{"id":5229,"date":"2025-02-03T17:10:59","date_gmt":"2025-02-03T16:10:59","guid":{"rendered":"https:\/\/insbrok.com\/solicitud-de-cotizacion-de-seguro-de-vida\/"},"modified":"2025-02-07T15:22:02","modified_gmt":"2025-02-07T14:22:02","slug":"solicitud-de-cotizacion-de-seguro-de-vida","status":"publish","type":"page","link":"https:\/\/insbrok.com\/es\/solicitud-de-cotizacion-de-seguro-de-vida\/","title":{"rendered":"Solicitud de Cotizaci\u00f3n de Seguro de Vida"},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof 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gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_20' style='display:none'><div id='gf_20' class='gform_anchor' tabindex='-1'><\/div>\n                        <div class='gform_heading'>\n\t\t\t\t\t\t\t<p class='gform_required_legend'>&quot;<span class=\"gfield_required gfield_required_asterisk\">*<\/span>&quot; indica campos obligatorios<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_20'  action='\/es\/wp-json\/wp\/v2\/pages\/5229#gf_20' data-formid='20' novalidate><div id='gf_page_steps_20' class='gf_page_steps'><div id='gf_step_20_1' class='gf_step gf_step_active gf_step_first'><span class='gf_step_number'>1<\/span><span class='gf_step_label'>Capital<\/span><\/div><div id='gf_step_20_2' class='gf_step gf_step_next gf_step_pending'><span class='gf_step_number'>2<\/span><span class='gf_step_label'>Tomador<\/span><\/div><div id='gf_step_20_3' class='gf_step gf_step_pending'><span class='gf_step_number'>3<\/span><span class='gf_step_label'>Asegurado<\/span><\/div><div id='gf_step_20_4' class='gf_step gf_step_last gf_step_pending'><span class='gf_step_number'>4<\/span><span class='gf_step_label'>Beneficiarios<\/span><\/div><\/div>\n                        <div class='gform-body gform_body'><div id='gform_page_20_1' class='gform_page ' data-js='page-field-id-0' >\n\t\t\t\t\t<div class='gform_page_fields'><div id='gform_fields_20' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_20_42\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Informaci\u00f3n b\u00e1sica<\/h3><\/div><div id=\"field_20_93\" class=\"gfield gfield--type-text gfield--input-type-adminonly_hidden field_admin_only field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_administrative\"  ><input name='input_93' id='input_20_93' class='gform_hidden' type='hidden' value=''\/><\/div><div id=\"field_20_94\" class=\"gfield gfield--type-text gfield--input-type-adminonly_hidden field_admin_only field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_administrative\"  ><input name='input_94' id='input_20_94' class='gform_hidden' type='hidden' value=''\/><\/div><div id=\"field_20_22\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_22'>Profesi\u00f3n<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_20_22' type='text' value='' class='large'    placeholder='Profesi\u00f3n' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_20_3\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_3'>Actividad de riesgo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_3' id='input_20_3' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Actividad de riesgo<\/option><option value='Sin actividad' >Sin actividad<\/option><option value='Alpinismo' >Alpinismo<\/option><option value='Tiro con arco' >Tiro con arco<\/option><option value='Boxeo' >Boxing<\/option><option value='Encierros de toros' >Encierros de toros<\/option><option value='Escalada' >Climbing<\/option><option value='Ciclismo' >Ciclismo<\/option><option value='Buceo' >Buceo<\/option><option value='Instructor de vuelo' >Instructor de vuelo<\/option><option value='Futbol' >Futbol<\/option><option value='Alturas' >Alturas<\/option><option value='Equitacion' >Equitacion<\/option><option value='Caza' >Caza<\/option><option value='Karate' >Karate<\/option><option value='Artes marciales' >Artes marciales<\/option><option value='Motocross' >Motocross<\/option><option value='Motociclismo' >Motociclismo<\/option><option value='Ciclismo de monta\u00f1a' >Ciclismo de monta\u00f1a<\/option><option value='Sin actividad' >Sin actividad<\/option><option value='Parapente' >Parapente<\/option><option value='Piloto' >Piloto<\/option><option value='Aviacion privada' >Aviacion privada<\/option><option value='Restauracion' >Restauracion<\/option><option value='Submarinismo' >Submarinismo<\/option><option value='Tiro' >Tiro<\/option><option value='Esqui' >Esqui<\/option><option value='Paracaidismo' >Paracaidismo<\/option><option value='Espeleologia' >Espeleologia<\/option><option value='Surf' >Surf<\/option><option value='Triatlon' >Triatlon<\/option><option value='Viajes' >Viajes<\/option><option value='Senderismo' >Senderismo<\/option><\/select><\/div><\/div><div id=\"field_20_100\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-third gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label screen-reader-text' for='input_20_100'>\u00bfCon qu\u00e9 frecuencia?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_100' id='input_20_100' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>\u00bfCon qu\u00e9 frecuencia?