{"id":3216,"date":"2020-09-01T11:12:16","date_gmt":"2020-09-01T09:12:16","guid":{"rendered":"https:\/\/www.pspi.ch\/?page_id=3216"},"modified":"2024-03-20T11:01:56","modified_gmt":"2024-03-20T10:01:56","slug":"loss-of-income-in-case-of-illness","status":"publish","type":"page","link":"https:\/\/www.pspi.ch\/en\/loss-of-income-in-case-of-illness\/","title":{"rendered":"Loss of income in case of illness"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"3216\" class=\"elementor elementor-3216 elementor-3089\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-41fea46 e-flex e-con-boxed e-con e-parent\" data-id=\"41fea46\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t<div class=\"elementor-element elementor-element-aa84126 e-con-full e-flex e-con e-child\" data-id=\"aa84126\" data-element_type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t<div class=\"elementor-element elementor-element-b43bfab e-flex e-con-boxed e-con e-child\" data-id=\"b43bfab\" data-element_type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;,&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-430380b elementor-widget__width-auto elementor-widget-tablet__width-auto elementor-widget elementor-widget-heading\" data-id=\"430380b\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Loss of income<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-075a8de elementor-widget__width-auto elementor-widget-tablet__width-auto elementor-widget elementor-widget-heading\" data-id=\"075a8de\" data-element_type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class=\"elementor-heading-title elementor-size-default\">in case of illness<\/div>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-47c2080 e-flex e-con-boxed e-con e-child\" data-id=\"47c2080\" data-element_type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-dbf8e13 uael-gf-ajax-yes uael-gf-style-underline uael-gf-check-yes uael-gf-btn-size-md uael-gf-input-size-sm uael-gf-enable-classes-no uael-gf-button-left elementor-widget elementor-widget-uael-gf-styler\" data-id=\"dbf8e13\" data-element_type=\"widget\" data-widget_type=\"uael-gf-styler.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t<div class=\"uael-gf-style uael-gf-check-style elementor-clickable\">\n\t<script type=\"text\/javascript\">var gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,initializeOnLoaded:function(o){gform.domLoaded&&gform.scriptsLoaded?o():!gform.domLoaded&&gform.scriptsLoaded?window.addEventListener(\"DOMContentLoaded\",o):document.addEventListener(\"gform_main_scripts_loaded\",o)},hooks:{action:{},filter:{}},addAction:function(o,n,r,t){gform.addHook(\"action\",o,n,r,t)},addFilter:function(o,n,r,t){gform.addHook(\"filter\",o,n,r,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,n){gform.removeHook(\"action\",o,n)},removeFilter:function(o,n,r){gform.removeHook(\"filter\",o,n,r)},addHook:function(o,n,r,t,i){null==gform.hooks[o][n]&&(gform.hooks[o][n]=[]);var e=gform.hooks[o][n];null==i&&(i=n+\"_\"+e.length),gform.hooks[o][n].push({tag:i,callable:r,priority:t=null==t?10:t})},doHook:function(n,o,r){var t;if(r=Array.prototype.slice.call(r,1),null!=gform.hooks[n][o]&&((o=gform.hooks[n][o]).sort(function(o,n){return o.priority-n.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==n?t.apply(null,r):r[0]=t.apply(null,r)})),\"filter\"==n)return r[0]},removeHook:function(o,n,t,i){var r;null!=gform.hooks[o][n]&&(r=(r=gform.hooks[o][n]).filter(function(o,n,r){return!!(null!=i&&i!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][n]=r)}});<\/script>\n                <div class='gf_browser_gecko gform_wrapper gform_legacy_markup_wrapper gform-theme--no-framework' data-form-theme='legacy' data-form-index='0' id='gform_wrapper_8' style='display:none'><div id='gf_8' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_8' id='gform_8'  action='\/en\/wp-json\/wp\/v2\/pages\/3216#gf_8' data-formid='8' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_8' class='gform_fields left_label form_sublabel_below description_below validation_below'><li id=\"field_8_1\" class=\"gfield gfield--type-email gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_1\" ><label class='gfield_label gform-field-label' for='input_8_1'>Your email address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_email'>\n                            <input name='input_1' id='input_8_1' type='email' value='' class='large' tabindex='1'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_8_118\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_118\" ><label class='gfield_label gform-field-label' >Sickness<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_118'>\n\t\t\t<li class='gchoice gchoice_8_118_0'>\n\t\t\t\t<input name='input_118' type='radio' value='Sickness'  id='choice_8_118_0' tabindex='2'   \/>\n\t\t\t\t<label for='choice_8_118_0' id='label_8_118_0' class='gform-field-label gform-field-label--type-inline'>Sickness<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_118_1'>\n\t\t\t\t<input name='input_118' type='radio' value='Maternity'  id='choice_8_118_1' tabindex='3'   \/>\n\t\t\t\t<label for='choice_8_118_1' id='label_8_118_1' class='gform-field-label gform-field-label--type-inline'>Maternity<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_118_2'>\n\t\t\t\t<input name='input_118' type='radio' value='Death'  id='choice_8_118_2' tabindex='4'   \/>\n\t\t\t\t<label for='choice_8_118_2' id='label_8_118_2' class='gform-field-label gform-field-label--type-inline'>Death<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_119\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_119\" ><label class='gfield_label gform-field-label' for='input_8_119'>Date of birth<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_119' id='input_8_119' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon' tabindex='5'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_8_119_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_8_119_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_119' class='gform_hidden' value='https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_8_120\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_120\" ><label class='gfield_label gform-field-label' for='input_8_120'>Death on<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_120' id='input_8_120' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon' tabindex='6'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_8_120_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_8_120_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_120' class='gform_hidden' value='https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_8_3\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_3\" ><h2 