Assurance dépendance Aviva, le formulaire de documentation

<br /> <b>Warning</b>: session_start(): Cannot send session cookie - headers already sent by (output started at /data0/web/norwichdirect.com/www/francais/common/frame6.php3:5) in <b>/data0/web/norwichdirect.com/www/francais/common/doc.php3</b> on line <b>1</b><br /> <br /> <b>Warning</b>: session_start(): Cannot send session cache limiter - headers already sent (output started at /data0/web/norwichdirect.com/www/francais/common/frame6.php3:5) in <b>/data0/web/norwichdirect.com/www/francais/common/doc.php3</b> on line <b>1</b><br /> <br /> <b>Warning</b>: Cannot modify header information - headers already sent by (output started at /data0/web/norwichdirect.com/www/francais/common/frame6.php3:5) in <b>/data0/web/norwichdirect.com/www/francais/common/doc.php3</b> on line <b>26</b><br /> <br /> <b>Warning</b>: Cannot modify header information - headers already sent by (output started at /data0/web/norwichdirect.com/www/francais/common/frame6.php3:5) in <b>/data0/web/norwichdirect.com/www/francais/common/doc.php3</b> on line <b>27</b><br /> <br /> <b>Warning</b>: Cannot modify header information - headers already sent by (output started at /data0/web/norwichdirect.com/www/francais/common/frame6.php3:5) in <b>/data0/web/norwichdirect.com/www/francais/common/doc.php3</b> on line <b>28</b><br /> <br /> <b>Warning</b>: Cannot modify header information - headers already sent by (output started at /data0/web/norwichdirect.com/www/francais/common/frame6.php3:5) in <b>/data0/web/norwichdirect.com/www/francais/common/doc.php3</b> on line <b>29</b><br /> <br /> <b>Warning</b>: Cannot modify header information - headers already sent by (output started at /data0/web/norwichdirect.com/www/francais/common/frame6.php3:5) in <b>/data0/web/norwichdirect.com/www/francais/common/doc.php3</b> on line <b>30</b><br /> <br /> <b>Warning</b>: Cannot modify header information - headers already sent by (output started at /data0/web/norwichdirect.com/www/francais/common/frame6.php3:5) in <b>/data0/web/norwichdirect.com/www/francais/common/doc.php3</b> on line <b>31</b><br /> <br /> <b>Warning</b>: Cannot modify header information - headers already sent by (output started at /data0/web/norwichdirect.com/www/francais/common/frame6.php3:5) in <b>/data0/web/norwichdirect.com/www/francais/common/doc.php3</b> on line <b>32</b><br /> <br /> <b>Warning</b>: Cannot modify header information - headers already sent by (output started at /data0/web/norwichdirect.com/www/francais/common/frame6.php3:5) in <b>/data0/web/norwichdirect.com/www/francais/common/doc.php3</b> on line <b>33</b><br /> <br /> <b>Warning</b>: Cannot modify header information - headers already sent by (output started at /data0/web/norwichdirect.com/www/francais/common/frame6.php3:5) in <b>/data0/web/norwichdirect.com/www/francais/common/doc.php3</b> on line <b>34</b><br /> <br /> <b>Warning</b>: Cannot modify header information - headers already sent by (output started at /data0/web/norwichdirect.com/www/francais/common/frame6.php3:5) in <b>/data0/web/norwichdirect.com/www/francais/common/doc.php3</b> on line <b>35</b><br /> <br /> <b>Warning</b>: Cannot modify header information - headers already sent by (output started at /data0/web/norwichdirect.com/www/francais/common/frame6.php3:5) in <b>/data0/web/norwichdirect.com/www/francais/common/doc.php3</b> on line <b>36</b><br /> <br /> <b>Warning</b>: Cannot modify header information - headers already