{"id":6377,"date":"2020-09-01T10:27:28","date_gmt":"2020-09-01T08:27:28","guid":{"rendered":"https:\/\/pspi.webmaster-satigny.ch\/declaration-accident-bagatelle-laa\/"},"modified":"2024-03-20T10:53:09","modified_gmt":"2024-03-20T09:53:09","slug":"declaration-accident-bagatelle-laa","status":"publish","type":"page","link":"https:\/\/www.pspi.ch\/en\/declaration-accident-bagatelle-laa\/","title":{"rendered":"Declaration Accident Bagatelle LAA"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"6377\" class=\"elementor elementor-6377 elementor-3078\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-440ee25 e-flex e-con-boxed e-con e-parent\" data-id=\"440ee25\" 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-c349dd0 e-con-full e-flex e-con e-child\" data-id=\"c349dd0\" data-element_type=\"container\" data-settings=\"{&quot;_ha_eqh_enable&quot;:false}\">\n\t\t<div class=\"elementor-element elementor-element-d86e931 e-flex e-con-boxed e-con e-child\" data-id=\"d86e931\" 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-a4b9430 elementor-widget__width-auto elementor-widget-tablet__width-auto elementor-widget elementor-widget-heading\" data-id=\"a4b9430\" 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\">Accident <\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-bcb8618 elementor-widget__width-auto elementor-widget-tablet__width-auto elementor-widget elementor-widget-heading\" data-id=\"bcb8618\" 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\">Bagatelle LAA<\/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-0396503 e-flex e-con-boxed e-con e-child\" data-id=\"0396503\" 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-0dc7dd6 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=\"0dc7dd6\" 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_6' style='display:none'><div id='gf_6' class='gform_anchor' tabindex='-1'><\/div><form method='post' enctype='multipart\/form-data' target='gform_ajax_frame_6' id='gform_6'  action='\/en\/wp-json\/wp\/v2\/pages\/6377#gf_6' data-formid='6' novalidate>\n                        <div class='gform-body gform_body'><ul id='gform_fields_6' class='gform_fields left_label form_sublabel_below description_below validation_below'><li id=\"field_6_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_6_1\" ><label class='gfield_label gform-field-label' for='input_6_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_6_1' type='email' value='' class='large' tabindex='1'   aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/li><li id=\"field_6_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_6_3\" ><h2 class=\"gsection_title\">Statement of insurance informations<\/h2><\/li><li id=\"field_6_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_6_4\" ><label class='gfield_label gform-field-label' for='input_6_4'>Insurance company<\/label><div class='ginput_container ginput_container_text'><input name='input_4' id='input_6_4' type='text' value='' class='large'   tabindex='2'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_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_6_5\" ><label class='gfield_label gform-field-label' for='input_6_5'>No of insurance policy<\/label><div class='ginput_container ginput_container_text'><input name='input_5' id='input_6_5' type='text' value='' class='large'   tabindex='3'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_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_6_6\" ><h2 class=\"gsection_title\">Employer<\/h2><\/li><li id=\"field_6_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_6_8\" ><label class='gfield_label gform-field-label' for='input_6_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_6_8' type='text' value='' class='large'   tabindex='4'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_7\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_7\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/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_6_7' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_7_1_container' >\n                                        <input type='text' name='input_7.1' id='input_6_7_1' value='' tabindex='5'   aria-required='false'    \/>\n                                        <label for='input_6_7_1' id='input_6_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_6_7_2_container' >\n                                        <input type='text' name='input_7.2' id='input_6_7_2' value='' tabindex='6'    aria-required='false'   \/>\n                                        <label for='input_6_7_2' id='input_6_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_6_7_3_container' >\n                                    <input type='text' name='input_7.3' id='input_6_7_3' value='' tabindex='7'   aria-required='false'    \/>\n                                    <label for='input_6_7_3' id='input_6_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_6_7_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_6_7_5_container' >\n                                    <input type='text' name='input_7.5' id='input_6_7_5' value='' tabindex='8'   aria-required='false'    \/>\n                                    <label for='input_6_7_5' id='input_6_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_6_7_6_container' >\n                                        <select name='input_7.6' id='input_6_7_6' tabindex='9'  aria-required='false'    ><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_6_7_6' id='input_6_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_6_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_6_9\" ><h2 class=\"gsection_title\">Insured person<\/h2><\/li><li id=\"field_6_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_6_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_6_10'>\n                            \n                            <span id='input_6_10_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_10.3' id='input_6_10_3' value='' tabindex='11'  aria-required='true'     \/>\n                                                    <label for='input_6_10_3' class='gform-field-label gform-field-label--type-sub '>First Name<\/label>\n                                                <\/span>\n                            \n                            <span id='input_6_10_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_10.6' id='input_6_10_6' value='' tabindex='13'  