{"id":17233674,"date":"2026-03-24T09:31:21","date_gmt":"2026-03-24T09:31:21","guid":{"rendered":"https:\/\/ambrelia.com\/questionnaire-hospisafe-lifesafe\/"},"modified":"2026-03-26T15:15:47","modified_gmt":"2026-03-26T15:15:47","slug":"questionnaire-hospisafe-lifesafe","status":"publish","type":"page","link":"https:\/\/ambrelia.com\/en\/questionnaire-hospisafe-lifesafe\/","title":{"rendered":"Questionnaire hospisafe"},"content":{"rendered":"<p>[et_pb_section fb_built=&#8221;1&#8243; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; custom_padding=&#8221;||3px|||&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_row _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; custom_padding=&#8221;||1px|||&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_column type=&#8221;4_4&#8243; _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; header_text_color=&#8221;#1359D3&#8243; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h1>Finalize your application in just a few minutes<\/h1>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p data-start=\"322\" data-end=\"481\">To complete the setup of your coverage, we need to collect certain mandatory information as part of our advisory duty.<\/p>\n<p data-start=\"483\" data-end=\"680\">This questionnaire allows us to better understand your situation, tailor the coverage to your needs, and ensure that your subscription complies with regulatory requirements (DDA \/ ACPR).<\/p>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<p data-section-id=\"x2fm5a\" data-start=\"687\" data-end=\"715\"><strong>Practical information<\/strong><\/p>\n<p data-start=\"716\" data-end=\"867\">\u23f1\ufe0f Duration: approximately 3 to 5 minutes<br data-start=\"748\" data-end=\"751\">\ud83d\udd12 Your information is strictly confidential and used solely for the purpose of supporting you<\/p>\n<p data-start=\"869\" data-end=\"992\">We invite you to complete this form carefully in order to finalize your application under the best possible conditions.<\/p>\n<p>[\/et_pb_text][et_pb_text _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; header_3_text_color=&#8221;#0039A3&#8243; header_4_text_color=&#8221;#1359D3&#8243; custom_margin=&#8221;||17px|||&#8221; global_colors_info=&#8221;{}&#8221;]<\/p>\n<h4 data-start=\"1277\" data-end=\"1323\">Please fill in the information below:<\/h4>\n<p>[\/et_pb_text][\/et_pb_column][\/et_pb_row][et_pb_row _builder_version=&#8221;4.27.4&#8243; _module_preset=&#8221;default&#8221; custom_margin=&#8221;|auto|-7px|auto||&#8221;][et_pb_column _builder_version=&#8221;4.27.4&#8243; 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-->.btn-mail{display:inline-block;padding:12px 24px;border-radius:9px;font-size:13.5px;font-weight:700;cursor:pointer;margin:5px;text-decoration:none;background:var(--blue);color:#fff;border:none}<!-- [et_pb_line_break_holder] -->.btn-dl{display:inline-block;padding:12px 24px;border-radius:9px;font-size:13.5px;font-weight:700;cursor:pointer;margin:5px;background:var(--lightblue);color:var(--blue);border:1.5px solid #c5d5f5}<!-- [et_pb_line_break_holder] -->.btn-new{background:none;border:1.5px solid var(--border);color:var(--gray);padding:9px 22px;border-radius:8px;font-size:12.5px;cursor:pointer;margin-top:14px}<!-- [et_pb_line_break_holder] -->.warn-box{background:#fffbf0;border-left:4px solid var(--orange);border-radius:0 8px 8px 0;padding:11px 14px;font-size:12px;color:#6b4c10;margin-top:10px;line-height:1.6}<!-- [et_pb_line_break_holder] -->.mention{font-size:10.5px;color:#aaa;text-align:center;margin-top:18px;line-height:1.7}<!-- [et_pb_line_break_holder] --><\/style>\n<p><!-- [et_pb_line_break_holder] --><script src=\"https:\/\/cdnjs.cloudflare.com\/ajax\/libs\/jspdf\/2.5.1\/jspdf.umd.min.js\"><\/script><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"page\"><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"header\"><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"logo-wrap\">\n<div class=\"logo-arc\"><\/div>\n<div class=\"logo-text\">Ambrelia<\/div>\n<div class=\"logo-tag\">We cover Anyone, Anywhere<\/div>\n<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"doc-title\">Duty of Advice Form<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"doc-sub\">Hospi Safe &amp; Life Safe Contracts \u2014 Allianz<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"badges\"><span class=\"badge badge-date\" id=\"dateBadge\"><\/span><span class=\"badge badge-acpr\">\u2713 DDA \/ ACPR Compliant<\/span><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div id=\"formArea\"><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"card\"><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"section-title\"><span class=\"section-num\">1<\/span> Distributor Identity<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"info-box\"><!