<\/option><option value='Diariamente' >Diariamente<\/option><option value='3-4 veces a la semana' >3-4 veces a la semana<\/option><option value='1-2 veces a la semana' >1-2 veces a la semana<\/option><option value='1-2 veces al mes' >1-2 veces al mes<\/option><option value='Menos de una vez al mes' >Menos de una vez al mes<\/option><\/select><\/div><\/div><div id=\"field_20_88\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_88'>Fecha de nacimiento<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_88' id='input_20_88' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='dd-mm-aaaa' aria-describedby=\"input_20_88_date_format gfield_description_20_88\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_20_88_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_20_88' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_20_88'>dd-mm-yyyy<\/div><\/div><div id=\"field_20_4\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield--width-half gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_4'>Fecha de inicio de la p\u00f3liza<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_4' id='input_20_4' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='dd-mm-aaaa' aria-describedby=\"input_20_4_date_format gfield_description_20_4\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_20_4_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_20_4' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_20_4'>dd-mm-yyyy<\/div><\/div><fieldset id=\"field_20_95\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gf_list_3col gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Empleo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_20_95'>\n\t\t\t<div class='gchoice gchoice_20_95_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_95' type='radio' value='Empleado'  id='choice_20_95_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_95_0' id='label_20_95_0' class='gform-field-label gform-field-label--type-inline'>Empleado<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_20_95_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_95' type='radio' value='Autonomo'  id='choice_20_95_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_95_1' id='label_20_95_1' class='gform-field-label gform-field-label--type-inline'>Autonomo<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_20_95_2'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_95' type='radio' value='Jubilado'  id='choice_20_95_2' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_95_2' id='label_20_95_2' class='gform-field-label gform-field-label--type-inline'>Jubilado<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_20_20\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Garant\u00edas de la p\u00f3liza seleccionada<\/h3><\/div><fieldset id=\"field_20_12\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-half field_sublabel_below gfield--has-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Muerte por cualquier causa<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_20_12'><div class='gchoice gchoice_20_12_1'>\n\t\t\t\t\t\t\t\t<input disabled='disabled' class='gfield-choice-input' name='input_12.1' type='checkbox'  value='Muerte por cualquier causa' checked='checked' id='choice_20_12_1'   aria-describedby=\"gfield_description_20_12\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_20_12_1' id='label_20_12_1' class='gform-field-label gform-field-label--type-inline'>Muerte por cualquier causa<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><input type=\"hidden\" id=\"gwro_hidden_capture_20_12_1\" name=\"gwro_hidden_capture_20_12_1\" value=\"Muerte por cualquier causa\" class=\"gf-default-disabled\" \/><\/div><div class='gfield_description' id='gfield_description_20_12'>Es la principal garant\u00eda del seguro de vida. Los beneficiarios reciben el 100% del capital contratado si el fallecimiento se produce independientemente de la causa. <\/div><\/fieldset><div id=\"field_20_5\" class=\"gfield gfield--type-number gfield--input-type-number gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_5'>Capital<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_5' id='input_20_5' type='text' step='any' min='18000' max='3000000' value='' class='medium'    placeholder='Capital' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_20_101\" class=\"gfield gfield--type-html gfield--input-type-html gfield--width-full gfield_html gfield_html_formatted gfield_no_follows_desc field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  >El Asegurado estar\u00e1 obligado a proporcionar un informe m\u00e9dico para respaldar su solicitud de seguro.<\/div><fieldset id=\"field_20_13\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--has-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Doble capital en muerte por un accidente<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_20_13'><div class='gchoice gchoice_20_13_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_13.1' type='checkbox'  value='Doble capital en muerte por un accidente'  id='choice_20_13_1'   aria-describedby=\"gfield_description_20_13\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_20_13_1' id='label_20_13_1' class='gform-field-label gform-field-label--type-inline'>Doble capital en muerte por un accidente<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_20_13'>Cuando la causa del fallecimiento sea un accidente, el beneficiario recibir\u00e1 <strong>el doble del capital contratado<\/strong>.