aria-required='true'     \/>\n                                                    <label for='input_6_10_6' class='gform-field-label gform-field-label--type-sub '>Last Name<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/li><li id=\"field_6_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_6_11\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Adress<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_6_11' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_11_1_container' >\n                                        <input type='text' name='input_11.1' id='input_6_11_1' value='' tabindex='15'   aria-required='true'    \/>\n                                        <label for='input_6_11_1' id='input_6_11_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_6_11_2_container' >\n                                        <input type='text' name='input_11.2' id='input_6_11_2' value='' tabindex='16'    aria-required='false'   \/>\n                                        <label for='input_6_11_2' id='input_6_11_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_6_11_3_container' >\n                                    <input type='text' name='input_11.3' id='input_6_11_3' value='' tabindex='17'   aria-required='true'    \/>\n                                    <label for='input_6_11_3' id='input_6_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_6_11_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_6_11_5_container' >\n                                    <input type='text' name='input_11.5' id='input_6_11_5' value='' tabindex='18'   aria-required='true'    \/>\n                                    <label for='input_6_11_5' id='input_6_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_6_11_6_container' >\n                                        <select name='input_11.6' id='input_6_11_6' tabindex='19'  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_6_11_6' id='input_6_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_6_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_6_12\" ><label class='gfield_label gform-field-label' for='input_6_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_6_12' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon' tabindex='20'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_6_12_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_12_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_12' class='gform_hidden' value='https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_6_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_6_110\" ><label class='gfield_label gform-field-label' for='input_6_110'>Civil 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_6_110' class='medium gfield_select' tabindex='21'   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_6_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_6_14\" ><label class='gfield_label gform-field-label' for='input_6_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_6_14' type='text' value='' class='large'   tabindex='22'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_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_6_15\" ><label class='gfield_label gform-field-label' for='input_6_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_6_15' type='text' value='' class='large'   tabindex='23'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_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_6_16\" ><label class='gfield_label gform-field-label' for='input_6_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_6_16' type='text' value='' class='large'   tabindex='24'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_17\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_17\" ><label class='gfield_label gform-field-label' for='input_6_17'>Children under 18 years of age or still in education till 25 years<\/label><div class='ginput_container ginput_container_select'><select name='input_17' id='input_6_17' class='medium gfield_select' tabindex='25'    aria-invalid=\"false\" ><option value='None' >None<\/option><option value='1' >1<\/option><option value='2' >2<\/option><option value='3' >3<\/option><option value='4' >4<\/option><option value='5' >5<\/option><\/select><\/div><\/li><li id=\"field_6_18\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_18\" ><label class='gfield_label gform-field-label' for='input_6_18'>Reimbursement of expenses<\/label><div class='ginput_container ginput_container_select'><select name='input_18' id='input_6_18' class='medium gfield_select' tabindex='26'    aria-invalid=\"false\" ><option value='No' >No<\/option><option value='Yes' >Yes<\/option><\/select><\/div><\/li><li id=\"field_6_111\" class=\"gfield gfield--type-select field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_111\" ><label class='gfield_label gform-field-label' for='input_6_111'>By<\/label><div class='ginput_container ginput_container_select'><select name='input_111' id='input_6_111' class='medium gfield_select' tabindex='27'    aria-invalid=\"false\" ><option value='Transfer' >Transfer<\/option><option value='CCP' >CCP<\/option><\/select><\/div><\/li><li id=\"field_6_112\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_112\" ><label class='gfield_label gform-field-label' for='input_6_112'>Name of the bank<\/label><div class='ginput_container ginput_container_text'><input name='input_112' id='input_6_112' type='text' value='' class='large'   tabindex='28'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_113\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_113\" ><label class='gfield_label gform-field-label' for='input_6_113'>IBAN<\/label><div class='ginput_container ginput_container_text'><input name='input_113' id='input_6_113' type='text' value='' class='large'   tabindex='29'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_114\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_114\" ><label class='gfield_label gform-field-label' for='input_6_114'>N\u00b0CCP<\/label><div class='ginput_container ginput_container_text'><input name='input_114' id='input_6_114' type='text' value='' class='large'   tabindex='30'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_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_6_19\" ><h2 class=\"gsection_title\">Commitment<\/h2><\/li><li id=\"field_6_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_6_20\" ><label