-- [et_pb_line_break_holder] --><strong>Name:<\/strong> Kevin Elbaz &nbsp;\u00b7&nbsp; <strong>Company:<\/strong> Ambrelia<!\u2013- [et_pb_br_holder] -\u2013><!-- [et_pb_line_break_holder] --><strong>Status:<\/strong> Insurance Broker \u2014 Allianz Authorised Agent<!\u2013- [et_pb_br_holder] -\u2013><!-- [et_pb_line_break_holder] --><strong>ORIAS No.:<\/strong> <span class=\"orias-val\">11 064 575<\/span><!\u2013- [et_pb_br_holder] -\u2013><!-- [et_pb_line_break_holder] --><strong>Email:<\/strong> kevin.elbaz@ambrelia.com<!\u2013- [et_pb_br_holder] -\u2013><!-- [et_pb_line_break_holder] --><strong>Remuneration:<\/strong> Commission on premium paid by Allianz<!\u2013- [et_pb_br_holder] -\u2013><!-- [et_pb_line_break_holder] --><strong>Conflict of interest:<\/strong> As Allianz agent, the broker represents the insurer for these specific contracts.<!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"card\"><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"section-title\"><span class=\"section-num\">2<\/span> Client Information<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"grid2\"><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"field\" id=\"f-nom\"><label>Last name <span class=\"req\">*<\/span><\/label><input type=\"text\" id=\"nom\" placeholder=\"Smith\"><\/p>\n<div class=\"error-msg\">Required field<\/div>\n<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"field\" id=\"f-prenom\"><label>First name <span class=\"req\">*<\/span><\/label><input type=\"text\" id=\"prenom\" placeholder=\"John\"><\/p>\n<div class=\"error-msg\">Required field<\/div>\n<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"grid2\"><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"field\" id=\"f-ddn\"><label>Date of birth <span class=\"req\">*<\/span><\/label><input type=\"date\" id=\"ddn\"><\/p>\n<div class=\"error-msg\">Required field<\/div>\n<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"field\" id=\"f-marital\"><label>Marital status <span class=\"req\">*<\/span><\/label><!-- [et_pb_line_break_holder] --><select id=\"marital\"><option value=\"\">\u2014 Select \u2014<\/option><option>Single<\/option><option>Married<\/option><option>Civil partnership<\/option><option>Divorced<\/option><option>Widowed<\/option><\/select><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"error-msg\">Required field<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"grid2\"><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"field\"><label>Number of dependent children<\/label><input type=\"number\" id=\"nbEnfants\" min=\"0\" max=\"15\" value=\"0\" oninput=\"updateChildren(this.value)\"><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"field\" id=\"f-employeur\"><label>Employer \/ Organisation <span class=\"req\">*<\/span><\/label><input type=\"text\" id=\"employeur\" placeholder=\"European Commission\"><\/p>\n<div class=\"error-msg\">Required field<\/div>\n<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"children-list\" id=\"childrenList\"><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"grid2\" style=\"margin-top:4px\"><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"field\" id=\"f-adresse\"><label>Postal address <span class=\"req\">*<\/span><\/label><input type=\"text\" id=\"adresse\" placeholder=\"12 Rue de la Paix, 75001 Paris\"><\/p>\n<div class=\"error-msg\">Required field<\/div>\n<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"field\" id=\"f-email\"><label>Email address <span class=\"req\">*<\/span><\/label><input type=\"email\" id=\"emailClient\" placeholder=\"client@organisation.eu\"><\/p>\n<div class=\"error-msg\">Valid email required<\/div>\n<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"card\"><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"section-title\"><span class=\"section-num\">3<\/span> Needs Analysis <span class=\"section-tag\">DDA Art. L.521-4<\/span><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"field\" id=\"f-couverture\"><!-- [et_pb_line_break_holder] --><label>Existing coverage? <span class=\"req\">*<\/span><\/label><!