<\/div><\/fieldset><div id=\"field_20_90\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_90'>Muerte por accidente<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_90' id='input_20_90' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"  placeholder='Muerte por accidente' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_20_18\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--has-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Incapacidad permanente y absoluta<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_20_18'><div class='gchoice gchoice_20_18_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_18.1' type='checkbox'  value='Disabilidad permanente y absoluta'  id='choice_20_18_1'   aria-describedby=\"gfield_description_20_18\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_20_18_1' id='label_20_18_1' class='gform-field-label gform-field-label--type-inline'>Disabilidad permanente y absoluta<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_20_18'>Implica, ya sea por enfermedad o accidente, la incapacidad del asegurado para realizar cualquier actividad profesional. En este caso, el asegurado ser\u00e1 el beneficiario de la p\u00f3liza. <\/div><\/fieldset><div id=\"field_20_91\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_91'>Incapacidad permanente<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_91' id='input_20_91' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"  placeholder='Incapacidad permanente' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_20_19\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--has-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Doble capital en invalidez por accidente<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_20_19'><div class='gchoice gchoice_20_19_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_19.1' type='checkbox'  value='Doble capital en absoluta y permanente disabilidad por un accidente'  id='choice_20_19_1'   aria-describedby=\"gfield_description_20_19\"\/>\n\t\t\t\t\t\t\t\t<label for='choice_20_19_1' id='label_20_19_1' class='gform-field-label gform-field-label--type-inline'>Doble capital en incapacidad permanente y absoluta por accidente<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_20_19'>Cuando el fallecimiento se deba a un accidente, el beneficiario recibir\u00e1 <strong>el doble del capital contratado<\/strong>.<\/div><\/fieldset><div id=\"field_20_92\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required gfield_calculation field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_92'>Doble incapacidad por accidente<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_92' id='input_20_92' type='text' step='any'   value='' class='small gform-text-input-reset'  readonly=\"readonly\"  placeholder='Incapacidad permanente' aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                         <input type='button' id='gform_next_button_20_23' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_20_2' class='gform_page' data-js='page-field-id-23' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_20_2' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_20_26\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfEres t\u00fa el asegurado?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_20_26'>\n\t\t\t<div class='gchoice gchoice_20_26_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='S\u00ed'  id='choice_20_26_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_26_0' id='label_20_26_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_20_26_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_26' type='radio' value='No, s\u00f3lo soy el tomador'  id='choice_20_26_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_26_1' id='label_20_26_1' class='gform-field-label gform-field-label--type-inline'>No, s\u00f3lo soy el tomador del seguro<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_20_32\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Informaci\u00f3n del asegurado<\/h3><\/div><fieldset id=\"field_20_24\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><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_20_24'>\n                            \n                            <span id='input_20_24_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.3' id='input_20_24_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_20_24_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_20_24_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_24.6' id='input_20_24_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_20_24_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_20_25\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sexo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_20_25'>\n\t\t\t<div class='gchoice gchoice_20_25_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Hombre'  id='choice_20_25_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_25_0' id='label_20_25_0' class='gform-field-label gform-field-label--type-inline'>Hombre<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_20_25_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_25' type='radio' value='Mujer'  id='choice_20_25_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_25_1' id='label_20_25_1' class='gform-field-label gform-field-label--type-inline'>Mujer<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_20_27\" class=\"gfield gfield--type-date gfield--input-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\"  ><label class='gfield_label gform-field-label' for='input_20_27'>Fecha de nacimiento Tomador<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_27' id='input_20_27' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='dd\/mm\/aaaa' aria-describedby=\"input_20_27_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_20_27_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_20_27' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_20_28\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_28'>Estado civil<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_28' id='input_20_28' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Estado civil<\/option><option value='Casado\/a' >Casado\/a<\/option><option