class='gfield_label gform-field-label' for='input_6_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_6_20' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon' tabindex='31'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_6_20_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_20_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_20' class='gform_hidden' value='https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_6_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_6_21\" ><label class='gfield_label gform-field-label' for='input_6_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_6_21' type='text' value='' class='large'   tabindex='32'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_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_6_22\" ><label class='gfield_label gform-field-label' for='input_6_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_6_22' type='text' value='' class='large'  aria-describedby=\"gfield_description_6_22\" tabindex='33'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_6_22'>business sector: reception, secretarial, IT, machine room, etc.<\/div><\/li><li id=\"field_6_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_6_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_6_23'>\n\t\t\t<li class='gchoice gchoice_6_23_0'>\n\t\t\t\t<input name='input_23' type='radio' value='Senior executive'  id='choice_6_23_0' tabindex='34'   \/>\n\t\t\t\t<label for='choice_6_23_0' id='label_6_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_6_23_1'>\n\t\t\t\t<input name='input_23' type='radio' value='Middle management'  id='choice_6_23_1' tabindex='35'   \/>\n\t\t\t\t<label for='choice_6_23_1' id='label_6_23_1' class='gform-field-label gform-field-label--type-inline'>Middle management<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_23_2'>\n\t\t\t\t<input name='input_23' type='radio' value='Employee\/worker'  id='choice_6_23_2' tabindex='36'   \/>\n\t\t\t\t<label for='choice_6_23_2' id='label_6_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_6_23_3'>\n\t\t\t\t<input name='input_23' type='radio' value='Apprentice'  id='choice_6_23_3' tabindex='37'   \/>\n\t\t\t\t<label for='choice_6_23_3' id='label_6_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_6_23_4'>\n\t\t\t\t<input name='input_23' type='radio' value='Intern'  id='choice_6_23_4' tabindex='38'   \/>\n\t\t\t\t<label for='choice_6_23_4' id='label_6_23_4' class='gform-field-label gform-field-label--type-inline'>Intern<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_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_6_24\" ><label class='gfield_label gform-field-label' for='input_6_24'>End date of the course<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_24' id='input_6_24' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon' tabindex='39'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_6_24_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_24_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_24' class='gform_hidden' value='https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_6_115\" 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_6_115\" ><label class='gfield_label gform-field-label' for='input_6_115'>Apprenticeship end date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_115' id='input_6_115' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon' tabindex='40'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_6_115_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_115_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_115' class='gform_hidden' value='https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_6_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_6_25\" ><label class='gfield_label gform-field-label' >Employment relationship<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_6_25'>\n\t\t\t<li class='gchoice gchoice_6_25_0'>\n\t\t\t\t<input name='input_25' type='radio' value='Permanent employment relationship'  id='choice_6_25_0' tabindex='41'   \/>\n\t\t\t\t<label for='choice_6_25_0' id='label_6_25_0' class='gform-field-label gform-field-label--type-inline'>Permanent employment relationship<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_25_1'>\n\t\t\t\t<input name='input_25' type='radio' value='Temporary employment relationship'  id='choice_6_25_1' tabindex='42'   \/>\n\t\t\t\t<label for='choice_6_25_1' id='label_6_25_1' class='gform-field-label gform-field-label--type-inline'>Temporary employment relationship<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_25_2'>\n\t\t\t\t<input name='input_25' type='radio' value='Terminated employment relationship'  id='choice_6_25_2' tabindex='43'   \/>\n\t\t\t\t<label for='choice_6_25_2' id='label_6_25_2' class='gform-field-label gform-field-label--type-inline'>Terminated employment relationship<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_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_6_27\" ><label class='gfield_label gform-field-label' for='input_6_27'>until<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_27' id='input_6_27' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon' tabindex='44'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_6_27_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_27_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_27' class='gform_hidden' value='https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_6_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_6_28\" ><label class='gfield_label gform-field-label' for='input_6_28'>for the<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_28' id='input_6_28' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon' tabindex='45'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_6_28_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_28_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_28' class='gform_hidden' value='https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_6_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_6_26\" ><label class='gfield_label gform-field-label' for='input_6_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_6_26' type='text' value='' class='large'   tabindex='46'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_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_6_29\" ><label class='gfield_label