sent by (output started at /data0/web/norwichdirect.com/www/francais/common/frame6.php3:5) in <b>/data0/web/norwichdirect.com/www/francais/common/doc.php3</b> on line <b>37</b><br /> <HTML> <HEAD> <meta name="description" content="Notre formulaire de documentation gratuite vous permettra de comparer tranquillement chez vous notre contrat d’assurance et votre devis assurance complémentaire santé, devis assurance décès assurance vie, prévoyance. Ce service vous est proposé sur l’ensemble de nos contrats d’assurance en ligne : assurance hospitalisation, convention obseques, assurance obseques, assurance dépendance, prevoyance, accident, décès invalidité."> <meta name="Keywords" content="documentation gratuite, contrat d’assurance, devis assurance complémentaire santé, devis assurance décès assurance vie , assurance en ligne, assurance hospitalisation, convention obseques, assurance obseques, assurance dépendance, assurance prevoyance, assurance accident, aviva, assurance prevoyance."> <script language="JavaScript"> /** * Configuration du tag */ var bir_id = 348; var bir_ignore = new Array("avivadirect.fr"); var bir_no_trac = new Array("bi_tracked"); /** * Configuration interne ne rien toucher */ var bir_serveur = "track-"+bir_id+".trafiz.net/css.php"; var bir_serveurRoi = "roi.trafiz.net/roi.php"; var bir_roi = 1; var bir_doc = document var bir_referer = bir_doc.referrer var bir_loc = bir_doc.location var bir_protocol = bir_loc.protocol var bir_conf = false; var bir_lock = false var bir_method = false; var bir_trackUrl = false; /** * Ajouter le tag de trafic */ function add_tag_trafic() { if(bir_lock) return false; if(!bir_isAllowed()) return false bir_url = bir_protocol+"//"+bir_serveur+"?id="+bir_id; bir_url+= "&thereferer="+escape(bir_referer); bir_url+= "&page="+escape(bir_loc); bir_url+= "&random="+Math.round(Math.random()*10000); bir_url+= "&roi="+bir_roi; bir_insertTag(bir_url); bir_conf = "trafic"; bir_lock = true; bir_method = "add_tag_trafic()"; bir_setCookie("bir_visite", 1, 15*60); } /** * Ajoute le tag de ROI */ function add_tag_roi() { if(bir_lock) return false; bir_url = bir_protocol+"//"+bir_serveurRoi+"?id="+bir_id; bir_url+= '&reference='+escape(bi_ref); bir_url+= '&comment='+escape(bi_comment); bir_url+= '&price='+escape(bi_price); bir_url+= '&page='+escape(bi_loct); bir_insertTag(bir_url); bir_method = "add_tag_roi()"; bir_conf = "roi"; bir_lock = true; } /** * Insére le tag dans la page */ function bir_insertTag(bir_url) { bir_css = '<link rel="stylesheet" id="bir_css" type="text/css" href="'+bir_url+'" />'; document.write(bir_css); bir_trackUrl = bir_url; } /** * Vérifie si l'on met le tracking * o s'il y a un referer * o si le referer est autorisé * o si l'utilisateur n'est pas déjà venu * o si l'utilisateur ne vient pas du cpc */ function bir_isAllowed() { if(!bir_referer) { bir_conf = "noreferer"; return false; } if(bir_getCookie("bir_visite") == 1) { bir_conf = "visited"; return false; } _bir_cpcReg = bir_no_trac.join("|"); _bir_ignoreReg = new RegExp("("+_bir_cpcReg+")", "i") if(_bir_ignoreReg.exec(bir_loc)) { bir_conf = "cpc" return false; } _bir_urls = bir_ignore.join("|"); _bir_ignoreReg = new RegExp('http\:\/\/(?:[a-z0-9-]+\.)?