class=\"gsection_title\">Insurance information<\/h2><\/li><li id=\"field_8_4\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_4\" ><label class='gfield_label gform-field-label' for='input_8_4'>Insurance company<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_8_4' type='text' value='' class='large'   tabindex='7'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_5\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_5\" ><label class='gfield_label gform-field-label' for='input_8_5'>No of insurance policy<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_8_5' type='text' value='' class='large'   tabindex='8'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_6\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_6\" ><h2 class=\"gsection_title\">Employer<\/h2><\/li><li id=\"field_8_8\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_8\" ><label class='gfield_label gform-field-label' for='input_8_8'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_8' id='input_8_8' type='text' value='' class='large'   tabindex='9'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_7\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_7\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_zip has_country ginput_container_address gform-grid-row' id='input_8_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_8_7_1_container' >\n                                        <input type='text' name='input_7.1' id='input_8_7_1' value='' tabindex='10'   aria-required='true'    \/>\n                                        <label for='input_8_7_1' id='input_8_7_1_label' class='gform-field-label gform-field-label--type-sub '>Street Adress<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_8_7_2_container' >\n                                        <input type='text' name='input_7.2' id='input_8_7_2' value='' tabindex='11'    aria-required='false'   \/>\n                                        <label for='input_8_7_2' id='input_8_7_2_label' class='gform-field-label gform-field-label--type-sub '>Street Adress 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_8_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_8_7_3' value='' tabindex='12'   aria-required='true'    \/>\n                                    <label for='input_8_7_3' id='input_8_7_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_7.4' id='input_8_7_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_8_7_5_container' >\n                                    <input type='text' name='input_7.5' id='input_8_7_5' value='' tabindex='13'   aria-required='true'    \/>\n                                    <label for='input_8_7_5' id='input_8_7_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_8_7_6_container' >\n                                        <select name='input_7.6' id='input_8_7_6' tabindex='14'  aria-required='true'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_8_7_6' id='input_8_7_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_8_9\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_9\" ><h2 class=\"gsection_title\">Insured person<\/h2><\/li><li id=\"field_8_10\" class=\"gfield gfield--type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_10\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_8_10'>\n                            \n                            <span id='input_8_10_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_10.3' id='input_8_10_3' value='' tabindex='16'  aria-required='true'     \/>\n                                                    <label for='input_8_10_3' class='gform-field-label gform-field-label--type-sub '>First Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_8_10_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_10.6' id='input_8_10_6' value='' tabindex='18'  aria-required='true'     \/>\n                                                    <label for='input_8_10_6' class='gform-field-label gform-field-label--type-sub '>Last Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_8_11\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_11\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_zip has_country ginput_container_address gform-grid-row' id='input_8_11' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_8_11_1_container' >\n                                        <input type='text' name='input_11.1' id='input_8_11_1' value='' tabindex='20'   aria-required='true'    \/>\n                                        <label for='input_8_11_1' id='input_8_11_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_8_11_2_container' >\n                                        <input type='text' name='input_11.2' id='input_8_11_2' value='' tabindex='21'    aria-required='false'   \/>\n                                        <label for='input_8_11_2' id='input_8_11_2_label' class='gform-field-label gform-field-label--type-sub '>Street Address 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_8_11_3_container' >\n                                    <input type='text' name='input_11.3' id='input_8_11_3' value='' tabindex='22'   aria-required='true'    \/>\n                                    <label for='input_8_11_3' id='input_8_11_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_11.4' id='input_8_11_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_8_11_5_container' >\n                                    <input type='text' name='input_11.5' id='input_8_11_5' value='' tabindex='23'   aria-required='true'    \/>\n                                    <label for='input_8_11_5' id='input_8_11_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_8_11_6_container' >\n                                        <select name='input_11.6' id='input_8_11_6' tabindex='24'  aria-required='true'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_8_11_6' id='input_8_11_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_8_12\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_12\" ><label class='gfield_label gform-field-label' for='input_8_12'>Date of birth<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_12' id='input_8_12' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon' tabindex='25'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_8_12_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_8_12_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_12' class='gform_hidden' value='https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_8_110\" class=\"gfield gfield--type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_110\" ><label