value='Soltero\/a' >Soltero\/a<\/option><option value='Divorciado\/a' >Divorciado\/a<\/option><option value='Viudo\/a' >Viudo\/a<\/option><\/select><\/div><\/div><div id=\"field_20_29\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_29'>Nacionalidad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_29' id='input_20_29' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Nacionalidad<\/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='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/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='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brazil' >Brazil<\/option><option value='Brunei' >Brunei<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/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='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/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='Czech Republic' >Czech Republic<\/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='East Timor' >East Timor<\/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='Ethiopia' >Ethiopia<\/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 Polynesia' >French Polynesia<\/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='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/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='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='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='North Korea' >North Korea<\/option><option value='South Korea' >South Korea<\/option><option value='Kosovo' >Kosovo<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Laos' >Laos<\/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='Macedonia' >Macedonia<\/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='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/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='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 Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/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='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='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/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='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Sudan, South' >Sudan, South<\/option><option value='Suriname' >Suriname<\/option><option value='Swaziland' >Swaziland<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Togo' >Togo<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Tuvalu' >Tuvalu<\/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='Vatican City' >Vatican City<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/div><div id=\"field_20_30\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_30'>Documento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_30' id='input_20_30' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Documento<\/option><option value='Pasaporte' >Pasaporte<\/option><option value='NIE' >NIE<\/option><option value='DNI' >DNI<\/option><\/select><\/div><\/div><div id=\"field_20_31\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_31'>n\u00famero<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_20_31' type='text' value='' class='large'    placeholder='n\u00famero' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_20_97\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_97'>Adjunta el pasaporte o NIE del asegurado<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_97' id='input_20_97' type='file' class='large' aria-describedby=\"gfield_upload_rules_20_97 gfield_description_20_97\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_20_97'>Tipos de archivos aceptados: jpg, jpeg, png, pdf, m\u00e1x. tama\u00f1o del archivo: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_20_97'><\/div> <\/div><div class='gfield_description' id='gfield_description_20_97'>Por favor, adjunte un escaneo o una foto de buena calidad del documento<\/div><\/div><fieldset id=\"field_20_33\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_20_33' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_20_33_1_container' >\n                                        <input type='text' name='input_33.1' id='input_20_33_1' value=''    aria-required='true'    \/>\n                                        <label for='input_20_33_1' id='input_20_33_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_20_33_3_container' >\n                                    <input type='text' name='input_33.3' id='input_20_33_3' value=''    aria-required='true'    \/>\n                                    <label for='input_20_33_3' id='input_20_33_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_20_33_4_container' >\n                                        <input type='text' name='input_33.4' id='input_20_33_4' value=''      aria-required='true'    \/>\n                                        <label for='input_20_33_4' id='input_20_33_4_label' class='gform-field-label gform-field-label--type-sub '>Estado \/ Provincia \/ Regi\u00f3n<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_20_33_5_container' >\n                                    <input type='text' name='input_33.5' id='input_20_33_5' value=''    aria-required='true'    \/>\n                                    <label for='input_20_33_5' id='input_20_33_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ C\u00f3digo Postal<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_20_33_6_container' >\n                                        <select name='input_33.6' id='input_20_33_6'   aria-required='true'    ><option value='' ><\/option><option