('+_bir_urls+')', "i"); if(_bir_ignoreReg.exec(bir_referer)) { bir_conf = "internal" return false; } return true } /** * Tag le visiteur pour lui donner une identité unique */ function bir_uniqueVisitor() { str = ""; } /** * Lis le cookie nommé name */ function bir_getCookie(name) { var nameEQ = name + "="; var ca = document.cookie.split(';'); for(var i=0;i < ca.length;i++) { var c = ca[i]; while (c.charAt(0)==' ') c = c.substring(1,c.length); if (c.indexOf(nameEQ) == 0) return c.substring(nameEQ.length,c.length); } return false; } /** * Crée un cookie et le sauve */ function bir_setCookie(name, value, sec) { if (sec) { var date = new Date(); date.setTime(date.getTime()+(sec*1000)); var expires = ";expires="+date.toGMTString(); } else var expires = ""; document.cookie = name+"="+value+expires+";path=/"; } /** * Affiche les informations de debug */ function bir_showDebug() { bir_cssExist = (document.getElementById("bir_css")) ? "oui" : "non"; bir_cookie = (bir_getCookie("bir_visite")) ? "oui" : "non"; bir_debug = "Configuration : "+bir_conf+"<br>"; bir_debug+= "Serveur : "+bir_serveur+"<br>"; bir_debug+= "Serveur roi : "+bir_serveurRoi+"<br>"; bir_debug+= "Page courante : "+bir_loc+"<br>"; bir_debug+= "Referer : "+bir_referer+"<br>"; bir_debug+= "Referer ignorées : "+bir_ignore.join(", ")+"<br>"; bir_debug+= "Cookie : "+bir_cookie+"<br>"; bir_debug+= "Url de tracking : "+bir_trackUrl+"<br>"; bir_debug+= "CSS mise en place : "+bir_cssExist; document.write(bir_debug); } /** * Vérifie que le tag est bien mis après 5 seconde */ setTimeout("eval(bir_method)", 5000);</script> <SCRIPT> function clearFrm() { document.frm.reset(); } /************* DEBUT SCRIPT POUR LA NAVIGATION ******************/ var s= new String(window.top.menuhaut.location) var pdf="pdf/"; if (window.top.menuhaut.document.soustitre) { /* SANTE*/ if (s.match("sante")) { pdf += "SAN_kit_souscription"; window.top.menuhaut.document.soustitre.src="../sante/images/ss_t_doc.gif"; } /* COMPTE LIBRE EPARGNE */ else if (s.match("epargne/menuhaut_int")) { pdf += "CLE_kit_souscription"; window.top.menuhaut.document.soustitre.src="../epargne/images/ss_t_epargne.gif"; } /* MULTIPERFORMANCE */ else if (s.match("epargne/menuhaut_multi")){ pdf += "MUL_Kit_souscription"; window.top.menuhaut.document.soustitre.src="../epargne/images/homepage/b_soustitredependance.gif"; } /* PREVOYANCE FAMILIALE */ else if (s.match("accident/menuhaut.php3")) { pdf += "PFA_kit_souscription"; window.top.menuhaut.document.soustitre.src="../accident/images/sstitre_doc.gif"; } /* ASSURANCE DEPENDANCE */ else if (s.match("accident/menuhaut_dependance")) { pdf += "ADA_kit_souscription"; window.top.menuhaut.document.soustitre.src="../accident/images/homepage/b_soustitredependance.gif"; } /* ASSURANCE LONGUE VIE */ else if (s.match("accident/menuhaut_longuevie")) { pdf += "PLV_kit_souscription"; window.top.menuhaut.document.soustitre.src="../accident/images/assurancevie/t_assurance_vie.gif"; } /* OBSEQUES */ else if (s.match("obseques/menuhaut")) { pdf += "FOB_kit_souscription"; window.top.menuhaut.document.soustitre.src="../obseques/images/sstitre_doc.gif"; } pdf += ".pdf"; } /************* FIN SCRIPT POUR LA NAVIGATION ******************/ /*** DEBUT CHECK QUEL PDF OUVRIR ?? ***/ /*** FIN CHECK QUEL PDF OUVRIR ?? ***/ function open_kit(){ window.open('kit.php3?id=5','_blank'); } </SCRIPT> <link rel="STYLESHEET" type="text/css" href="../common/css.css"> </HEAD> <BODY BGCOLOR="#ffffff" MARGINLEFT=0 MARGINTOP=0 LEFTMARGIN=0 TOPMARGIN=0> <script language="JavaScript" type="text/javascript">add_tag_trafic()</script>   <FORM action="/francais/common/frame6.php3?TITLE=Assurance+d%26eacute%3Bpendance+Aviva%2C+le+formulaire+de++documentation&CONTENU=doc.php3&page=doc.php3?prod_assurdependance=1&menuhaut=../accident/menuhaut.php3?button=15&menugauche=../accident/menugauche_dependance.php3?button=0?" METHOD="GET" NAME="frm"> <input