class='gfield_label gform-field-label' for='input_8_110'>Marital status<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_110' id='input_8_110' class='medium gfield_select' tabindex='26'   aria-required=\"true\" aria-invalid=\"false\" ><option value='Married' >Married<\/option><option value='Single' >Single<\/option><option value='Divorced' >Divorced<\/option><option value='Widow\/Widower' >Widow\/Widower<\/option><\/select><\/div><\/li><li id=\"field_8_14\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_14\" ><label class='gfield_label gform-field-label' for='input_8_14'>Nationality<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_14' id='input_8_14' type='text' value='' class='large'   tabindex='27'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_15\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_15\" ><label class='gfield_label gform-field-label' for='input_8_15'>Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_15' id='input_8_15' type='text' value='' class='large'   tabindex='28'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_16\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_16\" ><label class='gfield_label gform-field-label' for='input_8_16'>No AVS<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_16' id='input_8_16' type='text' value='' class='large'   tabindex='29'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_19\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_19\" ><h2 class=\"gsection_title\">Commitment<\/h2><\/li><li id=\"field_8_20\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_20\" ><label class='gfield_label gform-field-label' for='input_8_20'>Commitment date<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_20' id='input_8_20' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon' tabindex='30'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_8_20_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_8_20_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_20' class='gform_hidden' value='https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_8_21\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_21\" ><label class='gfield_label gform-field-label' for='input_8_21'>Position in the company<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_21' id='input_8_21' type='text' value='' class='large'   tabindex='31'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_22\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_22\" ><label class='gfield_label gform-field-label' for='input_8_22'>Usual place of the insured<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_22' id='input_8_22' type='text' value='' class='large'  aria-describedby=\"gfield_description_8_22\" tabindex='32'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_8_22'>business sector: reception, secretarial, IT, machine room, etc.<\/div><\/li><li id=\"field_8_23\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_23\" ><label class='gfield_label gform-field-label' >Function<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_23'>\n\t\t\t<li class='gchoice gchoice_8_23_0'>\n\t\t\t\t<input name='input_23' type='radio' value='Senior Executive'  id='choice_8_23_0' tabindex='33'   \/>\n\t\t\t\t<label for='choice_8_23_0' id='label_8_23_0' class='gform-field-label gform-field-label--type-inline'>Senior Executive<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_23_1'>\n\t\t\t\t<input name='input_23' type='radio' value='Middle Manager'  id='choice_8_23_1' tabindex='34'   \/>\n\t\t\t\t<label for='choice_8_23_1' id='label_8_23_1' class='gform-field-label gform-field-label--type-inline'>Middle Manager<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_23_2'>\n\t\t\t\t<input name='input_23' type='radio' value='Employee\/worker'  id='choice_8_23_2' tabindex='35'   \/>\n\t\t\t\t<label for='choice_8_23_2' id='label_8_23_2' class='gform-field-label gform-field-label--type-inline'>Employee\/worker<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_23_3'>\n\t\t\t\t<input name='input_23' type='radio' value='Apprentice'  id='choice_8_23_3' tabindex='36'   \/>\n\t\t\t\t<label for='choice_8_23_3' id='label_8_23_3' class='gform-field-label gform-field-label--type-inline'>Apprentice<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_23_4'>\n\t\t\t\t<input name='input_23' type='radio' value='Trainee'  id='choice_8_23_4' tabindex='37'   \/>\n\t\t\t\t<label for='choice_8_23_4' id='label_8_23_4' class='gform-field-label gform-field-label--type-inline'>Trainee<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_24\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_24\" ><label class='gfield_label gform-field-label' for='input_8_24'>End date of the course<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_24' id='input_8_24' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon' tabindex='38'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_8_24_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_8_24_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_24' class='gform_hidden' value='https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_8_117\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_117\" ><label class='gfield_label gform-field-label' for='input_8_117'>Apprenticeship end date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_117' id='input_8_117' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon' tabindex='39'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_8_117_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_8_117_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_117' class='gform_hidden' value='https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_8_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_25\" ><label class='gfield_label gform-field-label' >Contract of employment<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_25'>\n\t\t\t<li class='gchoice gchoice_8_25_0'>\n\t\t\t\t<input name='input_25' type='radio' value='Open-ended contract'  id='choice_8_25_0' tabindex='40'   \/>\n\t\t\t\t<label for='choice_8_25_0' id='label_8_25_0' class='gform-field-label gform-field-label--type-inline'>Open-ended contract<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_25_1'>\n\t\t\t\t<input name='input_25' type='radio' value='Fixed-term contract'  id='choice_8_25_1' tabindex='41'   \/>\n\t\t\t\t<label for='choice_8_25_1' id='label_8_25_1' class='gform-field-label gform-field-label--type-inline'>Fixed-term contract<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_25_2'>\n\t\t\t\t<input name='input_25' type='radio' value='Terminated employment contract'  