gform-field-label' >Occupation<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_29'>\n\t\t\t<li class='gchoice gchoice_6_29_0'>\n\t\t\t\t<input name='input_29' type='radio' value='Temporary'  id='choice_6_29_0' tabindex='47'   \/>\n\t\t\t\t<label for='choice_6_29_0' id='label_6_29_0' class='gform-field-label gform-field-label--type-inline'>Temporary<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_29_1'>\n\t\t\t\t<input name='input_29' type='radio' value='Part time'  id='choice_6_29_1' tabindex='48'   \/>\n\t\t\t\t<label for='choice_6_29_1' id='label_6_29_1' class='gform-field-label gform-field-label--type-inline'>Part time<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_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_6_31\" ><label class='gfield_label gform-field-label' for='input_6_31'>Work schedule 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_6_31' type='text' value='' class='large'  aria-describedby=\"gfield_description_6_31\" tabindex='49'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_6_31'>Hours per week\n<\/div><\/li><li id=\"field_6_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_6_30\" ><label class='gfield_label gform-field-label' for='input_6_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_6_30' type='text' value='' class='large'   tabindex='50'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_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_6_32\" ><label class='gfield_label gform-field-label' for='input_6_32'>Standard 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_6_32' type='text' value='' class='large'  aria-describedby=\"gfield_description_6_32\" tabindex='51'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_6_32'>Hours per week\n<\/div><\/li><li id=\"field_6_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_6_33\" ><h2 class=\"gsection_title\">Date of the accident<\/h2><\/li><li id=\"field_6_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_6_48\" ><label class='gfield_label gform-field-label' for='input_6_48'>Date of the Accident<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_6_48' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon' tabindex='52'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_6_48_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_48_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_48' class='gform_hidden' value='https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_6_35\" class=\"gfield gfield--type-time gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_35\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Time of Accident<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"clear-multi\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_6_35'>\n                            <input type='number' maxlength='2' name='input_35[]' id='input_6_35_1' value='' tabindex='53' min='0' max='24' step='1'  placeholder='HH' aria-required='true'   \/> <i>:<\/i>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_6_35_1'>Hours<\/label>\n                        <\/div>\n                        \n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' maxlength='2' name='input_35[]' id='input_6_35_2' value='' tabindex='54' min='0' max='59' step='1'  placeholder='MM' aria-required='true'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_6_35_2'>Minutes<\/label>\n                        <\/div>\n                        \n                    <\/div><\/div><\/li><li id=\"field_6_36\" 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_6_36\" ><h2 class=\"gsection_title\">Location of the accident<\/h2><\/li><li id=\"field_6_37\" 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_6_37\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Where did the accident happen?<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_6_37' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_37_1_container' >\n                                        <input type='text' name='input_37.1' id='input_6_37_1' value='' tabindex='56'   aria-required='true'    \/>\n                                        <label for='input_6_37_1' id='input_6_37_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_6_37_2_container' >\n                                        <input type='text' name='input_37.2' id='input_6_37_2' value='' tabindex='57'    aria-required='false'   \/>\n                                        <label for='input_6_37_2' id='input_6_37_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_6_37_3_container' >\n                                    <input type='text' name='input_37.3' id='input_6_37_3' value='' tabindex='58'   aria-required='true'    \/>\n                                    <label for='input_6_37_3' id='input_6_37_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_37.4' id='input_6_37_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_6_37_5_container' >\n                                    <input type='text' name='input_37.5' id='input_6_37_5' value='' tabindex='59'   aria-required='true'    \/>\n                                    <label for='input_6_37_5' id='input_6_37_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_6_37_6_container' >\n                                        <select name='input_37.6' id='input_6_37_6' tabindex='60'  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_6_37_6' id='input_6_37_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_6_39\" 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_6_39\" ><label class='gfield_label gform-field-label' for='input_6_39'>for ex. Hotel, XX, workshop, street, garden, sitting room\u2026.