type=hidden name=n_affilie value=> <input type=hidden name=flash value=>  <TABLE WIDTH="570" BORDER="0"> <tr><td class="quatorze-pix-bleu-gras" align="center">Demande de documentation gratuite sans engagement</td></tr>  <tr><td><span style="font-size:1pt">  <img src="http://s0b.bluestreak.com/ix.e?bb&t=803" width=1 height=1 border=0>  </span></td></tr> <TR> <TD BGCOLOR="#0950A0" class="douze-pix-blanc-gras"><b>Cocher la case de chaque contrat sur lequel vous souhaitez recevoir de l'information</b></TD> </TR> <TR > <td align=center> <table width="100%" CELLSPACING="0" border="0" cellpadding="0"> <tr> <TD width="33%" class="douze-pix-bleu"><INPUT TYPE=CHECKBOX VALUE="sante" NAME="prod_sante" >   <b>Complémentaire Santé</b></TD> <TD width="35%" class="douze-pix-bleu"><INPUT TYPE=CHECKBOX VALUE="assurance_vie" NAME="prod_assurvie" >   <b>Assurance Décès</b></TD> <TD width="32%" class="douze-pix-bleu"><INPUT TYPE=CHECKBOX VALUE="accident" NAME="prod_accident" >   <b>Assurance Accident</b></TD> </TR> <TR> <TD class="douze-pix-bleu"><INPUT TYPE=CHECKBOX VALUE="hospi" NAME="prod_hospi" >   <b>Assurance Hospitalisation</b></TD> <td class="douze-pix-bleu"><INPUT TYPE=CHECKBOX VALUE="cap_famille" NAME="prod_cap_famille" >   <b>Assurance Décès Invalidité</b></td> <TD width="32%" class="douze-pix-bleu"><INPUT TYPE=CHECKBOX VALUE="assurance_dependance" NAME="prod_assurdependance" >   <b>Assurance Dépendance</b></TD> </TR> <TR> <td class="douze-pix-bleu"> </td> <TD class="douze-pix-bleu"><INPUT TYPE=CHECKBOX VALUE="obseques" NAME="prod_obseques" >   <b>Convention Obsèques</b></TD> <td class="douze-pix-bleu"> </td> </TR> </table> </td> </TR> <tr><td><span style="font-size:1pt"> </span></td></tr> <TR> <TD BGCOLOR="#0950A0" class="douze-pix-blanc-gras"><b>Afin de recevoir votre documentation, remplissez les champs suivants :</b><img src="pix.gif" border="0" height="1" width="20"><font class="dix-pix-blanc">*champs obligatoires</font><br></TD> </TR>   <INPUT type="Hidden" NAME="filled" value="1"> <TR> <TD> <TABLE BORDER="0" CELLSPACING="0" CELLPADDING="2" > <TR> <TD WIDTH="190" class="douze-pix-bleu">Nom*</TD> <TD WIDTH="244" class="douze-pix-bleu"> <select size="1" style="font-size:8pt; color:#012993" name="civ"> <option value="M" >Mr <option value="ML" >Melle <option value="ME" >Mme </select> <INPUT NAME="nom" SIZE="15" maxlength="30" VALUE=""> </TD> <td rowspan="7" align="right" valign="top" width="136"> </td> </TR> </td> </TR> <TR> <TD class="douze-pix-bleu">Prénom*</TD> <TD class="douze-pix-bleu"> <FONT SIZE="-1" FACE="Arial, Helvetica, sans-serif"><INPUT NAME="prenom" maxlength="30" VALUE="" SIZE="20"></FONT></TD> </TR> <TR> <TD class="douze-pix-bleu">Adresse*</TD> <TD class="douze-pix-bleu"><FONT SIZE="-1" FACE="Arial, Helvetica, sans-serif"><INPUT NAME="voie" VALUE="" SIZE="30" maxlength="32"></FONT></TD> </TR> <TR> <TD class="douze-pix-bleu">Complément Adresse</TD> <TD class="douze-pix-bleu"><FONT SIZE="-1" FACE="Arial, Helvetica, sans-serif"><INPUT NAME="voie2" VALUE="" SIZE="30" maxlength="32"></FONT></TD> </TR> <TR> <TD class="douze-pix-bleu">Code Postal & Ville*</TD> <TD class="douze-pix-bleu"><FONT SIZE="-1" FACE="Arial, Helvetica, sans-serif"><INPUT NAME="cp" VALUE="" SIZE="5" maxlength="5"></FONT> <FONT SIZE="-1" FACE="Arial, Helvetica, sans-serif"><INPUT NAME="ville" VALUE="" maxlength="26" SIZE="15"> (FRANCE)</FONT></TD> </TR> <TR> <TD