id='choice_8_25_2' tabindex='42'   \/>\n\t\t\t\t<label for='choice_8_25_2' id='label_8_25_2' class='gform-field-label gform-field-label--type-inline'>Terminated employment contract<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_27\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_27\" ><label class='gfield_label gform-field-label' for='input_8_27'>until<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_27' id='input_8_27' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon' tabindex='43'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_8_27_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_8_27_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_27' class='gform_hidden' value='https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_8_28\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_28\" ><label class='gfield_label gform-field-label' for='input_8_28'>for the<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_28' id='input_8_28' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon' tabindex='44'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_8_28_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_8_28_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_28' class='gform_hidden' value='https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_8_26\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_26\" ><label class='gfield_label gform-field-label' for='input_8_26'>Contractual occupancy rate (%)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_26' id='input_8_26' type='text' value='' class='large'   tabindex='45'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_29\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_29\" ><label class='gfield_label gform-field-label' >Occupation<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_29'>\n\t\t\t<li class='gchoice gchoice_8_29_0'>\n\t\t\t\t<input name='input_29' type='radio' value='Irregular'  id='choice_8_29_0' tabindex='46'   \/>\n\t\t\t\t<label for='choice_8_29_0' id='label_8_29_0' class='gform-field-label gform-field-label--type-inline'>Irregular<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_29_1'>\n\t\t\t\t<input name='input_29' type='radio' value='Partial unemployment'  id='choice_8_29_1' tabindex='47'   \/>\n\t\t\t\t<label for='choice_8_29_1' id='label_8_29_1' class='gform-field-label gform-field-label--type-inline'>Partial unemployment<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_31\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_31\" ><label class='gfield_label gform-field-label' for='input_8_31'>Working hours of the insured person<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_31' id='input_8_31' type='text' value='' class='large'  aria-describedby=\"gfield_description_8_31\" tabindex='48'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_8_31'>hour per week<\/div><\/li><li id=\"field_8_30\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_30\" ><label class='gfield_label gform-field-label' for='input_8_30'>Number of days per week<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_30' id='input_8_30' type='text' value='' class='large'   tabindex='49'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_32\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_32\" ><label class='gfield_label gform-field-label' for='input_8_32'>Usual working hours of the company<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_32' id='input_8_32' type='text' value='' class='large'  aria-describedby=\"gfield_description_8_32\" tabindex='50'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_8_32'>hours per week<\/div><\/li><li id=\"field_8_33\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_33\" ><h2 class=\"gsection_title\">Incapacity to work<\/h2><\/li><li id=\"field_8_48\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_48\" ><label class='gfield_label gform-field-label' for='input_8_48'>Stopped working due to illness as of<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_48' id='input_8_48' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon' tabindex='51'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_8_48_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_8_48_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_48' class='gform_hidden' value='https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_8_121\" class=\"gfield gfield--type-radio gfield--type-choice gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_121\" ><label class='gfield_label gform-field-label screen-reader-text' ><span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_121'>\n\t\t\t<li class='gchoice gchoice_8_121_0'>\n\t\t\t\t<input name='input_121' type='radio' value='Completely'  id='choice_8_121_0' tabindex='52'   \/>\n\t\t\t\t<label for='choice_8_121_0' id='label_8_121_0' class='gform-field-label gform-field-label--type-inline'>Completely<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_121_1'>\n\t\t\t\t<input name='input_121' type='radio' value='Partly'  id='choice_8_121_1' tabindex='53'   \/>\n\t\t\t\t<label for='choice_8_121_1' id='label_8_121_1' class='gform-field-label gform-field-label--type-inline'>Partly<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_122\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_122\" ><label class='gfield_label gform-field-label' for='input_8_122'>Partially to (in %)<\/label><div class='ginput_container ginput_container_text'><input name='input_122' id='input_8_122' type='text' value='' class='large'   tabindex='54'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_59\" class=\"gfield gfield--type-checkbox gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_59\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Expected duration of absence<\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_8_59'><li class='gchoice gchoice_8_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Sup\u00e9rieure \u00e0 1mois'  id='choice_8_59_1' tabindex='55'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_8_59_1' id='label_8_59_1' class='gform-field-label gform-field-label--type-inline'>Sup\u00e9rieure \u00e0 1mois<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_60\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_60\" ><label class='gfield_label gform-field-label' for='input_8_60'>Has the work been resumed?