value='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antigua y Barbuda' >Antigua y Barbuda<\/option><option value='Ant\u00e1rtida' >Ant\u00e1rtida<\/option><option value='Arabia Saudita' >Arabia Saudita<\/option><option value='Argelia' >Argelia<\/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='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='Belice' >Belice<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/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='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos \u00c1rabes Unidos<\/option><option value='Eritrea' >Eritrea<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estados Unidos' >Estados Unidos<\/option><option value='Estonia' >Estonia<\/option><option value='Esuatini' >Esuatini<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Federaci\u00f3n Rusa' >Federaci\u00f3n Rusa<\/option><option value='Fiji' >Fiji<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Granada' >Granada<\/option><option value='Grecia' >Grecia<\/option><option value='Groenlandia' >Groenlandia<\/option><option value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Islas \u00c5land' >Islas \u00c5land<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jord\u00e1n' >Jord\u00e1n<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='LIbia' >LIbia<\/option><option value='Lesoto' >Lesoto<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituania' >Lituania<\/option><option value='Lituania' >Lituania<\/option><option value='Luxemburgo' >Luxemburgo<\/option><option value='L\u00edbano' >L\u00edbano<\/option><option value='Macau' >Macau<\/option><option value='Macedonia del Norte' >Macedonia del Norte<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malawi' >Malawi<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Martinica' >Martinica<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mayotte' >Mayotte<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldavia' >Moldavia<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noruega' >Noruega<\/option><option value='Nueva Caledonia' >Nueva Caledonia<\/option><option value='Nueva Zelanda' >Nueva Zelanda<\/option><option value='N\u00edger' >N\u00edger<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Paises Bajos' >Paises Bajos<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Estado de' >Palestina, Estado de<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Pap\u00faa Nueva Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polinesia Francesa' >Polinesia Francesa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica Centroafricana' >Rep\u00fablica Centroafricana<\/option><option value='Rep\u00fablica Democr\u00e1tica Popular de Laos' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Rep\u00fablica \u00c1rabe de Siria' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='Reuni\u00f3n' >Reuni\u00f3n<\/option><option value='Ruanda' >Ruanda<\/option><option value='Ruman\u00eda' >Ruman\u00eda<\/option><option value='Sahara Occidental' >Sahara Occidental<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='San Bartolom\u00e9' >San Bartolom\u00e9<\/option><option value='San Crist\u00f3bal y Nieves' >San Crist\u00f3bal y Nieves<\/option><option value='San Marino' >San Marino<\/option><option value='San Mart\u00edn' >San Mart\u00edn<\/option><option value='San Pedro y Miquel\u00f3n' >San Pedro y Miquel\u00f3n<\/option><option value='San Vicente y las Granadinas' >San Vicente y las Granadinas<\/option><option value='Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='Santa Luc\u00eda' >Santa Luc\u00eda<\/option><option value='Santa Sede' >Santa Sede<\/option><option value='Santo Tom\u00e9 y Principe' >Santo Tom\u00e9 y Principe<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >Zimbaue<\/option><\/select>\n                                        <label for='input_20_33_6' id='input_20_33_6_label' class='gform-field-label gform-field-label--type-sub '>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_20_35\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_35'>Tel\u00e9fono<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_35' id='input_20_35' type='tel' value='' class='large'  placeholder='Tel\u00e9fono' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_20_34\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_34'>Correo electr\u00f3nico<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_34' id='input_20_34' type='email' value='' class='large'   placeholder='Correo electr\u00f3nico' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_20_36' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='button' id='gform_next_button_20_36' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_20_3' class='gform_page' data-js='page-field-id-36' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_20_3' class='gform_fields top_label form_sublabel_below description_below validation_below'><div id=\"field_20_38\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Informaci\u00f3n del asegurado<\/h3><\/div><fieldset id=\"field_20_37\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><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_20_37'>\n                            \n                            <span id='input_20_37_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_37.3' id='input_20_37_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_20_37_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_20_37_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_37.6' id='input_20_37_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_20_37_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><fieldset