{"id":242,"date":"2018-01-18T13:27:17","date_gmt":"2018-01-18T12:27:17","guid":{"rendered":"https:\/\/www.agima.be\/?page_id=242"},"modified":"2018-01-18T13:27:17","modified_gmt":"2018-01-18T12:27:17","slug":"declarez-sinistre-ligne","status":"publish","type":"page","link":"https:\/\/agima.full-moon.dev\/?page_id=242","title":{"rendered":"D\u00e9clarez-nous un sinistre en ligne"},"content":{"rendered":"<div role=\"form\" class=\"wpcf7\" id=\"wpcf7-f240-o1\" lang=\"fr-FR\" dir=\"ltr\">\n<div class=\"screen-reader-response\" role=\"alert\" aria-live=\"polite\"><\/div>\n<form action=\"\/index.php?rest_route=%2Fwp%2Fv2%2Fpages%2F242#wpcf7-f240-o1\" method=\"post\" class=\"wpcf7-form init\" novalidate=\"novalidate\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"240\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"5.2.2\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"fr_FR\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f240-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<\/div>\n<h2>Preneur d'assurance<\/h2>\n<div class=\"form-group nom\"><label class=\"\">Nom: <span class=\"required\">*<\/span><\/label><input class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" name=\"nom\" type=\"text\" value=\"\" aria-invalid=\"false\" aria-required=\"true\" required><\/div>\n<div class=\"form-group prenom\"><label class=\"\">Pr\u00e9nom:<\/label><input class=\"wpcf7-form-control wpcf7-text form-control\" name=\"prenom\" type=\"text\" value=\"\" aria-invalid=\"false\"><\/div>\n<div class=\"form-group email\"><label class=\"\">E-Mail: <span class=\"required\">*<\/span><\/label><input class=\"wpcf7-form-control wpcf7-text wpcf7-email wpcf7-validates-as-required wpcf7-validates-as-email form-control\" name=\"email\" type=\"email\" value=\"\" aria-invalid=\"false\" aria-required=\"true\" required><\/div>\n<p><small>votre adresse e-mail sur laquelle nous pouvons vous tenir inform\u00e9 de l\u2019\u00e9volution de votre dossier<\/small><\/p>\n\n<h2>Sinistre<\/h2>\n<p>Veuillez d\u00e9clarer un type de sinistre \u00e0 la fois. Si il y a plusieurs types de sinistres, remplissez un formulaire par type<\/p>\n<div class=\"form-group date\"><label class=\"\">Date du sinistre: <span class=\"required\">*<\/span><\/label><input class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required form-control\" name=\"date\" type=\"text\" value=\"\" aria-invalid=\"false\" aria-required=\"true\" required><\/div>\n<div class=\"form-group adresse\"><label class=\"\">Adresse du sinistre: <span class=\"required\">*<\/span><\/label><textarea class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required form-control\" name=\"adresse\" rows=\"4\" aria-invalid=\"false\" aria-required=\"true\" required><\/textarea><\/div>\n<div class=\"form-group type\"><label class=\"\">Type de sinistre: <span class=\"required\">*<\/span><\/label><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required form-control\" name=\"type\" aria-invalid=\"false\" aria-required=\"true\" required><option value=\"Auto\">Auto<\/option><option value=\"Incendie\">Incendie<\/option><option value=\"D\u00e9g\u00e2ts des eaux\">D\u00e9g\u00e2ts des eaux<\/option><option value=\"Dommage \u00e9lectrique\">Dommage \u00e9lectrique<\/option><option value=\"Responsabilit\u00e9 civile (dommage aux tiers)\">Responsabilit\u00e9 civile (dommage aux tiers)<\/option><option value=\"Accident corporel\">Accident corporel<\/option><option value=\"Autre\">Autre<\/option><\/select><\/div>\n<div class=\"form-group circonstances\"><label class=\"\">Circonstances exactes: <span class=\"required\">*<\/span><\/label><textarea class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required form-control\" name=\"circonstances\" rows=\"4\" aria-invalid=\"false\" aria-required=\"true\" required><\/textarea><\/div>\n\n<h2>Si tiers impliqu\u00e9<\/h2>\n<p>Si une autre personne est impliqu\u00e9e, veuillez remplir les champs suivants<\/p>\n<div class=\"form-group nomtiers\"><label class=\"\">Nom du tiers:<\/label><input class=\"wpcf7-form-control wpcf7-text form-control\" name=\"nomtiers\" type=\"text\" value=\"\" aria-invalid=\"false\"><\/div>\n<div class=\"form-group prenomtiers\"><label class=\"\">Pr\u00e9nom du tiers:<\/label><input class=\"wpcf7-form-control wpcf7-text form-control\" name=\"prenomtiers\" type=\"text\" value=\"\" aria-invalid=\"false\"><\/div>\n<div class=\"form-group adressetiers\"><label class=\"\">Adresse compl\u00e8te du tiers:<\/label><textarea class=\"wpcf7-form-control wpcf7-textarea form-control\" name=\"adressetiers\" rows=\"4\" aria-invalid=\"false\"><\/textarea><\/div>\n\n<h2>Si les faits ont fait l\u2019objet d\u2019un PV de police<\/h2>\n<div class=\"form-group autorite\"><label class=\"\">Autorit\u00e9 verbalisante:<\/label><input class=\"wpcf7-form-control wpcf7-text form-control\" name=\"autorite\" type=\"text\" value=\"\" aria-invalid=\"false\"><\/div>\n<div class=\"form-group pv\"><label class=\"\">Num\u00e9ro de PV:<\/label><input class=\"wpcf7-form-control wpcf7-text form-control\" name=\"pv\" type=\"text\" value=\"\" aria-invalid=\"false\"><\/div>\n\n[recaptcha]\n<p>&nbsp;<\/p>\n\n<div class=\"form-group\"><div><input class=\"wpcf7-form-control wpcf7-submit btn-lg btn-block btn btn-primary\" type=\"submit\" value=\"Envoyer le formulaire\"><\/div><\/div><div class=\"wpcf7-response-output alert alert-warning\"><\/div><\/form><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v14.9 - 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