-- [et_pb_line_break_holder] --><select id=\"couverture\"><option value=\"\">\u2014 Select \u2014<\/option><option value=\"non\">No, no existing coverage<\/option><option value=\"partielle\">Yes, partial coverage (supplement desired)<\/option><option value=\"autre\">Yes, existing coverage (replacement or supplement)<\/option><\/select><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"error-msg\">Required field<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"field\"><label>Needs expressed by the client<\/label><textarea id=\"besoins\" placeholder=\"E.g.: hospital coverage for the family, death\/disability protection, international coverage...\"><\/textarea><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"field\" id=\"f-adequation\"><label>Suitability rationale <span class=\"req\">*<\/span><\/label><textarea id=\"adequation\" placeholder=\"Why this contract meets the expressed needs...\"><\/textarea><\/p>\n<div class=\"error-msg\">Required field<\/div>\n<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"card\"><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"section-title\"><span class=\"section-num\">4<\/span> Contract(s) subscribed <span class=\"req\">*<\/span><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"contrat-group\" id=\"contratGroup\"><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"contrat-btn\" onclick=\"toggleContrat(this)\">\n<div class=\"ct-icon\">\ud83c\udfe5<\/div>\n<div class=\"ct-name\">Hospi Safe<\/div>\n<div class=\"ct-sub\">Allianz \u00b7 Hospitalisation<\/div>\n<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"contrat-btn\" onclick=\"toggleContrat(this)\">\n<div class=\"ct-icon\">\ud83d\udee1\ufe0f<\/div>\n<div class=\"ct-name\">Life Safe<\/div>\n<div class=\"ct-sub\">Allianz \u00b7 Life \/ Death cover<\/div>\n<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"dual-notice\" id=\"dualNotice\">\u2139\ufe0f Combined subscription Hospi Safe + Life Safe. The client acknowledges being informed of the guarantees and cost of each contract separately.<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"error-msg\" id=\"contratError\">Please select at least one contract<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"card\"><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"section-title\"><span class=\"section-num\">5<\/span> Pre-contractual documents provided <span class=\"section-tag\">DDA Art. L.521-3<\/span><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"check-list\"><!-- [et_pb_line_break_holder] --><label class=\"check-item\"><input type=\"checkbox\" class=\"decl\" id=\"doc1\"><\/p>\n<div class=\"check-box\"><\/div>\n<p><span class=\"check-text\">The <strong>IPID product information document<\/strong> was provided to me before subscription. <span class=\"check-tag\">IPID<\/span><\/span><\/label><!-- [et_pb_line_break_holder] --><label class=\"check-item\"><input type=\"checkbox\" class=\"decl\" id=\"doc2\"><\/p>\n<div class=\"check-box\"><\/div>\n<p><span class=\"check-text\">The <strong>General and Particular Conditions<\/strong> have been communicated to me. <span class=\"check-tag\">T&#038;C<\/span><\/span><\/label><!-- [et_pb_line_break_holder] --><label class=\"check-item\"><input type=\"checkbox\" class=\"decl\" id=\"doc3\"><\/p>\n<div class=\"check-box\"><\/div>\n<p><span class=\"check-text\">An <strong>online subscription link<\/strong> was sent to me by email. <span class=\"check-tag\">Subscription<\/span><\/span><\/label><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"card\"><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"section-title\"><span class=\"section-num\">6<\/span> Client Declarations<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"check-list\"><!-- [et_pb_line_break_holder] --><label class=\"check-item\"><input type=\"checkbox\" class=\"decl\" id=\"d1\"><\/p>\n<div class=\"check-box\"><\/div>\n<p><span class=\"check-text\">I have been informed and advised by <strong>Mr Kevin Elbaz<\/strong> (Ambrelia), Allianz authorised agent. <span class=\"check-tag\">L.521-1<\/span><\/span><\/label><!-- [et_pb_line_break_holder] --><label class=\"check-item\"><input type=\"checkbox\" class=\"decl\" id=\"d2\"><\/p>\n<div class=\"check-box\"><\/div>\n<p><span class=\"check-text\">I understand this contract is offered under the <strong>European Commission staff coverage programme<\/strong>.<\/span><\/label><!-- [et_pb_line_break_holder] --><label class=\"check-item\"><input type=\"checkbox\" class=\"decl\" id=\"d3\"><\/p>\n<div class=\"check-box\"><\/div>\n<p><span class=\"check-text\">I have been informed of the broker&#8217;s <strong>commission-based remuneration<\/strong>. <span class=\"check-tag\">L.521-2<\/span><\/span><\/label><!