id=\"field_20_39\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >Sexo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_20_39'>\n\t\t\t<div class='gchoice gchoice_20_39_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Hombre'  id='choice_20_39_0' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_39_0' id='label_20_39_0' class='gform-field-label gform-field-label--type-inline'>Hombre<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_20_39_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_39' type='radio' value='Mujer'  id='choice_20_39_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_39_1' id='label_20_39_1' class='gform-field-label gform-field-label--type-inline'>Mujer<\/label>\n\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_20_89\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_hidden\"  ><div class=\"admin-hidden-markup\"><i class=\"gform-icon gform-icon--hidden\" aria-hidden=\"true\" title=\"Este campo est\u00e1 oculto cuando se visualiza el formulario\"><\/i><span>Este campo est\u00e1 oculto cuando se visualiza el formulario<\/span><\/div><label class='gfield_label gform-field-label' for='input_20_89'>Fecha de nacimiento<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_89' id='input_20_89' type='text' value='' class='datepicker gform-datepicker dmy_dash datepicker_with_icon gdatepicker_with_icon'   placeholder='dd-mm-aaaa' aria-describedby=\"input_20_89_date_format gfield_description_20_89\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_20_89_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_20_89' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><div class='gfield_description' id='gfield_description_20_89'>dd-mm-yyyy<\/div><\/div><div id=\"field_20_43\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_43'>Estado civil<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_43' id='input_20_43' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Estado civil<\/option><option value='Casado\/a' >Casado\/a<\/option><option value='Soltero\/a' >Soltero\/a<\/option><option value='Divorciado\/a' >Divorciado\/a<\/option><option value='Viudo\/a' >Viudo\/a<\/option><\/select><\/div><\/div><div id=\"field_20_44\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_44'>Nacionalidad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_44' id='input_20_44' class='medium gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Nacionalidad<\/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='Antigua and Barbuda' >Antigua and Barbuda<\/option><option value='Argentina' >Argentina<\/option><option value='Armenia' >Armenia<\/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='Bosnia and Herzegovina' >Bosnia and Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brazil' >Brazil<\/option><option value='Brunei' >Brunei<\/option><option value='Bulgaria' >Bulgaria<\/option><option value='Burkina Faso' >Burkina Faso<\/option><option value='Burundi' >Burundi<\/option><option value='Cambodia' >Cambodia<\/option><option value='Cameroon' >Cameroon<\/option><option value='Canada' >Canada<\/option><option value='Cape Verde' >Cape Verde<\/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='Colombia' >Colombia<\/option><option value='Comoros' >Comoros<\/option><option value='Congo, Democratic Republic of the' >Congo, Democratic Republic of the<\/option><option value='Congo, Republic of the' >Congo, Republic of the<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='C\u00f4te d&#039;Ivoire' >C\u00f4te d&#039;Ivoire<\/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='Czech Republic' >Czech Republic<\/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='East Timor' >East Timor<\/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='Ethiopia' >Ethiopia<\/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 Polynesia' >French Polynesia<\/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='Greece' >Greece<\/option><option value='Greenland' >Greenland<\/option><option value='Grenada' >Grenada<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/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='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='Israel' >Israel<\/option><option value='Italy' >Italy<\/option><option value='Jamaica' >Jamaica<\/option><option value='Japan' >Japan<\/option><option value='Jordan' >Jordan<\/option><option value='Kazakhstan' >Kazakhstan<\/option><option value='Kenya' >Kenya<\/option><option value='Kiribati' >Kiribati<\/option><option value='North Korea' >North Korea<\/option><option value='South Korea' >South Korea<\/option><option value='Kosovo' >Kosovo<\/option><option value='Kuwait' >Kuwait<\/option><option value='Kyrgyzstan' >Kyrgyzstan<\/option><option value='Laos' >Laos<\/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='Macedonia' >Macedonia<\/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='Mauritania' >Mauritania<\/option><option value='Mauritius' >Mauritius<\/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='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 Zealand' >New Zealand<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Niger' >Niger<\/option><option value='Nigeria' >Nigeria<\/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='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='Russia' >Russia<\/option><option value='Rwanda' >Rwanda<\/option><option value='Saint Kitts and Nevis' >Saint Kitts and Nevis<\/option><option value='Saint Lucia' >Saint