto Rico\" data-country-code=\"PR\" >Puerto Rico<\/option><option value=\"Qatar\" data-country-code=\"QA\" >Qatar<\/option><option value=\"Reunion Island\" data-country-code=\"RE\" >Reunion Island<\/option><option value=\"Romania\" data-country-code=\"RO\" >Romania<\/option><option value=\"Russia\" data-country-code=\"RU\" >Russia<\/option><option value=\"Rwanda\" data-country-code=\"RW\" >Rwanda<\/option><option value=\"Saint Helena\" data-country-code=\"SH\" >Saint Helena<\/option><option value=\"Saint Kitts and Nevis\" data-country-code=\"KN\" >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\" data-country-code=\"LC\" >Saint Lucia<\/option><option value=\"Saint Pierre & Miquelon\" data-country-code=\"PM\" >Saint Pierre & Miquelon<\/option><option value=\"Saint Vincent and the Grenadines\" data-country-code=\"VC\" >Saint Vincent and the Grenadines<\/option><option value=\"Samoa\" data-country-code=\"WS\" >Samoa<\/option><option value=\"San Marino\" data-country-code=\"SM\" >San Marino<\/option><option value=\"Sao Tome and Principe\" data-country-code=\"ST\" >Sao Tome and Principe<\/option><option value=\"Saudi Arabia\" data-country-code=\"SA\" >Saudi Arabia<\/option><option value=\"Senegal\" data-country-code=\"SN\" >Senegal<\/option><option value=\"Serbia\" data-country-code=\"RS\" >Serbia<\/option><option value=\"Seychelles\" data-country-code=\"SC\" >Seychelles<\/option><option value=\"Sierra Leone\" data-country-code=\"SL\" >Sierra Leone<\/option><option value=\"Singapore\" data-country-code=\"SG\" >Singapore<\/option><option value=\"Sint Maarten\" data-country-code=\"MF\" >Sint Maarten<\/option><option value=\"Slovakia\" data-country-code=\"SK\" >Slovakia<\/option><option value=\"Slovenia\" data-country-code=\"SI\" >Slovenia<\/option><option value=\"Solomon Islands\" data-country-code=\"SB\" >Solomon Islands<\/option><option value=\"Somalia\" data-country-code=\"SO\" >Somalia<\/option><option value=\"South Africa\" data-country-code=\"ZA\" >South Africa<\/option><option value=\"South Georgia and South Sandwich\" data-country-code=\"GS\" >South Georgia and South Sandwich<\/option><option value=\"Spain\" data-country-code=\"ES\" >Spain<\/option><option value=\"Sri Lanka\" data-country-code=\"LK\" >Sri Lanka<\/option><option value=\"Stateless Persons\" data-country-code=\"XX\" >Stateless Persons<\/option><option value=\"Sudan\" data-country-code=\"SD\" >Sudan<\/option><option value=\"Sudan, South\" data-country-code=\"SS\" >Sudan, South<\/option><option value=\"Suriname\" data-country-code=\"SR\" >Suriname<\/option><option value=\"Svalbard and Jan Mayen\" data-country-code=\"SJ\" >Svalbard and Jan Mayen<\/option><option value=\"Swaziland\" data-country-code=\"SZ\" >Swaziland<\/option><option value=\"Sweden\" data-country-code=\"SE\" >Sweden<\/option><option value=\"Switzerland\" data-country-code=\"CH\" >Switzerland<\/option><option value=\"Syria\" data-country-code=\"SY\" >Syria<\/option><option value=\"Taiwan, Republic of China\" data-country-code=\"TW\" >Taiwan, Republic of China<\/option><option value=\"Tajikistan\" data-country-code=\"TJ\" >Tajikistan<\/option><option value=\"Tanzania\" data-country-code=\"TZ\" >Tanzania<\/option><option value=\"Thailand\" data-country-code=\"TH\" >Thailand<\/option><option value=\"Togo\" data-country-code=\"TG\" >Togo<\/option><option value=\"Tokelau\" data-country-code=\"TK\" >Tokelau<\/option><option value=\"Tonga\" data-country-code=\"TO\" >Tonga<\/option><option value=\"Trinidad and Tobago\" data-country-code=\"TT\" >Trinidad and Tobago<\/option><option value=\"Tunisia\" data-country-code=\"TN\" >Tunisia<\/option><option value=\"Turkey\" data-country-code=\"TR\" >Turkey<\/option><option value=\"Turkmenistan\" data-country-code=\"TM\" >Turkmenistan<\/option><option value=\"Turks And Caicos Islands\" data-country-code=\"TC\" >Turks And Caicos Islands<\/option><option value=\"Tuvalu\" data-country-code=\"TV\" >Tuvalu<\/option><option value=\"US Minor Outlying Islands\" data-country-code=\"UM\" >US Minor Outlying Islands<\/option><option value=\"Uganda\" data-country-code=\"UG\" >Uganda<\/option><option value=\"Ukraine\" data-country-code=\"UA\" >Ukraine<\/option><option value=\"United Arab Emirates\" data-country-code=\"AE\" >United Arab Emirates<\/option><option value=\"United Kingdom\" data-country-code=\"GB\" >United Kingdom<\/option><option value=\"United States of America (USA)\" data-country-code=\"US\" >United States of America (USA)<\/option><option value=\"Uruguay\" data-country-code=\"UY\" >Uruguay<\/option><option value=\"Uzbekistan\" data-country-code=\"UZ\" >Uzbekistan<\/option><option value=\"Vanuatu\" data-country-code=\"VU\" >Vanuatu<\/option><option value=\"Vatican City\" data-country-code=\"VA\" >Vatican City<\/option><option value=\"Venezuela\" data-country-code=\"VE\" >Venezuela<\/option><option value=\"Vietnam\" data-country-code=\"VN\" >Vietnam<\/option><option value=\"Virgin Islands, British\" data-country-code=\"VG\" >Virgin Islands, British<\/option><option value=\"Virgin Islands, U.S.