-- [et_pb_line_break_holder] --><label class=\"check-item\"><input type=\"checkbox\" class=\"decl\" id=\"d4\"><\/p>\n<div class=\"check-box\"><\/div>\n<p><span class=\"check-text\">I received clear information on <strong>guarantees, exclusions, caps<\/strong> and general conditions.<\/span><\/label><!-- [et_pb_line_break_holder] --><label class=\"check-item\"><input type=\"checkbox\" class=\"decl\" id=\"d5\"><\/p>\n<div class=\"check-box\"><\/div>\n<p><span class=\"check-text\">I have been informed of my <strong>right of withdrawal<\/strong> and the cancellation procedures.<\/span><\/label><!-- [et_pb_line_break_holder] --><label class=\"check-item\"><input type=\"checkbox\" class=\"decl\" id=\"d6\"><\/p>\n<div class=\"check-box\"><\/div>\n<p><span class=\"check-text\">I had the opportunity to <strong>ask all my questions<\/strong> and receive satisfactory answers.<\/span><\/label><!-- [et_pb_line_break_holder] --><label class=\"check-item\"><input type=\"checkbox\" class=\"decl\" id=\"d7\"><\/p>\n<div class=\"check-box\"><\/div>\n<p><span class=\"check-text\">The <strong>personal information<\/strong> provided is accurate and complete.<\/span><\/label><!-- [et_pb_line_break_holder] --><label class=\"check-item\" id=\"dualCheck\" style=\"display:none\"><input type=\"checkbox\" class=\"decl\" id=\"d8\"><\/p>\n<div class=\"check-box\"><\/div>\n<p><span class=\"check-text\"><strong>[Dual subscription]<\/strong> I was informed separately of the guarantees and costs of each contract. <span class=\"check-tag\">Dual contract<\/span><\/span><\/label><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"error-msg\" id=\"declError\" style=\"margin-top:12px\">All declarations must be checked<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"card\"><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"section-title\"><span class=\"section-num\">7<\/span> Electronic Signature<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"grid2\"><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"field\" id=\"f-sigNom\"><label>Full name (confirmation) <span class=\"req\">*<\/span><\/label><input type=\"text\" id=\"sigNom\" placeholder=\"John Smith\"><\/p>\n<div class=\"error-msg\">Required field<\/div>\n<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"field\"><label>Date<\/label><input type=\"text\" id=\"sigDate\" readonly><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"warn-box\">By submitting this form, the client certifies the accuracy of the information provided and confirms having received advice prior to any subscription, in accordance with Articles L.521-1 et seq. of the French Insurance Code.<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"global-error\" id=\"globalError\">Please correct the errors below before submitting.<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"submit-card\"><!-- [et_pb_line_break_holder] --><button class=\"btn-submit\" id=\"btnSubmit\" onclick=\"submitForm()\">Validate and generate PDF \u2192<\/button><!-- [et_pb_line_break_holder] --><\/p>\n<div id=\"uploadStatus\">\u23f3 Generating and uploading PDF\u2026<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"card success-screen\" id=\"successScreen\"><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"success-icon\">\u2705<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"success-title\">Form validated!<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"success-body\" id=\"successBody\"><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div><!-- [et_pb_line_break_holder] --><a class=\"btn-mail\" id=\"mailLink\" href=\"#\" onclick=\"return checkMailLink(this)\">\u2709 Open email<\/a><!-- [et_pb_line_break_holder] --><button class=\"btn-dl\" onclick=\"downloadPDF()\">\u2b07 Download PDF<\/button><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><!\u2013- [et_pb_br_holder] -\u2013><button class=\"btn-new\" onclick=\"resetForm()\">+ New form<\/button><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><\/p>\n<div class=\"mention\">Document generated via Ambrelia \u2014 Duty of Advice Form compliant with DDA \/ ACPR<!\u2013- [et_pb_br_holder] -\u2013>Legal ref.: Art. L.521-1 to L.521-6 French Insurance Code \u2014 Directive (EU) 2016\/97<\/div>\n<p><!-- [et_pb_line_break_holder] --><\/div>\n<p><!-- [et_pb_line_break_holder] --><script><!-- [et_pb_line_break_holder] -->const pad=n=>String(n).padStart(2,'0');<!-- [et_pb_line_break_holder] -->const TODAY=new Date();<!-- [et_pb_line_break_holder] -->const fmtDate=d=>`${pad(d.getDate())}\/${pad(d.getMonth()+1)}\/${d.getFullYear()}`;<!