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_39' id='input_6_39' type='text' value='' class='large'   tabindex='61'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_40\" 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_6_40\" ><h2 class=\"gsection_title\">Description of the accident<\/h2><\/li><li id=\"field_6_41\" 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_6_41\" ><label class='gfield_label gform-field-label' for='input_6_41'>Activity at the time of the accident<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_41' id='input_6_41' type='text' value='' class='large'  aria-describedby=\"gfield_description_6_41\" tabindex='62'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_6_41'>(bike, Ski, Trekking, ...) <\/div><\/li><li id=\"field_6_42\" class=\"gfield gfield--type-textarea gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_42\" ><label class='gfield_label gform-field-label' for='input_6_42'>Accident course<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_42' id='input_6_42' class='textarea large' tabindex='63' aria-describedby=\"gfield_description_6_42\"   aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><div class='gfield_description' id='gfield_description_6_42'>Persons, machines, objects, vehicles, products that played a role in the accident<\/div><\/li><li id=\"field_6_43\" 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_6_43\" ><label class='gfield_label gform-field-label' >Person(s) involved<\/label><div class='ginput_container ginput_container_radio'><ul class='gfield_radio' id='input_6_43'>\n\t\t\t<li class='gchoice gchoice_6_43_0'>\n\t\t\t\t<input name='input_43' type='radio' value='None'  id='choice_6_43_0' tabindex='64'   \/>\n\t\t\t\t<label for='choice_6_43_0' id='label_6_43_0' class='gform-field-label gform-field-label--type-inline'>None<\/label>\n\t\t\t<\/li>\n\t\t\t<li class='gchoice gchoice_6_43_1'>\n\t\t\t\t<input name='input_43' type='radio' value='Yes'  id='choice_6_43_1' tabindex='65'   \/>\n\t\t\t\t<label for='choice_6_43_1' id='label_6_43_1' class='gform-field-label gform-field-label--type-inline'>Yes<\/label>\n\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_44\" class=\"gfield gfield--type-textarea field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_44\" ><label class='gfield_label gform-field-label' for='input_6_44'>If yes, name + address<\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_44' id='input_6_44' class='textarea large' tabindex='66'     aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/li><li id=\"field_6_45\" 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_6_45\" ><h2 class=\"gsection_title\">Work-related accident<\/h2><\/li><li id=\"field_6_46\" 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_6_46\" ><label class='gfield_label gform-field-label' for='input_6_46'>Involved items<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_46' id='input_6_46' type='text' value='' class='large'  aria-describedby=\"gfield_description_6_46\" tabindex='67'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_6_46'>for ex: tools, vehicule, substance involved\n<\/div><\/li><li id=\"field_6_47\" 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_6_47\" ><h2 class=\"gsection_title\">Work-unrelated accident<\/h2><\/li><li id=\"field_6_34\" 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_6_34\" ><label class='gfield_label gform-field-label' for='input_6_34'>Until when has the injured person worked for the last time in the company before the accident.<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_34' id='input_6_34' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon' tabindex='68'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_6_34_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_6_34_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_34' class='gform_hidden' value='https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_6_49\" class=\"gfield gfield--type-time field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_49\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Hour<\/label><div class=\"ginput_container ginput_complex gform-grid-row\"><div class=\"clear-multi\">\n                        <div class='gfield_time_hour ginput_container ginput_container_time gform-grid-col' id='input_6_49'>\n                            <input type='number' maxlength='2' name='input_49[]' id='input_6_49_1' value='' tabindex='69' min='0' max='24' step='1'  placeholder='HH' aria-required='false'   \/> <i>:<\/i>\n                            <label class='gform-field-label gform-field-label--type-sub hour_label screen-reader-text' for='input_6_49_1'>Hours<\/label>\n                        <\/div>\n                        \n                        <div class='gfield_time_minute ginput_container ginput_container_time gform-grid-col'>\n                            <input type='number' maxlength='2' name='input_49[]' id='input_6_49_2' value='' tabindex='70' min='0' max='59' step='1'  placeholder='MM' aria-required='false'  \/>\n                            <label class='gform-field-label gform-field-label--type-sub minute_label screen-reader-text' for='input_6_49_2'>Minutes<\/label>\n                        <\/div>\n                        \n                    <\/div><\/div><\/li><li id=\"field_6_50\" class=\"gfield gfield--type-text field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_50\" ><label class='gfield_label gform-field-label' for='input_6_50'>Cause of absence<\/label><div class='ginput_container ginput_container_text'><input name='input_50' id='input_6_50' type='text' value='' class='large'  aria-describedby=\"gfield_description_6_50\" tabindex='72'   aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_6_50'>Holidays, sickness, vacations, end of work,...<\/div><\/li><li id=\"field_6_51\" 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_6_51\" ><h2 class=\"gsection_title\">Injury<\/h2><\/li><li id=\"field_6_52\" 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_6_52\" ><label class='gfield_label gform-field-label' for='input_6_52'>Part of the body affected<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_52' id='input_6_52' type='text' value='' class='large'  aria-describedby=\"gfield_description_6_52\" tabindex='73'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_6_52'>hand, foot, elbow...