\" data-country-code=\"VI\" >Virgin Islands, U.S.<\/option><option value=\"Wallis And Futuna Islands\" data-country-code=\"WF\" >Wallis And Futuna Islands<\/option><option value=\"Western Sahara\" data-country-code=\"EH\" >Western Sahara<\/option><option value=\"Yemen\" data-country-code=\"YE\" >Yemen<\/option><option value=\"Zambia\" data-country-code=\"ZM\" >Zambia<\/option><option value=\"Zimbabwe\" data-country-code=\"ZW\" >Zimbabwe<\/option><\/select><\/div><\/div><\/div><\/div><div id=\"text-8\" class=\"forminator-field-text forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-8_69f27e24a28fd\" id=\"forminator-field-text-8_69f27e24a28fd-label\" class=\"forminator-label\">Province<\/label><input type=\"text\" name=\"text-8\" value=\"\" placeholder=\"E.g. text placeholder\" id=\"forminator-field-text-8_69f27e24a28fd\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-3\" class=\"forminator-field-address forminator-col forminator-col-6 \"><div class=\"forminator-row\"><div id=\"address-3-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-3-street_address_69f27e24a28fd\" id=\"forminator-field-address-3-street_address_69f27e24a28fd-label\" class=\"forminator-label\">Address<\/label><input type=\"text\" name=\"address-3-street_address\" placeholder=\"\" id=\"forminator-field-address-3-street_address_69f27e24a28fd\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/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_69f27e24a28fd\" id=\"forminator-field-phone-2_69f27e24a28fd-label\" class=\"forminator-label\">Phone<\/label><input type=\"text\" name=\"phone-2\" value=\"\" placeholder=\"E.g. +258 848191186\" id=\"forminator-field-phone-2_69f27e24a28fd\" class=\"forminator-input forminator-field--phone\" data-required=\"\" aria-required=\"false\" autocomplete=\"off\" data-national_mode=\"enabled\" data-country=\"mz\" data-validation=\"standard\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"email-2\" class=\"forminator-field-email forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-email-2_69f27e24a28fd\" id=\"forminator-field-email-2_69f27e24a28fd-label\" class=\"forminator-label\">Email<\/label><input type=\"email\" name=\"email-2\" value=\"\" placeholder=\"E.g. gervasiochavane798@gmail.com\" id=\"forminator-field-email-2_69f27e24a28fd\" class=\"forminator-input forminator-email--field\" data-required=\"\" aria-required=\"false\" \/><\/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. Accident Details<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"date-2\" class=\"forminator-field-date forminator-col forminator-col-6 \"><div class=\"forminator-field\"><label for=\"forminator-field-date-2-picker_69f27e24a28fd\" id=\"forminator-field-date-2-picker_69f27e24a28fd-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-2\" value=\"\" placeholder=\"Choose Date\" id=\"forminator-field-date-2-picker_69f27e24a28fd\" class=\"forminator-input forminator-datepicker\" data-required=\"\" data-format=\"yy\/mm\/dd\" 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-6 \"><label for=\"forminator-field-time-1\" id=\"forminator-field-time-1-label\" class=\"forminator-label\">Time of Accident<\/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\"><input type=\"number\" name=\"time-1-hours\" min=\"0\" max=\"23\" placeholder=\"E.g. 08\" id=\"forminator-field-time-1-hours_69f27e24a28fd\" class=\"forminator-input time-hours \" data-field=\"hours\" value=\"\" \/><\/div><\/div><div id=\"time-1-minutes\" class=\"forminator-col forminator-col-6\"><div class=\"forminator-field\"><input type=\"number\" min=\"0\" max=\"59\" name=\"time-1-minutes\" placeholder=\"E.g. 00\" id=\"forminator-field-time-1-minutes_69f27e24a28fd\" class=\"forminator-input time-minutes \" data-field=\"minutes\" value=\"\" \/><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"text-9\" class=\"forminator-field-text forminator-col forminator-col-12 \"><div class=\"forminator-field\"><label for=\"forminator-field-text-9_69f27e24a28fd\" id=\"forminator-field-text-9_69f27e24a28fd-label\" class=\"forminator-label\">Date and time work was interrupted due to the accident<\/label><input type=\"text\" name=\"text-9\" value=\"\" placeholder=\"E.g. text placeholder\" id=\"forminator-field-text-9_69f27e24a28fd\" class=\"forminator-input forminator-name--field\" data-required=\"\" \/><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"address-4\" class=\"forminator-field-address forminator-col forminator-col-12 \"><div class=\"forminator-row\"><div id=\"address-4-street_address\" class=\"forminator-col\"><div class=\"forminator-field\"><label for=\"forminator-field-address-4-street_address_69f27e24a28fd\" id=\"forminator-field-address-4-street_address_69f27e24a28fd-label\" class=\"forminator-label\">Accident Location<\/label><input type=\"text\" name=\"address-4-street_address\" placeholder=\"E.g. 42 Wallaby Way\" id=\"forminator-field-address-4-street_address_69f27e24a28fd\" class=\"forminator-input\" data-required=\"\" aria-required=\"false\" value=\"\" \/><\/div><\/div><\/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\">5. Accident Circumstances<\/h2><\/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_69f27e24a28fd\" id=\"forminator-field-textarea-1_69f27e24a28fd-label\" class=\"forminator-label\">Detailed Description<\/label><textarea name=\"textarea-1\" placeholder=\"E.g. text placeholder\nYou can add new line\" id=\"forminator-field-textarea-1_69f27e24a28fd\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/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\">6. Consequences of the Accident<\/h2><\/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_69f27e24a28fd\" id=\"forminator-field-textarea-2_69f27e24a28fd-label\" class=\"forminator-label\">Nature of Injury<\/label><textarea name=\"textarea-2\" placeholder=\"E.g. text placeholder\nYou can add new line\" id=\"forminator-field-textarea-2_69f27e24a28fd\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/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_69f27e24a28fd\" id=\"forminator-field-textarea-3_69f27e24a28fd-label\" class=\"forminator-label\">Location of Injury<\/label><textarea name=\"textarea-3\" placeholder=\"E.g. text placeholder\nYou can add new line\" id=\"forminator-field-textarea-3_69f27e24a28fd\" class=\"forminator-textarea\" rows=\"6\" style=\"min-height:140px;\" ><\/textarea><\/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\">Attach Documents<\/h2><\/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>All documents must be submitted within a maximum of 10 working days from the date of the accident.<br data-end=\"1232\" data-start=\"1229\">Failure to comply with this deadline may result in denial of coverage by the Insurer, with the Policyholder being responsible for all expenses related to the accident suffered by the employee.<\/p><\/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-69f27e24a28fd-label\"><span id=\"forminator-checkbox-group-69f27e24a28fd-label\" class=\"forminator-label\">Please attach all required documents:<\/span><label id=\"forminator-field-checkbox-3-1-69f27e24a28fd-label\" for=\"forminator-field-checkbox-3-1-69f27e24a28fd\" class=\"forminator-checkbox\" title=\"Valid Identity Card\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"one\" id=\"forminator-field-checkbox-3-1-69f27e24a28fd\" aria-labelledby=\"forminator-field-checkbox-3-1-69f27e24a28fd-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Valid Identity Card<\/span><\/label><label id=\"forminator-field-checkbox-3-2-69f27e24a28fd-label\" for=\"forminator-field-checkbox-3-2-69f27e24a28fd\" class=\"forminator-checkbox\" title=\"Employment Contract\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"two\" id=\"forminator-field-checkbox-3-2-69f27e24a28fd\" aria-labelledby=\"forminator-field-checkbox-3-2-69f27e24a28fd-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Employment Contract<\/span><\/label><label id=\"forminator-field-checkbox-3-3-69f27e24a28fd-label\" for=\"forminator-field-checkbox-3-3-69f27e24a28fd\" class=\"forminator-checkbox\" title=\"Hospital Admission Form, Medical