<\/label><div class='ginput_container ginput_container_select'><select name='input_60' id='input_8_60' class='medium gfield_select' tabindex='56'    aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Yes, full time' >Yes, full time<\/option><option value='Yes, part-time' >Yes, part-time<\/option><\/select><\/div><\/li><li id=\"field_8_61\" class=\"gfield gfield--type-date gfield--input-type-datepicker gfield--datepicker-default-icon field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_61\" ><label class='gfield_label gform-field-label' for='input_8_61'>If so, since when?<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_61' id='input_8_61' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon' tabindex='57'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_8_61_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_8_61_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_8_61' class='gform_hidden' value='https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_8_62\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_62\" ><label class='gfield_label gform-field-label' for='input_8_62'>partially (%)<\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_8_62' type='text' value='' class='large'   tabindex='58'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_123\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_123\" ><label class='gfield_label gform-field-label' >Do you consider patient monitoring necessary?<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_123'>\n\t\t\t<li class='gchoice gchoice_8_123_0'>\n\t\t\t\t<input name='input_123' type='radio' value='Yes'  id='choice_8_123_0' tabindex='59'   \/>\n\t\t\t\t<label for='choice_8_123_0' id='label_8_123_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_123_1'>\n\t\t\t\t<input name='input_123' type='radio' value='No'  id='choice_8_123_1' tabindex='60'   \/>\n\t\t\t\t<label for='choice_8_123_1' id='label_8_123_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_65\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_65\" ><h2 class=\"gsection_title\">Treating doctor\/hospital<\/h2><\/li><li id=\"field_8_69\" class=\"gfield gfield--type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_69\" ><label class='gfield_label gform-field-label' for='input_8_69'>Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_69' id='input_8_69' type='text' value='' class='large'   tabindex='61'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_70\" class=\"gfield gfield--type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_70\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label>    \n                    <div class='ginput_complex ginput_container has_street has_street2 has_city has_zip has_country ginput_container_address gform-grid-row' id='input_8_70' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_8_70_1_container' >\n                                        <input type='text' name='input_70.1' id='input_8_70_1' value='' tabindex='62'   aria-required='true'    \/>\n                                        <label for='input_8_70_1' id='input_8_70_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_full address_line_2 ginput_address_line_2 gform-grid-col' id='input_8_70_2_container' >\n                                        <input type='text' name='input_70.2' id='input_8_70_2' value='' tabindex='63'    aria-required='false'   \/>\n                                        <label for='input_8_70_2' id='input_8_70_2_label' class='gform-field-label gform-field-label--type-sub '>Street Address 2<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_8_70_3_container' >\n                                    <input type='text' name='input_70.3' id='input_8_70_3' value='' tabindex='64'   aria-required='true'    \/>\n                                    <label for='input_8_70_3' id='input_8_70_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_70.4' id='input_8_70_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_8_70_5_container' >\n                                    <input type='text' name='input_70.5' id='input_8_70_5' value='' tabindex='65'   aria-required='true'    \/>\n                                    <label for='input_8_70_5' id='input_8_70_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_8_70_6_container' >\n                                        <select name='input_70.6' id='input_8_70_6' tabindex='66'  aria-required='true'    ><option value='' ><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_8_70_6' id='input_8_70_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_8_71\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_71\" ><label class='gfield_label gform-field-label' for='input_8_71'>Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_8_71' type='text' value='' class='large'   tabindex='67'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_76\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_76\" ><h2 class=\"gsection_title\">Salary<\/h2><div class='gsection_description' id='gfield_description_8_76'>According to AVS or policy if agreed differently<\/div><\/li><li id=\"field_8_88\" class=\"gfield gfield--type-list gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_88\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Gross basic pay before the beginning of the incapacity for work or the average of the last 12 months in the case of irregular periods of work or strong variations<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><style type=\"text\/css\">\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons {\n\t\t\t\t\t\t\tvertical-align: middle !important;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons img {\n\t\t\t\t\t\t\tbackground-color: transparent !important;\n\t\t\t\t\t\t\tbackground-position: 0 0;\n\t\t\t\t\t\t\tbackground-size: 16px 16px !important;\n\t\t\t\t\t\t\tbackground-repeat: no-repeat;\n\t\t\t\t\t\t\tborder: none !important;\n\t\t\t\t\t\t\twidth: 16px !important;\n\t\t\t\t\t\t\theight: 16px !important;\n\t\t\t\t\t\t\topacity: 0.5;\n\t\t\t\t\t\t\ttransition: opacity .5s ease-out;\n\t\t\t\t\t\t    -moz-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -webkit-transition: opacity .5s ease-out;\n\t\t\t\t\t\t    -o-transition: opacity .5s ease-out;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\tbody .ginput_container_list table.gfield_list tbody tr td.gfield_list_icons a:hover img {\n\t\t\t\t\t\t\topacity: 1.0;\n\t\t\t\t\t\t}\n\n\t\t\t\t\t\t<\/style><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_88_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_88_col_2' class='gfield_list_col_even' \/><col id='gfield_list_88_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_88_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th scope=\"col\">CHF per hour<\/th><th scope=\"col\">CHF per Month<\/th><th scope=\"col\">CHF per Year<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_88_cell1' data-label='CHF