-- [et_pb_line_break_holder] -->document.getElementById('dateBadge').textContent='\ud83d\udcc5 '+fmtDate(TODAY);<!-- [et_pb_line_break_holder] -->document.getElementById('sigDate').value=fmtDate(TODAY);<!-- [et_pb_line_break_holder] -->let _pdf=null;<!-- [et_pb_line_break_holder] -->function updateChildren(n){<!-- [et_pb_line_break_holder] -->  n=Math.max(0,Math.min(15,parseInt(n)||0));<!-- [et_pb_line_break_holder] -->  const list=document.getElementById('childrenList');<!-- [et_pb_line_break_holder] -->  while(list.children.length>n)list.removeChild(list.lastChild);<!-- [et_pb_line_break_holder] -->  while(list.children.length<n){const i=list.children.length,row=document.createElement('div');row.className='child-row';row.innerHTML=`\n\n<div class=\"field\"><label>Child ${i+1} \u2014 First name<\/label><input type=\"text\" placeholder=\"First name\"><\/div>\n<div class=\"field\"><label>Age<\/label><input type=\"number\" min=\"0\" max=\"25\" placeholder=\"yrs\"><\/div>\n<p>`;list.appendChild(row);}<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] -->function toggleContrat(el){el.classList.toggle('selected');const dual=getContrats().length===2;document.getElementById('dualNotice').style.display=dual?'block':'none';document.getElementById('dualCheck').style.display=dual?'flex':'none';if(!dual)document.getElementById('d8').checked=false;}<!-- [et_pb_line_break_holder] -->function getContrats(){return[...document.querySelectorAll('#contratGroup .contrat-btn.selected')].map(e=>e.querySelector('.ct-name').textContent);}<!-- [et_pb_line_break_holder] -->function req(id){const f=document.getElementById('f-'+id),val=document.getElementById(id).value.trim();if(!val){f.classList.add('error');return false;}f.classList.remove('error');return true;}<!-- [et_pb_line_break_holder] -->function validate(){<!-- [et_pb_line_break_holder] -->  let ok=true;<!-- [et_pb_line_break_holder] -->  ['nom','prenom','ddn','marital','employeur','adresse','couverture','adequation'].forEach(id=>{if(!req(id))ok=false;});<!-- [et_pb_line_break_holder] -->  const ef=document.getElementById('f-email'),ev=document.getElementById('emailClient').value.trim();<!-- [et_pb_line_break_holder] -->  if(!ev||!\/^[^\\s@]+@[^\\s@]+\\.[^\\s@]+$\/.test(ev)){ef.classList.add('error');ok=false;}else ef.classList.remove('error');<!-- [et_pb_line_break_holder] -->  if(!req('sigNom'))ok=false;<!-- [et_pb_line_break_holder] -->  const c=getContrats();document.getElementById('contratError').style.display=c.length?'none':'block';if(!c.length)ok=false;<!-- [et_pb_line_break_holder] -->  const allDecl=[...document.querySelectorAll('.decl')].filter(d=>d.closest('label').style.display!=='none').every(d=>d.checked);<!-- [et_pb_line_break_holder] -->  document.getElementById('declError').style.display=allDecl?'none':'block';if(!allDecl)ok=false;<!-- [et_pb_line_break_holder] -->  document.getElementById('globalError').style.display=ok?'none':'block';return ok;<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] -->function getChildren(){return[...document.querySelectorAll('#childrenList .child-row')].map((r,i)=>{const ins=r.querySelectorAll('input');return`Child ${i+1}: ${ins[0].value||'\u2014'}, ${ins[1].value||'?'} yrs`;});}<!-- [et_pb_line_break_holder] -->function v(id){return document.getElementById(id).value.trim();}<!-- [et_pb_line_break_holder] -->function buildPDF(){<!-- [et_pb_line_break_holder] -->  const{jsPDF}=window.jspdf;const doc=new jsPDF({unit:'mm',format:'a4'});<!-- [et_pb_line_break_holder] -->  const W=210,ML=12,MR=12,CW=W-ML-MR;<!-- [et_pb_line_break_holder] -->  const BLUE=[20,87,184],ORANGE=[245,166,35],LGRAY=[245,247,252],MGRAY=[90,100,119],WHITE=[255,255,255];<!-- [et_pb_line_break_holder] -->  const contrats=getContrats().join(' + ')||'\u2014';let y=0;<!-- [et_pb_line_break_holder] -->  doc.setFillColor(...BLUE);doc.rect(0,0,W,34,'F');<!-- [et_pb_line_break_holder] -->  doc.setDrawColor(...ORANGE);doc.setLineWidth(2.5);doc.ellipse(W\/2,34,9,5,'S');<!-- [et_pb_line_break_holder] -->  doc.setTextColor(...WHITE);doc.setFont('helvetica','bold');doc.setFontSize(19);doc.text('Ambrelia',W\/2,12,{align:'center'});<!-- [et_pb_line_break_holder] -->  doc.setFontSize(7.5);doc.setFont('helvetica','normal');doc.text('We cover Anyone, Anywhere',W\/2,18,{align:'center'});<!-- [et_pb_line_break_holder] -->  doc.setFontSize(10);doc.setFont('helvetica','bold');doc.text('DUTY OF ADVICE FORM \u2014 DDA \/ ACPR',W\/2,25.5,{align:'center'});<!