Report\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Hospital-Admission-Form,-Medical-Report\" id=\"forminator-field-checkbox-3-3-69f27e24a28fd\" aria-labelledby=\"forminator-field-checkbox-3-3-69f27e24a28fd-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Hospital Admission Form, Medical Report<\/span><\/label><label id=\"forminator-field-checkbox-3-4-69f27e24a28fd-label\" for=\"forminator-field-checkbox-3-4-69f27e24a28fd\" class=\"forminator-checkbox\" title=\"Medical Certificate\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Medical-Certificate\" id=\"forminator-field-checkbox-3-4-69f27e24a28fd\" aria-labelledby=\"forminator-field-checkbox-3-4-69f27e24a28fd-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Medical Certificate<\/span><\/label><label id=\"forminator-field-checkbox-3-5-69f27e24a28fd-label\" for=\"forminator-field-checkbox-3-5-69f27e24a28fd\" class=\"forminator-checkbox\" title=\"Medical Expenses accompanied by the respective prescriptions\"><input type=\"checkbox\" name=\"checkbox-3[]\" value=\"Medical-Expenses-accompanied-by-the-respective-prescriptions\" id=\"forminator-field-checkbox-3-5-69f27e24a28fd\" aria-labelledby=\"forminator-field-checkbox-3-5-69f27e24a28fd-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">Medical Expenses accompanied by the respective prescriptions<\/span><\/label><\/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_69f27e24a28fd\" id=\"forminator-field-upload-1_69f27e24a28fd-label\" class=\"forminator-label\">Documents<\/label><div class=\"forminator-multi-upload \" data-element=\"upload-1_69f27e24a28fd\"><input type=\"file\" name=\"upload-1[]\" id=\"forminator-field-upload-1_69f27e24a28fd\" class=\"forminator-input-file forminator-field-upload-1_69f27e24a28fd-344\" 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_69f27e24a28fd\" href=\"#\" onclick=\"return false;\">Choose Files<\/a><\/p><\/div><\/div><ul class=\"forminator-uploaded-files upload-container-upload-1_69f27e24a28fd\"><\/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\">8. Declaration<\/h2><\/div><\/div><\/div><div class=\"forminator-row\"><div id=\"checkbox-2\" class=\"forminator-field-checkbox forminator-col forminator-col-12 \"><div role=\"group\" class=\"forminator-field\" aria-labelledby=\"forminator-checkbox-group-69f27e24a28fd-label\"><label id=\"forminator-field-checkbox-2-1-69f27e24a28fd-label\" for=\"forminator-field-checkbox-2-1-69f27e24a28fd\" class=\"forminator-checkbox\" title=\"The information provided is accurate, given in good faith and truthfulness, and I take full responsibility for it.\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"one\" id=\"forminator-field-checkbox-2-1-69f27e24a28fd\" aria-labelledby=\"forminator-field-checkbox-2-1-69f27e24a28fd-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">The information provided is accurate, given in good faith and truthfulness, and I take full responsibility for it.<\/span><\/label><label id=\"forminator-field-checkbox-2-2-69f27e24a28fd-label\" for=\"forminator-field-checkbox-2-2-69f27e24a28fd\" class=\"forminator-checkbox\" title=\"I authorize the Insurer to collect complementary personal data from public organizations, specialized companies and other economic units, with a view to confirming or supplementing the information collected that is necessary for the management of the contractual relationship. Omissions, inaccuracies and false statements in providing information are the responsibility of the client. Consultation of the personal data provided will be carried out under a regime of absolute confidentiality, provided it is compatible with the purpose of its collection.\"><input type=\"checkbox\" name=\"checkbox-2[]\" value=\"two\" id=\"forminator-field-checkbox-2-2-69f27e24a28fd\" aria-labelledby=\"forminator-field-checkbox-2-2-69f27e24a28fd-label\" data-calculation=\"0\"   data-hidden-behavior=\"zero\"\/><span class=\"forminator-checkbox-box\" aria-hidden=\"true\"><\/span><span class=\"forminator-checkbox-label\">I authorize the Insurer to collect complementary personal data from public organizations, specialized companies and other economic units, with a view to confirming or supplementing the information collected that is necessary for the management of the contractual relationship. Omissions, inaccuracies and false statements in providing information are the responsibility of the client. 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