per hour'><input aria-invalid='false' aria-required=\"true\"  aria-label='CHF per hour, Row 1' data-aria-label-template='CHF per hour, Row {0}' type='text' name='input_88[]' value='' tabindex='68'  \/><\/td><td class='gfield_list_cell gfield_list_88_cell2' data-label='CHF per Month'><input aria-invalid='false' aria-required=\"true\"  aria-label='CHF per Month, Row 1' data-aria-label-template='CHF per Month, Row {0}' type='text' name='input_88[]' value='' tabindex='69'  \/><\/td><td class='gfield_list_cell gfield_list_88_cell3' data-label='CHF per Year'><input aria-invalid='false' aria-required=\"true\"  aria-label='CHF per Year, Row 1' data-aria-label-template='CHF per Year, Row {0}' type='text' name='input_88[]' value='' tabindex='70'  \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id=\"field_8_124\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_124\" ><label class='gfield_label gform-field-label' for='input_8_124'>Child and family allowances<\/label><div class='ginput_container ginput_container_text'><input name='input_124' id='input_8_124' type='text' value='' class='large'   tabindex='71'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_90\" class=\"gfield gfield--type-list field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_90\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Gratuity, 13&quot; month&#039;s salary (and subsequent)*.<\/label><div class='ginput_container ginput_container_list ginput_list'><table class='gfield_list gfield_list_container'><colgroup><col id='gfield_list_90_col_1' class='gfield_list_col_odd' \/><col id='gfield_list_90_col_2' class='gfield_list_col_even' \/><col id='gfield_list_90_col_3' class='gfield_list_col_odd' \/><col id='gfield_list_90_col_4' class='gfield_list_col_even' \/><\/colgroup><thead><tr><th scope=\"col\">CHF per hour<\/th><th scope=\"col\">CHF per Month<\/th><th scope=\"col\">CHF per Year<\/th><\/tr><\/thead><tbody><tr class='gfield_list_row_odd gfield_list_group'><td class='gfield_list_cell gfield_list_90_cell1' data-label='CHF per hour'><input aria-invalid='false'   aria-label='CHF per hour, Row 1' data-aria-label-template='CHF per hour, Row {0}' type='text' name='input_90[]' value='' tabindex='72'  \/><\/td><td class='gfield_list_cell gfield_list_90_cell2' data-label='CHF per Month'><input aria-invalid='false'   aria-label='CHF per Month, Row 1' data-aria-label-template='CHF per Month, Row {0}' type='text' name='input_90[]' value='' tabindex='73'  \/><\/td><td class='gfield_list_cell gfield_list_90_cell3' data-label='CHF per Year'><input aria-invalid='false'   aria-label='CHF per Year, Row 1' data-aria-label-template='CHF per Year, Row {0}' type='text' name='input_90[]' value='' tabindex='74'  \/><\/td><\/tr><\/tbody><\/table><\/div><\/li><li id=\"field_8_125\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_125\" ><label class='gfield_label gform-field-label' for='input_8_125'>Holiday and public holiday pay<\/label><div class='ginput_container ginput_container_text'><input name='input_125' id='input_8_125' type='text' value='' class='large'   tabindex='75'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_126\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_126\" ><label class='gfield_label gform-field-label' for='input_8_126'>Other salary complements<\/label><div class='ginput_container ginput_container_text'><input name='input_126' id='input_8_126' type='text' value='' class='large'   tabindex='76'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_73\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_73\" ><label class='gfield_label gform-field-label' for='input_8_73'>Type of salary supplement<\/label><div class='ginput_container ginput_container_text'><input name='input_73' id='input_8_73' type='text' value='' class='large'   tabindex='77'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_94\" class=\"gfield gfield--type-radio gfield--type-choice gf_list_inline field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_94\" ><label class='gfield_label gform-field-label' >Taxed at source<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_94'>\n\t\t\t<li class='gchoice gchoice_8_94_0'>\n\t\t\t\t<input name='input_94' type='radio' value='Yes' checked='checked' id='choice_8_94_0' tabindex='78'   \/>\n\t\t\t\t<label for='choice_8_94_0' id='label_8_94_0' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_94_1'>\n\t\t\t\t<input name='input_94' type='radio' value='No'  id='choice_8_94_1' tabindex='79'   \/>\n\t\t\t\t<label for='choice_8_94_1' id='label_8_94_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_127\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_127\" ><label class='gfield_label gform-field-label' for='input_8_127'>No RCE<\/label><div class='ginput_container ginput_container_text'><input name='input_127' id='input_8_127' type='text' value='' class='large'   tabindex='80'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_95\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_95\" ><h2 class=\"gsection_title\">Payment details<\/h2><\/li><li id=\"field_8_96\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_96\" ><label class='gfield_label gform-field-label' >Payment to<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_96'>\n\t\t\t<li class='gchoice gchoice_8_96_0'>\n\t\t\t\t<input name='input_96' type='radio' value='Employer' checked='checked' id='choice_8_96_0' tabindex='81'   \/>\n\t\t\t\t<label for='choice_8_96_0' id='label_8_96_0' class='gform-field-label gform-field-label--type-inline'>Employer<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_96_1'>\n\t\t\t\t<input name='input_96' type='radio' value='Insured person'  id='choice_8_96_1' tabindex='82'   \/>\n\t\t\t\t<label for='choice_8_96_1' id='label_8_96_1' class='gform-field-label gform-field-label--type-inline'>Insured person<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_97\" class=\"gfield gfield--type-radio gfield--type-choice field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_97\" ><label class='gfield_label gform-field-label' >To be paid on<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_8_97'>\n\t\t\t<li class='gchoice gchoice_8_97_0'>\n\t\t\t\t<input name='input_97' type='radio' value='Bank account' checked='checked' id='choice_8_97_0' tabindex='83'   \/>\n\t\t\t\t<label for='choice_8_97_0' id='label_8_97_0' class='gform-field-label gform-field-label--type-inline'>Bank account<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_8_97_1'>\n\t\t\t\t<input name='input_97' type='radio' value='CCP'  id='choice_8_97_1' tabindex='84'   \/>\n\t\t\t\t<label