-- [et_pb_line_break_holder] -->  doc.setFontSize(7);doc.setFont('helvetica','normal');doc.text(`Contracts: ${contrats}  \u00b7  Allianz  \u00b7  Date: ${fmtDate(TODAY)}`,W\/2,30.5,{align:'center'});<!-- [et_pb_line_break_holder] -->  y=40;<!-- [et_pb_line_break_holder] -->  const sH=(num,title,tag='')=>{doc.setFillColor(...LGRAY);doc.roundedRect(ML,y-3,CW,8,2,2,'F');doc.setFillColor(...BLUE);doc.circle(ML+4,y+1,2.5,'F');doc.setTextColor(...WHITE);doc.setFont('helvetica','bold');doc.setFontSize(7);doc.text(num,ML+4,y+1.6,{align:'center'});doc.setTextColor(...BLUE);doc.setFontSize(8);doc.text(title.toUpperCase(),ML+9,y+1.8);if(tag){doc.setFontSize(6.5);doc.setTextColor(...MGRAY);doc.text(tag,W-MR,y+1.8,{align:'right'});}y+=9;};<!-- [et_pb_line_break_holder] -->  const r2=(lbl,val,x=ML)=>{doc.setFont('helvetica','bold');doc.setFontSize(7);doc.setTextColor(...MGRAY);doc.text(lbl,x,y);doc.setFont('helvetica','normal');doc.setTextColor(30,30,30);const lines=doc.splitTextToSize(String(val||'\u2014'),CW\/2-8);doc.text(lines,x+38,y);y+=4.5*lines.length;};<!-- [et_pb_line_break_holder] -->  const mline=(lbl,val)=>{doc.setFont('helvetica','bold');doc.setFontSize(7);doc.setTextColor(...MGRAY);doc.text(lbl,ML,y);y+=4;doc.setFont('helvetica','normal');doc.setTextColor(30,30,30);const lines=doc.splitTextToSize(val||'\u2014',CW);doc.text(lines,ML,y);y+=4*lines.length+1;};<!-- [et_pb_line_break_holder] -->  const LC=ML,RC=ML+CW\/2+3,HW=CW\/2-3;<!-- [et_pb_line_break_holder] -->  sH('1','Distributor Identity');<!-- [et_pb_line_break_holder] -->  let yL=y,yR=y;<!-- [et_pb_line_break_holder] -->  [['Name \/ Company:','Kevin Elbaz \u2014 Ambrelia'],['Status:','Insurance Broker \u2014 Allianz Agent'],['ORIAS No.:','11 064 575'],['Email:','kevin.elbaz@ambrelia.com'],['Remuneration:','Commission on premium \u2014 Allianz']].forEach(([lbl,val])=>{doc.setFont('helvetica','bold');doc.setFontSize(7);doc.setTextColor(...MGRAY);doc.text(lbl,LC,yL);doc.setFont('helvetica','normal');doc.setTextColor(30,30,30);const lines=doc.splitTextToSize(val,HW-28);doc.text(lines,LC+28,yL);yL+=4.5*lines.length;});<!-- [et_pb_line_break_holder] -->  doc.setFont('helvetica','bold');doc.setFontSize(7);doc.setTextColor(...BLUE);doc.text('CLIENT',RC,yR-1);yR+=1;<!-- [et_pb_line_break_holder] -->  const nb=parseInt(v('nbEnfants'))||0;const couv=document.getElementById('couverture');<!-- [et_pb_line_break_holder] -->  [['Last \/ First name:',`${v('nom')} ${v('prenom')}`],['Date of birth:',v('ddn')],['Marital status:',v('marital')],['Dep. children:',String(nb)],['Employer:',v('employeur')],['Address:',v('adresse')],['Email:',v('emailClient')]].forEach(([lbl,val])=>{doc.setFont('helvetica','bold');doc.setFontSize(7);doc.setTextColor(...MGRAY);doc.text(lbl,RC,yR);doc.setFont('helvetica','normal');doc.setTextColor(30,30,30);const lines=doc.splitTextToSize(val||'\u2014',HW-28);doc.text(lines,RC+28,yR);yR+=4.5*lines.length;});<!-- [et_pb_line_break_holder] -->  getChildren().forEach(c=>{doc.setFont('helvetica','normal');doc.setFontSize(7);doc.setTextColor(30,30,30);doc.text('\u00b7 '+c,RC+28,yR);yR+=4;});<!-- [et_pb_line_break_holder] -->  y=Math.max(yL,yR)+2;doc.setDrawColor(...LGRAY);doc.setLineWidth(0.3);doc.line(ML,y,ML+CW,y);y+=3;<!-- [et_pb_line_break_holder] -->  sH('3','Needs Analysis','DDA Art. L.521-4');<!-- [et_pb_line_break_holder] -->  r2('Existing coverage:',couv.options[couv.selectedIndex].text,ML);<!-- [et_pb_line_break_holder] -->  mline('Expressed needs:',document.getElementById('besoins').value||'\u2014');<!-- [et_pb_line_break_holder] -->  mline('Suitability rationale:',v('adequation'));y+=1;<!-- [et_pb_line_break_holder] -->  sH('4+5','Contracts subscribed & Documents provided');<!-- [et_pb_line_break_holder] -->  let yC=y,yD=y;<!-- [et_pb_line_break_holder] -->  doc.setFont('helvetica','bold');doc.setFontSize(8);doc.setTextColor(...BLUE);doc.text(contrats,LC,yC);yC+=5;<!-- [et_pb_line_break_holder] -->  if(getContrats().length===2){doc.setFont('helvetica','italic');doc.setFontSize(6.5);doc.setTextColor(46,125,50);doc.text('Combined subscription \u2014 client informed separately of each contract',LC,yC);yC+=5;}<!-- [et_pb_line_break_holder] -->  ['IPID document provided before subscription','General & Particular Conditions communicated','Online subscription link sent by email'].forEach(txt=>{doc.setFontSize(7);doc.setTextColor(...BLUE);doc.setFont('helvetica','bold');doc.text('\u2611',RC,yD);doc.setFont('helvetica','normal');doc.setTextColor(30,30,30);doc.text(txt,RC+6,yD);yD+=4.5;});<!-- [et_pb_line_break_holder] -->  y=Math.max(yC,yD)+2;doc.setDrawColor(...LGRAY);doc.setLineWidth(0.3);doc.line(ML,y,ML+CW,y);y+=3;<!