class="douze-pix-bleu">Date de naissance*</TD> <TD> <TABLE CELLSPACING="0" CELLPADDING="0" BORDER="0"> <TR> <TD class="douze-pix-bleu"> <SELECT NAME="nday" style="font-size:8pt; color:#012993"><OPTION>Jour <OPTION VALUE="1">1 <OPTION VALUE="2">2 <OPTION VALUE="3">3 <OPTION VALUE="4">4 <OPTION VALUE="5">5 <OPTION VALUE="6">6 <OPTION VALUE="7">7 <OPTION VALUE="8">8 <OPTION VALUE="9">9 <OPTION VALUE="10">10 <OPTION VALUE="11">11 <OPTION VALUE="12">12 <OPTION VALUE="13">13 <OPTION VALUE="14">14 <OPTION VALUE="15">15 <OPTION VALUE="16">16 <OPTION VALUE="17">17 <OPTION VALUE="18">18 <OPTION VALUE="19">19 <OPTION VALUE="20">20 <OPTION VALUE="21">21 <OPTION VALUE="22">22 <OPTION VALUE="23">23 <OPTION VALUE="24">24 <OPTION VALUE="25">25 <OPTION VALUE="26">26 <OPTION VALUE="27">27 <OPTION VALUE="28">28 <OPTION VALUE="29">29 <OPTION VALUE="30">30 <OPTION VALUE="31">31 </SELECT> </TD> <TD class="douze-pix-bleu"> <SELECT NAME="nmonth" style="font-size:8pt; color:#012993"><OPTION>Mois <OPTION VALUE="1">Janvier <OPTION VALUE="2">Février <OPTION VALUE="3">Mars <OPTION VALUE="4">Avril <OPTION VALUE="5">Mai <OPTION VALUE="6">Juin <OPTION VALUE="7">Juillet <OPTION VALUE="8">Août <OPTION VALUE="9">Septembre <OPTION VALUE="10">Octobre <OPTION VALUE="11">Novembre <OPTION VALUE="12">Décembre </SELECT> </TD> <TD class="douze-pix-bleu"> <INPUT NAME="nyear" SIZE="5" MAXLENGTH="4" VALUE="19"> </TD> </TR> </TABLE> </TD> </TR> <TR> <TD class="douze-pix-bleu">Téléphone</TD> <TD class="douze-pix-bleu"><FONT SIZE="-1" FACE="Arial, Helvetica, sans-serif"><INPUT NAME="tel" MAXLENGTH="10" VALUE="" SIZE="10"></FONT></TD> </TR> <TR> <TD class="douze-pix-bleu">Adresse email</TD> <TD class="douze-pix-bleu"><FONT SIZE="-1" FACE="Arial, Helvetica, sans-serif"><INPUT NAME="email" VALUE="" SIZE="20" ></FONT></TD> <td>  <a href="http://www.avivadirect.fr/francais/common/frame6.php3?TITLE=Assurance+d%26eacute%3Bpendance+Aviva%2C+le+formulaire+de++documentation&CONTENU=doc.php3&page=doc.php3?prod_assurdependance=1&menuhaut=../accident/menuhaut.php3?button=15&menugauche=../accident/menugauche_dependance.php3?button=0?#cnil"><font style="color:#999999; text-decoration:underline">cnil</font></a></td> </TR> <TR> <TD class="douze-pix-bleu"> Comment avez-vous connu notre site ? </td> <TD valign="top" class="douze-pix-bleu"> <SELECT name= "provenance" style="font-size:8pt; color:#012993"> <option> Faites votre choix <option value= "BoucheàOreille" >Bouche à Oreille <option value= "TV" >TV <option value="Presseécrite" >Presse <option value="PublicitéInternet" >Publicité Internet <option value="Mailing" >Mailing <option value="MoteursRecherche" >Moteurs Recherche <option value="Site" >Site affilié <option value="Autres" >Autres </SELECT> </td> </tr> </TABLE> </TD> </TR> <tr><td><span style="font-size:1pt"> </span></td></tr> <TR> <TD ALIGN=center class="douze-pix-bleu">   <INPUT NAME="Submit" TYPE="IMAGE" SRC="../images/but_valider.gif" VALUE="Submit" BORDER="0"> </TD> </TR> <TR> <TD class="moyen douze-pix-bleu"> <BR /><a name="cnil"></a>Nos contrats s'adressent à des personnes résidant en France Métropolitaine.<BR> Conformément à la loi Informatique et Libertés du 06/01/78, vous bénéficiez d'un droit d'accès et de rectification aux données vous concernant. Vous pouvez nous demander que vos coordonnées ne soient pas communiquées à des tiers en cochant cette case <INPUT TYPE=CHECKBOX NAME="sec" VALUE="1" > </TD> </TR> </TABLE> </FORM>    </BODY> </HTML>