for='choice_8_97_1' id='label_8_97_1' class='gform-field-label gform-field-label--type-inline'>CCP<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_8_98\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_98\" ><label class='gfield_label gform-field-label' for='input_8_98'>N\u00b0 CCP<\/label><div class='ginput_container ginput_container_text'><input name='input_98' id='input_8_98' type='text' value='' class='large'   tabindex='85'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_109\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_109\" ><label class='gfield_label gform-field-label' for='input_8_109'>Name of the bank<\/label><div class='ginput_container ginput_container_text'><input name='input_109' id='input_8_109' type='text' value='' class='large'   tabindex='86'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_99\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_99\" ><label class='gfield_label gform-field-label' for='input_8_99'>Account holder<\/label><div class='ginput_container ginput_container_text'><input name='input_99' id='input_8_99' type='text' value='' class='large'   tabindex='87'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_105\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_105\" ><label class='gfield_label gform-field-label' for='input_8_105'>IBAN<\/label><div class='ginput_container ginput_container_text'><input name='input_105' id='input_8_105' type='text' value='' class='large'   tabindex='88'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_128\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_128\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Bank address<\/label>    \n                    <div class='ginput_complex ginput_container has_street has_city has_zip has_country ginput_container_address gform-grid-row' id='input_8_128' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_8_128_1_container' >\n                                        <input type='text' name='input_128.1' id='input_8_128_1' value='' tabindex='89'   aria-required='false'    \/>\n                                        <label for='input_8_128_1' id='input_8_128_1_label' class='gform-field-label gform-field-label--type-sub '>Street Address<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_8_128_3_container' >\n                                    <input type='text' name='input_128.3' id='input_8_128_3' value='' tabindex='90'   aria-required='false'    \/>\n                                    <label for='input_8_128_3' id='input_8_128_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_128.4' id='input_8_128_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_8_128_5_container' >\n                                    <input type='text' name='input_128.5' id='input_8_128_5' value='' tabindex='91'   aria-required='false'    \/>\n                                    <label for='input_8_128_5' id='input_8_128_5_label' class='gform-field-label gform-field-label--type-sub '>Postal Code<\/label>\n                                <\/span><span class='ginput_left address_country ginput_address_country gform-grid-col' id='input_8_128_6_container' >\n                                        <select name='input_128.6' id='input_8_128_6' tabindex='92'  aria-required='false'    ><option value='' selected='selected'><\/option><option value='Afghanistan' >Afghanistan<\/option><option value='Albania' >Albania<\/option><option value='Algeria' >Algeria<\/option><option value='American Samoa' >American Samoa<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antarctica' >Antarctica<\/option><option value='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/option><option value='Aruba' >Aruba<\/option><option value='Australia' >Australia<\/option><option value='Austria' >Austria<\/option><option value='Azerbaijan' >Azerbaijan<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bahrain' >Bahrain<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Belarus' >Belarus<\/option><option value='Belgium' >Belgium<\/option><option value='Belize' >Belize<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhutan' >Bhutan<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, Sint Eustatius and Saba' >Bonaire, Sint Eustatius and Saba<\/option><option value='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Bouvet Island' >Bouvet Island<\/option><option value='Brazil' >Brazil<\/option><option value='British Indian Ocean Territory' >British Indian Ocean Territory<\/option><option value='Brunei Darussalam' >Brunei Darussalam<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cayman Islands' >Cayman Islands<\/option><option value='Central African Republic' >Central African Republic<\/option><option value='Chad' >Chad<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Christmas Island' >Christmas Island<\/option><option value='Cocos Islands' >Cocos Islands<\/option><option value='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo' >Congo<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Cook Islands' >Cook Islands<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Croatia' >Croatia<\/option><option value='Cuba' >Cuba<\/option><option value='Cura\u00e7ao' >Cura\u00e7ao<\/option><option value='Cyprus' >Cyprus<\/option><option value='Czechia' >Czechia<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/option><option value='Denmark' >Denmark<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Dominican Republic' >Dominican Republic<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egypt' >Egypt<\/option><option value='El Salvador' >El Salvador<\/option><option value='Equatorial Guinea' >Equatorial Guinea<\/option><option value='Eritrea' >Eritrea<\/option><option value='Estonia' >Estonia<\/option><option value='Eswatini' >Eswatini<\/option><option value='Ethiopia' >Ethiopia<\/option><option value='Falkland Islands' >Falkland Islands<\/option><option value='Faroe Islands' >Faroe Islands<\/option><option value='Fiji' >Fiji<\/option><option value='Finland' >Finland<\/option><option value='France' >France<\/option><option value='French Guiana' >French Guiana<\/option><option value='French Polynesia' >French Polynesia<\/option><option value='French Southern Territories' >French Southern Territories<\/option><option value='Gabon' >Gabon<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Germany' >Germany<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guadeloupe' >Guadeloupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea-Bissau' >Guinea-Bissau<\/option><option value='Guyana' >Guyana<\/option><option value='Haiti' >Haiti<\/option><option value='Heard