-- [et_pb_line_break_holder] -->  sH('6','Client Declarations \u2014 Duty of Advice');<!-- [et_pb_line_break_holder] -->  const decls=['Informed and advised by Mr Kevin Elbaz (Ambrelia), Allianz authorised agent (DDA L.521-1)','Subscription under the European Commission staff coverage programme','Informed of the broker\\'s commission-based remuneration (DDA L.521-2)','Informed of guarantees, exclusions, caps and general conditions','Informed of right of withdrawal and cancellation procedures','All questions asked and satisfactory answers received','Personal information is accurate and complete'];<!-- [et_pb_line_break_holder] -->  if(getContrats().length===2)decls.push('Dual subscription confirmed with full knowledge of each contract\\'s terms');<!-- [et_pb_line_break_holder] -->  const half=Math.ceil(decls.length\/2);let yD1=y,yD2=y;<!-- [et_pb_line_break_holder] -->  decls.forEach((d,i)=>{const isL=i<half;const x=isL?LC:RC;doc.setFontSize(7);doc.setTextColor(...BLUE);doc.setFont('helvetica','bold');if(isL){doc.text('\u2611',x,yD1);doc.setFont('helvetica','normal');doc.setTextColor(30,30,30);const lines=doc.splitTextToSize(d,HW-6);doc.text(lines,x+6,yD1);yD1+=4*lines.length+0.5;}else{doc.text('\u2611',x,yD2);doc.setFont('helvetica','normal');doc.setTextColor(30,30,30);const lines=doc.splitTextToSize(d,HW-6);doc.text(lines,x+6,yD2);yD2+=4*lines.length+0.5;}});<!-- [et_pb_line_break_holder] -->  y=Math.max(yD1,yD2)+3;<!-- [et_pb_line_break_holder] -->  sH('7','Electronic Signature');<!-- [et_pb_line_break_holder] -->  r2('Full name:',v('sigNom'),ML);r2('Date:',fmtDate(TODAY),ML);y+=1;<!-- [et_pb_line_break_holder] -->  doc.setFontSize(6.5);doc.setTextColor(...MGRAY);doc.setFont('helvetica','italic');<!-- [et_pb_line_break_holder] -->  const wl=doc.splitTextToSize('By submitting this form, the client certifies the accuracy of the information provided and confirms having received advice prior to any subscription, in accordance with Articles L.521-1 et seq. of the French Insurance Code.',CW);doc.text(wl,ML,y);<!-- [et_pb_line_break_holder] -->  doc.setFillColor(...BLUE);doc.rect(0,285,W,12,'F');doc.setTextColor(...WHITE);doc.setFontSize(6.5);doc.setFont('helvetica','normal');<!-- [et_pb_line_break_holder] -->  doc.text('Ambrelia \u2014 ORIAS 11 064 575 \u2014 kevin.elbaz@ambrelia.com',ML,291);doc.text('Art. L.521-1 to L.521-6 French Insurance Code \u2014 Directive (EU) 2016\/97',W-MR,291,{align:'right'});<!-- [et_pb_line_break_holder] -->  return doc;<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] -->async function uploadPDF(pdfDoc,filename){<!-- [et_pb_line_break_holder] -->  const blob=pdfDoc.output('blob');<!-- [et_pb_line_break_holder] -->  const srvRes=await fetch('https:\/\/api.gofile.io\/servers');if(!srvRes.ok)throw new Error('Server unavailable');<!-- [et_pb_line_break_holder] -->  const srvData=await srvRes.json();if(srvData.status!=='ok')throw new Error('gofile server error');<!-- [et_pb_line_break_holder] -->  const server=srvData.data.servers[0].name;<!-- [et_pb_line_break_holder] -->  const fd=new FormData();fd.append('file',blob,filename);<!-- [et_pb_line_break_holder] -->  const upRes=await fetch(`https:\/\/${server}.gofile.io\/contents\/uploadfile`,{method:'POST',body:fd});if(!upRes.ok)throw new Error('Upload failed');<!-- [et_pb_line_break_holder] -->  const upData=await upRes.json();if(upData.status!=='ok')throw new Error('Upload error');<!-- [et_pb_line_break_holder] -->  return upData.data.downloadPage;<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] -->function downloadPDF(){if(_pdf)_pdf.save(`DutyOfAdvice_${v('nom')}_${v('prenom')}_${fmtDate(TODAY).replace(\/\\\/\/g,'-')}.pdf`);}<!-- [et_pb_line_break_holder] -->async function submitForm(){<!-- [et_pb_line_break_holder] -->  if(!validate()){const fe=document.querySelector('.field.error input,.field.error select,.field.error textarea');if(fe)fe.scrollIntoView({behavior:'smooth',block:'center'});return;}<!-- [et_pb_line_break_holder] -->  const btn=document.getElementById('btnSubmit'),status=document.getElementById('uploadStatus');<!-- [et_pb_line_break_holder] -->  btn.disabled=true;btn.style.opacity='.6';status.style.display='block';<!-- [et_pb_line_break_holder] -->  try{<!-- [et_pb_line_break_holder] -->    _pdf=buildPDF();<!-- [et_pb_line_break_holder] -->    const nom=v('nom'),prenom=v('prenom'),contrats=getContrats().join(' + ');<!-- [et_pb_line_break_holder] -->    const filename=`DutyOfAdvice_${nom}_${prenom}_${fmtDate(TODAY).replace(\/\\\/\/g,'-')}.pdf`;<!