<\/div><\/li><li id=\"field_6_53\" class=\"gfield gfield--type-checkbox 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_6_53\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Affected body part(s)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_checkbox'><ul class='gfield_checkbox' id='input_6_53'><li class='gchoice gchoice_6_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='Left'  id='choice_6_53_1' tabindex='74'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_53_1' id='label_6_53_1' class='gform-field-label gform-field-label--type-inline'>Left<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_53_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.2' type='checkbox'  value='Right'  id='choice_6_53_2' tabindex='75'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_53_2' id='label_6_53_2' class='gform-field-label gform-field-label--type-inline'>Right<\/label>\n\t\t\t\t\t\t\t<\/li><li class='gchoice gchoice_6_53_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.3' type='checkbox'  value='Undetermined'  id='choice_6_53_3' tabindex='76'  \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_53_3' id='label_6_53_3' class='gform-field-label gform-field-label--type-inline'>Undetermined<\/label>\n\t\t\t\t\t\t\t<\/li><\/ul><\/div><\/li><li id=\"field_6_55\" 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_6_55\" ><label class='gfield_label gform-field-label' for='input_6_55'>Nature of the injury<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_55' id='input_6_55' type='text' value='' class='large'  aria-describedby=\"gfield_description_6_55\" tabindex='77'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><div class='gfield_description' id='gfield_description_6_55'>fracture, pain, sprain...<\/div><\/li><li id=\"field_6_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_6_65\" ><h2 class=\"gsection_title\">Doctors&#039; addresses<\/h2><\/li><li id=\"field_6_67\" 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_6_67\" ><h2 class=\"gsection_title\">First aid by<\/h2><\/li><li id=\"field_6_68\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_68\" ><label class='gfield_label gform-field-label' for='input_6_68'>Clinic \/ Hospital<\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_6_68' type='text' value='' class='large'   tabindex='78'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_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_6_69\" ><label class='gfield_label gform-field-label' for='input_6_69'>Name, surname of the doctor<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_6_69' type='text' value='' class='large'   tabindex='79'  aria-required=\"true\" aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_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_6_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_6_70' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_70_1_container' >\n                                        <input type='text' name='input_70.1' id='input_6_70_1' value='' tabindex='80'   aria-required='true'    \/>\n                                        <label for='input_6_70_1' id='input_6_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_6_70_2_container' >\n                                        <input type='text' name='input_70.2' id='input_6_70_2' value='' tabindex='81'    aria-required='false'   \/>\n                                        <label for='input_6_70_2' id='input_6_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_6_70_3_container' >\n                                    <input type='text' name='input_70.3' id='input_6_70_3' value='' tabindex='82'   aria-required='true'    \/>\n                                    <label for='input_6_70_3' id='input_6_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_6_70_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_6_70_5_container' >\n                                    <input type='text' name='input_70.5' id='input_6_70_5' value='' tabindex='83'   aria-required='true'    \/>\n                                    <label for='input_6_70_5' id='input_6_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_6_70_6_container' >\n                                        <select name='input_70.6' id='input_6_70_6' tabindex='84'  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_6_70_6' id='input_6_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_6_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_6_71\" ><label class='gfield_label gform-field-label' for='input_6_71'>Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_6_71' type='text' value='' class='large'   tabindex='85'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_72\" 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_6_72\" ><h2 class=\"gsection_title\">Following treatment by<\/h2><\/li><li id=\"field_6_93\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_93\" ><label class='gfield_label gform-field-label' for='input_6_93'>Clinic \/ Hospital<\/label><div class='ginput_container ginput_container_text'><input name='input_93' id='input_6_93' type='text' value='' class='large'   tabindex='86'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_74\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_74\" ><label class='gfield_label gform-field-label' for='input_6_74'>Surname, First name of the doctorNom, Pr\u00e9nom du m\u00e9decin<\/label><div class='ginput_container ginput_container_text'><input name='input_74' id='input_6_74' type='text' value='' class='large'   tabindex='87'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_75\" class=\"gfield gfield--type-address field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_75\" ><label class='gfield_label gform-field-label gfield_label_before_complex' >Address<\/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_6_75' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_6_75_1_container' >\n                                        <input type='text' name='input_75.1' id='input_6_75_1' value='' tabindex='88'   aria-required='false'    \/>\n                                        <label for='input_6_75_1' id='input_6_75_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_6_75_2_container' >\n                                        <input type='text' name='input_75.2' id='input_6_75_2' value='' tabindex='89'    aria-required='false'   \/>\n                                        <label for='input_6_75_2' id='input_6_75_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_6_75_3_container' >\n                                    <input type='text' name='input_75.3' id='input_6_75_3' value='' tabindex='90'   aria-required='false'    \/>\n                                    <label for='input_6_75_3' id='input_6_75_3_label' class='gform-field-label gform-field-label--type-sub '>City<\/label>\n                                 <\/span><input type='hidden' class='gform_hidden' name='input_75.4' id='input_6_75_4' value=''\/><span class='ginput_right address_zip ginput_address_zip gform-grid-col' id='input_6_75_5_container' >\n                                    <input type='text' name='input_75.5' id='input_6_75_5' value='' tabindex='91'   aria-required='false'    \/>\n                                    <label for='input_6_75_5' id='input_6_75_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_6_75_6_container' >\n                                        <select name='input_75.6' id='input_6_75_6' tabindex='92'  aria-required='false'    ><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_6_75_6' id='input_6_75_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_6_116\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_116\" ><label class='gfield_label gform-field-label' for='input_6_116'>Phone<\/label><div class='ginput_container ginput_container_text'><input name='input_116' id='input_6_116' type='text' value='' class='large'   tabindex='93'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_104\" 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_6_104\" ><h2 class=\"gsection_title\">Place and date<\/h2><\/li><li id=\"field_6_101\" class=\"gfield gfield--type-text field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_101\" ><label class='gfield_label gform-field-label' for='input_6_101'>Location<\/label><div class='ginput_container ginput_container_text'><input name='input_101' id='input_6_101' type='text' value='' class='large'   tabindex='94'   aria-invalid=\"false\"   \/> <\/div><\/li><li id=\"field_6_106\" 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_6_106\" ><label class='gfield_label gform-field-label' for='input_6_106'>Date<\/label><div class='ginput_container ginput_container_date'>\n                            <input name='input_106' id='input_6_106' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon' tabindex='95'  placeholder='dd\/mm\/yyyy' aria-describedby=\"input_6_106_date_format\" aria-invalid=\"false\" \/>\n                            <span id='input_6_106_date_format' class='screen-reader-text'>DD slash MM slash YYYY<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_6_106' class='gform_hidden' value='https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/li><li id=\"field_6_107\" 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_6_107\" ><h2 class=\"gsection_title\">Attach documents<\/h2><\/li><li id=\"field_6_108\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  data-js-reload=\"field_6_108\" ><label class='gfield_label gform-field-label' for='gform_browse_button_6_108'>Documents<\/label><div class='ginput_container ginput_container_fileupload'><div id='gform_multifile_upload_6_108' data-settings='{&quot;runtimes&quot;:&quot;html5,flash,html4&quot;,&quot;browse_button&quot;:&quot;gform_browse_button_6_108&quot;,&quot;container&quot;:&quot;gform_multifile_upload_6_108&quot;,&quot;drop_element&quot;:&quot;gform_drag_drop_area_6_108&quot;,&quot;filelist&quot;:&quot;gform_preview_6_108&quot;,&quot;unique_names&quot;:true,&quot;file_data_name&quot;:&quot;file&quot;,&quot;url&quot;:&quot;https:\\\/\\\/www.pspi.ch\\\/?gf_page=4a7934b99ad974a&quot;,&quot;flash_swf_url&quot;:&quot;https:\\\/\\\/www.pspi.ch\\\/wp-includes\\\/js\\\/plupload\\\/plupload.flash.swf&quot;,&quot;silverlight_xap_url&quot;:&quot;https:\\\/\\\/www.pspi.ch\\\/wp-includes\\\/js\\\/plupload\\\/plupload.silverlight.xap&quot;,&quot;filters&quot;:{&quot;mime_types&quot;:[{&quot;title&quot;:&quot;Allowed Files&quot;,&quot;extensions&quot;:&quot;iejpg,gif,png,pdf&quot;}],&quot;max_file_size&quot;:&quot;134217728b&quot;},&quot;multipart&quot;:true,&quot;urlstream_upload&quot;:false,&quot;multipart_params&quot;:{&quot;form_id&quot;:6,&quot;field_id&quot;:108},&quot;gf_vars&quot;:{&quot;max_files&quot;:0,&quot;message_id&quot;:&quot;gform_multifile_messages_6_108&quot;,&quot;disallowed_extensions&quot;:[&quot;php&quot;,&quot;asp&quot;,&quot;aspx&quot;,&quot;cmd&quot;,&quot;csh&quot;,&quot;bat&quot;,&quot;html&quot;,&quot;htm&quot;,&quot;hta&quot;,&quot;jar&quot;,&quot;exe&quot;,&quot;com&quot;,&quot;js&quot;,&quot;lnk&quot;,&quot;htaccess&quot;,&quot;phtml&quot;,&quot;ps1&quot;,&quot;ps2&quot;,&quot;php3&quot;,&quot;php4&quot;,&quot;php5&quot;,&quot;php6&quot;,&quot;py&quot;,&quot;rb&quot;,&quot;tmp&quot;]}}' class='gform_fileupload_multifile'>\n\t\t\t\t\t\t\t\t\t\t<div id='gform_drag_drop_area_6_108' class='gform_drop_area gform-theme-field-control'>\n\t\t\t\t\t\t\t\t\t\t\t<span class='gform_drop_instructions'>Drop files here or <\/span>\n\t\t\t\t\t\t\t\t\t\t\t<button type='button' id='gform_browse_button_6_108' class='button gform_button_select_files gform-theme-button gform-theme-button--control' aria-describedby=\"gfield_upload_rules_6_108\" tabindex='96' >Select files<\/button>\n\t\t\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t\t\t\t\t\t<\/div><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_6_108'>Accepted file types: iejpg, gif, png, pdf, Max. file size: 128 MB.<\/span><ul class='validation_message--hidden-on-empty gform-ul-reset' id='gform_multifile_messages_6_108'><\/ul> <!-- Leave <ul> empty to support CSS :empty selector. --><\/div><div id='gform_preview_6_108' class='ginput_preview_list'><\/div><\/li><\/ul><\/div>\n        <div class='gform_footer left_label'> <input type='submit' id='gform_submit_button_6' class='gform_button button' value='SEND THE FORM' tabindex='97' onclick='if(window[\"gf_submitting_6\"]){return false;}  if( !jQuery(\"#gform_6\")[0].checkValidity || jQuery(\"#gform_6\")[0].checkValidity()){window[\"gf_submitting_6\"]=true;}  ' onkeypress='if( event.keyCode == 13 ){ if(window[\"gf_submitting_6\"]){return false;} if( !jQuery(\"#gform_6\")[0].checkValidity || jQuery(\"#gform_6\")[0].checkValidity()){window[\"gf_submitting_6\"]=true;}  jQuery(\"#gform_6\").trigger(\"submit\",[true]); }' \/> <input type='hidden' name='gform_ajax' value='form_id=6&amp;title=&amp;description=&amp;tabindex=1&amp;theme=legacy' \/>\n            <input type='hidden' class='gform_hidden' name='is_submit_6' value='1' \/>\n            <input type='hidden' class='gform_hidden' name='gform_submit' value='6' \/>\n            \n            <input type='hidden' class='gform_hidden' name='gform_unique_id' value='' \/>\n            <input type='hidden' class='gform_hidden' name='state_6' value='WyJbXSIsIjA2MDc1ZGIwOGUzMjQ5NDQ4MTJlNzg4OWIzYWFmMzVjIl0=' \/>\n            <input type='hidden' class='gform_hidden' name='gform_target_page_number_6' id='gform_target_page_number_6' value='0' \/>\n            <input type='hidden' class='gform_hidden' name='gform_source_page_number_6' id='gform_source_page_number_6' value='1' \/>\n            <input type='hidden' name='gform_field_values' value='' \/>\n            <input type='hidden' name='gform_uploaded_files' id='gform_uploaded_files_6' value='' \/>\n        <\/div>\n                        <\/form>\n                        <\/div>\n\t\t                <iframe style='display:none;width:0px;height:0px;' src='about:blank' name='gform_ajax_frame_6' id='gform_ajax_frame_6' title='This iframe contains the logic required to handle Ajax powered Gravity Forms.'