Island and McDonald Islands' >Heard Island and McDonald Islands<\/option><option value='Holy See' >Holy See<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungary' >Hungary<\/option><option value='Iceland' >Iceland<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iran' >Iran<\/option><option value='Iraq' >Iraq<\/option><option value='Ireland' >Ireland<\/option><option value='Isle of Man' >Isle of Man<\/option><option value='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jersey' >Jersey<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='Korea, Democratic People&#039;s Republic of' >Korea, Democratic People&#039;s Republic of<\/option><option value='Korea, Republic of' >Korea, Republic of<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Lao People&#039;s Democratic Republic' >Lao People&#039;s Democratic Republic<\/option><option value='Latvia' >Latvia<\/option><option value='Lebanon' >Lebanon<\/option><option value='Lesotho' >Lesotho<\/option><option value='Liberia' >Liberia<\/option><option value='Libya' >Libya<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lithuania' >Lithuania<\/option><option value='Luxembourg' >Luxembourg<\/option><option value='Macao' >Macao<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malawi' >Malawi<\/option><option value='Malaysia' >Malaysia<\/option><option value='Maldives' >Maldives<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marshall Islands' >Marshall Islands<\/option><option value='Martinique' >Martinique<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/option><option value='Mayotte' >Mayotte<\/option><option value='Mexico' >Mexico<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldova' >Moldova<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Morocco' >Morocco<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Netherlands' >Netherlands<\/option><option value='New Caledonia' >New Caledonia<\/option><option value='New Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Norfolk Island' >Norfolk Island<\/option><option value='North Macedonia' >North Macedonia<\/option><option value='Northern Mariana Islands' >Northern Mariana Islands<\/option><option value='Norway' >Norway<\/option><option value='Oman' >Oman<\/option><option value='Pakistan' >Pakistan<\/option><option value='Palau' >Palau<\/option><option value='Palestine, State of' >Palestine, State of<\/option><option value='Panama' >Panama<\/option><option value='Papua New Guinea' >Papua New Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Peru' >Peru<\/option><option value='Philippines' >Philippines<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Poland' >Poland<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Romania' >Romania<\/option><option value='Russian Federation' >Russian Federation<\/option><option value='Rwanda' >Rwanda<\/option><option value='R\u00e9union' >R\u00e9union<\/option><option value='Saint Barth\u00e9lemy' >Saint Barth\u00e9lemy<\/option><option value='Saint Helena, Ascension and Tristan da Cunha' >Saint Helena, Ascension and Tristan da Cunha<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/option><option value='Saint Martin' >Saint Martin<\/option><option value='Saint Pierre and Miquelon' >Saint Pierre and Miquelon<\/option><option value='Saint Vincent and the Grenadines' >Saint Vincent and the Grenadines<\/option><option value='Samoa' >Samoa<\/option><option value='San Marino' >San Marino<\/option><option value='Sao Tome and Principe' >Sao Tome and Principe<\/option><option value='Saudi Arabia' >Saudi Arabia<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leone' >Sierra Leone<\/option><option value='Singapore' >Singapore<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Slovakia' >Slovakia<\/option><option value='Slovenia' >Slovenia<\/option><option value='Solomon Islands' >Solomon Islands<\/option><option value='Somalia' >Somalia<\/option><option value='South Africa' >South Africa<\/option><option value='South Georgia and the South Sandwich Islands' >South Georgia and the South Sandwich Islands<\/option><option value='South Sudan' >South Sudan<\/option><option value='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Suriname' >Suriname<\/option><option value='Svalbard and Jan Mayen' >Svalbard and Jan Mayen<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria Arab Republic' >Syria Arab Republic<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania, the United Republic of' >Tanzania, the United Republic of<\/option><option value='Thailand' >Thailand<\/option><option value='Timor-Leste' >Timor-Leste<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Turks and Caicos Islands' >Turks and Caicos Islands<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fcrkiye' >T\u00fcrkiye<\/option><option value='US Minor Outlying Islands' >US Minor Outlying Islands<\/option><option value='Uganda' >Uganda<\/option><option value='Ukraine' >Ukraine<\/option><option value='United Arab Emirates' >United Arab Emirates<\/option><option value='United Kingdom' >United Kingdom<\/option><option value='United States' >United States<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekistan' >Uzbekistan<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Viet Nam' >Viet Nam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Wallis and Futuna' >Wallis and Futuna<\/option><option value='Western Sahara' >Western Sahara<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><option value='\u00c5land Islands' >\u00c5land Islands<\/option><\/select>\n                                        <label for='input_8_128_6' id='input_8_128_6_label' class='gform-field-label gform-field-label--type-sub '>Country<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/li><li id=\"field_8_100\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_100\" ><label class='gfield_label gform-field-label' for='input_8_100'>Clearing<\/label><div class='ginput_container ginput_container_text'><input name='input_100' id='input_8_100' type='text' value='' class='large'   tabindex='93'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_8_102\" class=\"gfield gfield--type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_102\" ><h2 class=\"gsection_title\">Possible comments<\/h2><\/li><li id=\"field_8_103\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_8_103\" ><label class='gfield_label gform-field-label' for='input_8_103'>Comments<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_103' id='input_8_103' class='textarea medium' tabindex='94'     aria-invalid=\"false\"   rows='10' 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