-- [et_pb_line_break_holder] -->    const link=await uploadPDF(_pdf,filename);<!-- [et_pb_line_break_holder] -->    const clientEmail=document.getElementById('emailClient').value.trim();<!-- [et_pb_line_break_holder] -->    const subject=encodeURIComponent(`Duty of Advice \u2014 ${prenom} ${nom} \u2014 ${contrats} \u2014 ${fmtDate(TODAY)}`);<!-- [et_pb_line_break_holder] -->    const body=encodeURIComponent(`Dear ${prenom},\\n\\nYour Duty of Advice form (${contrats}) dated ${fmtDate(TODAY)} is available here:\\n\\n${link}\\n\\n\u26a0\ufe0f Single-use link, valid for 14 days.\\n\\nBest regards,\\nKevin Elbaz \u2014 Ambrelia\\nkevin.elbaz@ambrelia.com`);<!-- [et_pb_line_break_holder] -->    document.getElementById('mailLink').href=`mailto:${clientEmail}?cc=kevin.elbaz%40ambrelia.com&subject=${subject}&body=${body}`;<!-- [et_pb_line_break_holder] -->    document.getElementById('successBody').innerHTML=`Form for <strong>${prenom} ${nom}<\/strong> (${contrats}) is ready.<\/p>\n<div class=\"link-box\">\ud83d\udd17 <strong>PDF Link:<\/strong><!\u2013- [et_pb_br_holder] -\u2013><a href=\"${link}\" target=\"_blank\">${link}<\/a><\/div>\n<p><span style=\"font-size:11.5px;color:#888\">\ud83d\udce7 ${clientEmail} &nbsp;\u00b7&nbsp; \ud83d\udccb kevin.elbaz@ambrelia.com<!\u2013- [et_pb_br_holder] -\u2013>\u23f1 Link valid 14 days \u2014 single use<\/span>`;<!-- [et_pb_line_break_holder] -->    document.getElementById('formArea').style.display='none';document.getElementById('successScreen').style.display='block';window.scrollTo({top:0,behavior:'smooth'});<!-- [et_pb_line_break_holder] -->  }catch(err){status.textContent='\u274c Error: '+err.message+' \u2014 Please try again.';btn.disabled=false;btn.style.opacity='1';}<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] -->function checkMailLink(el){if(el.href==='#'||el.href.endsWith('#')){alert('Link not available.');return false;}return true;}<!-- [et_pb_line_break_holder] -->function resetForm(){<!-- [et_pb_line_break_holder] -->  _pdf=null;document.getElementById('successScreen').style.display='none';document.getElementById('formArea').style.display='block';<!-- [et_pb_line_break_holder] -->  document.querySelectorAll('input[type=text],input[type=email],textarea').forEach(i=>{if(i.id!=='sigDate')i.value='';});<!-- [et_pb_line_break_holder] -->  document.querySelectorAll('input[type=date]').forEach(i=>i.value='');<!-- [et_pb_line_break_holder] -->  document.getElementById('nbEnfants').value=0;document.getElementById('childrenList').innerHTML='';<!-- [et_pb_line_break_holder] -->  ['marital','couverture'].forEach(id=>document.getElementById(id).value='');<!-- [et_pb_line_break_holder] -->  document.querySelectorAll('.contrat-btn').forEach(b=>b.classList.remove('selected'));<!-- [et_pb_line_break_holder] -->  document.querySelectorAll('.decl').forEach(d=>d.checked=false);<!-- [et_pb_line_break_holder] -->  document.querySelectorAll('.field').forEach(f=>f.classList.remove('error'));<!-- [et_pb_line_break_holder] -->  ['contratError','declError','globalError'].forEach(id=>document.getElementById(id).style.display='none');<!-- [et_pb_line_break_holder] -->  document.getElementById('dualNotice').style.display='none';document.getElementById('dualCheck').style.display='none';<!-- [et_pb_line_break_holder] -->  document.getElementById('btnSubmit').disabled=false;document.getElementById('btnSubmit').style.opacity='1';<!-- [et_pb_line_break_holder] -->  document.getElementById('uploadStatus').style.display='none';window.scrollTo({top:0,behavior:'smooth'});<!-- [et_pb_line_break_holder] -->}<!-- [et_pb_line_break_holder] --><\/script>[\/et_pb_code][\/et_pb_column][\/et_pb_row][\/et_pb_section][et_pb_section fb_built=&#8221;1&#8243; 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This questionnaire allows us to better understand your situation, tailor the coverage to your needs, and ensure that your subscription complies with regulatory requirements (DDA \/ ACPR).Practical information [&hellip;]<\/p>\n","protected":false},"author":26,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_et_pb_use_builder":"on","_et_pb_old_content":"","_et_gb_content_width":"","footnotes":""},"dipi_cpt_category":[],"class_list":["post-17233674","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.5 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Questionnaire hospisafe - Ambrelia<\/title>\n<meta name=\"description\" content=\"Complete your Hospi Safe and Life Safe questionnaire online. 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