><\/iframe>\n\t\t                <script>\ngform.initializeOnLoaded( function() {gformInitSpinner( 6, 'https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery('#gform_ajax_frame_6').on('load',function(){var contents = jQuery(this).contents().find('*').html();var is_postback = contents.indexOf('GF_AJAX_POSTBACK') >= 0;if(!is_postback){return;}var form_content = jQuery(this).contents().find('#gform_wrapper_6');var is_confirmation = jQuery(this).contents().find('#gform_confirmation_wrapper_6').length > 0;var is_redirect = contents.indexOf('gformRedirect(){') >= 0;var is_form = form_content.length > 0 && ! is_redirect && ! is_confirmation;var mt = parseInt(jQuery('html').css('margin-top'), 10) + parseInt(jQuery('body').css('margin-top'), 10) + 100;if(is_form){form_content.find('form').css('opacity', 0);jQuery('#gform_wrapper_6').html(form_content.html());if(form_content.hasClass('gform_validation_error')){jQuery('#gform_wrapper_6').addClass('gform_validation_error');} else {jQuery('#gform_wrapper_6').removeClass('gform_validation_error');}setTimeout( function() { \/* delay the scroll by 50 milliseconds to fix a bug in chrome *\/ jQuery(document).scrollTop(jQuery('#gform_wrapper_6').offset().top - mt); }, 50 );if(window['gformInitDatepicker']) {gformInitDatepicker();}if(window['gformInitPriceFields']) {gformInitPriceFields();}var current_page = jQuery('#gform_source_page_number_6').val();gformInitSpinner( 6, 'https:\/\/www.pspi.ch\/wp-content\/plugins\/gravityforms\/images\/spinner.svg', true );jQuery(document).trigger('gform_page_loaded', [6, current_page]);window['gf_submitting_6'] = false;}else if(!is_redirect){var confirmation_content = jQuery(this).contents().find('.GF_AJAX_POSTBACK').html();if(!confirmation_content){confirmation_content = contents;}jQuery('#gform_wrapper_6').replaceWith(confirmation_content);jQuery(document).scrollTop(jQuery('#gf_6').offset().top - mt);jQuery(document).trigger('gform_confirmation_loaded', [6]);window['gf_submitting_6'] = false;wp.a11y.speak(jQuery('#gform_confirmation_message_6').text());}else{jQuery('#gform_6').append(contents);if(window['gformRedirect']) {gformRedirect();}}jQuery(document).trigger(\"gform_pre_post_render\", [{ formId: \"6\", currentPage: \"current_page\", abort: function() { this.preventDefault(); } }]);                if (event && event.defaultPrevented) {                return;         }        const gformWrapperDiv = document.getElementById( \"gform_wrapper_6\" );        if ( gformWrapperDiv ) {            const visibilitySpan = document.createElement( \"span\" );            visibilitySpan.id = \"gform_visibility_test_6\";            gformWrapperDiv.insertAdjacentElement( \"afterend\", visibilitySpan );        }        const visibilityTestDiv = document.getElementById( \"gform_visibility_test_6\" );        let postRenderFired = false;                function triggerPostRender() {            if ( postRenderFired ) {                return;            }            postRenderFired = true;            jQuery( document ).trigger( 'gform_post_render', [6, current_page] );            gform.utils.trigger( { event: 'gform\/postRender', native: false, data: { formId: 6, currentPage: current_page } } );            if ( visibilityTestDiv ) {                visibilityTestDiv.parentNode.removeChild( visibilityTestDiv );            }        }        function debounce( func, wait, immediate ) {            var timeout;            return function() {                var context = this, args = arguments;                var later = function() {                    timeout = null;                    if ( !immediate ) func.apply( context, args );                };                var callNow = immediate && !timeout;                clearTimeout( timeout );                timeout = setTimeout( later, wait );                if ( callNow ) func.apply( context, args );            };        }        const debouncedTriggerPostRender = debounce( function() {            triggerPostRender();        }, 200 );        if ( visibilityTestDiv && visibilityTestDiv.offsetParent === null ) {            const observer = new MutationObserver( ( mutations ) => {                mutations.forEach( ( mutation ) => {                    if ( mutation.type === 'attributes' && visibilityTestDiv.offsetParent !== null ) {                        debouncedTriggerPostRender();                        observer.disconnect();                    }                });            });            observer.observe( document.body, {                attributes: true,                childList: false,                subtree: true,                attributeFilter: [ 'style', 'class' ],            });        } else {            triggerPostRender();        }    } );} );\n<\/script>\n\n<\/div>\n\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\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Accident Bagatelle LAA Your email address* Statement of insurance informations Insurance company No of insurance policy Employer Name* Address Street Adress Street Adress 2 City Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCura\u00e7aoCyprusCzechiaC\u00f4te [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":7,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-6377","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.pspi.ch\/en\/wp-json\/wp\/v2\/pages\/6377"}],"collection":[{"href":"https:\/\/www.pspi.ch\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.pspi.ch\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.pspi.ch\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.pspi.ch\/en\/wp-json\/wp\/v2\/comments?post=6377"}],"version-history":[{"count":0,"href":"https:\/\/www.pspi.ch\/en\/wp-json\/wp\/v2\/pages\/6377\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.pspi.ch\/en\/wp-json\/wp\/v2\/media?parent=6377"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}