Lucia<\/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='Spain' >Spain<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sudan' >Sudan<\/option><option value='Sudan, South' >Sudan, South<\/option><option value='Suriname' >Suriname<\/option><option value='Swaziland' >Swaziland<\/option><option value='Sweden' >Sweden<\/option><option value='Switzerland' >Switzerland<\/option><option value='Syria' >Syria<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tajikistan' >Tajikistan<\/option><option value='Tanzania' >Tanzania<\/option><option value='Thailand' >Thailand<\/option><option value='Togo' >Togo<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad and Tobago' >Trinidad and Tobago<\/option><option value='Tunisia' >Tunisia<\/option><option value='Turkey' >Turkey<\/option><option value='Turkmenistan' >Turkmenistan<\/option><option value='Tuvalu' >Tuvalu<\/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='Vatican City' >Vatican City<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Virgin Islands, British' >Virgin Islands, British<\/option><option value='Virgin Islands, U.S.' >Virgin Islands, U.S.<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbabwe' >Zimbabwe<\/option><\/select><\/div><\/div><div id=\"field_20_45\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_45'>Documento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_45' id='input_20_45' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Documento<\/option><option value='Pasaporte' >Pasaporte<\/option><option value='NIE' >NIE<\/option><option value='DNI' >DNI<\/option><\/select><\/div><\/div><div id=\"field_20_46\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_46'>n\u00famero<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_20_46' type='text' value='' class='large'    placeholder='N\u00famero de documento' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_20_98\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_98'>Adjunta pasaporte asegurado o NIE<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_98' id='input_20_98' type='file' class='large' aria-describedby=\"gfield_upload_rules_20_98 gfield_description_20_98\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_20_98'>Tipos de archivos aceptados: jpg, jpeg, png, pdf, m\u00e1x. tama\u00f1o del archivo: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_20_98'><\/div> <\/div><div class='gfield_description' id='gfield_description_20_98'>Por favor, adjunte un escaneo o una foto de buena calidad del documento<\/div><\/div><fieldset id=\"field_20_47\" class=\"gfield gfield--type-address gfield--input-type-address gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Direcci\u00f3n<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend>    \n                    <div class='ginput_complex ginput_container has_street has_city has_state has_zip has_country ginput_container_address gform-grid-row' id='input_20_47' >\n                         <span class='ginput_full address_line_1 ginput_address_line_1 gform-grid-col' id='input_20_47_1_container' >\n                                        <input type='text' name='input_47.1' id='input_20_47_1' value=''    aria-required='true'    \/>\n                                        <label for='input_20_47_1' id='input_20_47_1_label' class='gform-field-label gform-field-label--type-sub '>Direcci\u00f3n<\/label>\n                                    <\/span><span class='ginput_left address_city ginput_address_city gform-grid-col' id='input_20_47_3_container' >\n                                    <input type='text' name='input_47.3' id='input_20_47_3' value=''    aria-required='true'    \/>\n                                    <label for='input_20_47_3' id='input_20_47_3_label' class='gform-field-label gform-field-label--type-sub '>Ciudad<\/label>\n                                 <\/span><span class='ginput_right address_state ginput_address_state gform-grid-col' id='input_20_47_4_container' >\n                                        <input type='text' name='input_47.4' id='input_20_47_4' value=''      aria-required='true'    \/>\n                                        <label for='input_20_47_4' id='input_20_47_4_label' class='gform-field-label gform-field-label--type-sub '>Estado \/ Provincia \/ Regi\u00f3n<\/label>\n                                      <\/span><span class='ginput_left address_zip ginput_address_zip gform-grid-col' id='input_20_47_5_container' >\n                                    <input type='text' name='input_47.5' id='input_20_47_5' value=''    aria-required='true'    \/>\n                                    <label for='input_20_47_5' id='input_20_47_5_label' class='gform-field-label gform-field-label--type-sub '>ZIP \/ C\u00f3digo Postal<\/label>\n                                <\/span><span class='ginput_right address_country ginput_address_country gform-grid-col' id='input_20_47_6_container' >\n                                        <select name='input_47.6' id='input_20_47_6'   aria-required='true'    ><option value='' ><\/option><option value='Afghanist\u00e1n' >Afghanist\u00e1n<\/option><option value='Albania' >Albania<\/option><option value='Alemania' >Alemania<\/option><option value='Andorra' >Andorra<\/option><option value='Angola' >Angola<\/option><option value='Anguilla' >Anguilla<\/option><option value='Antigua y Barbuda' >Antigua y Barbuda<\/option><option value='Ant\u00e1rtida' >Ant\u00e1rtida<\/option><option value='Arabia Saudita' >Arabia Saudita<\/option><option value='Argelia' >Argelia<\/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='Azerbaiy\u00e1n' >Azerbaiy\u00e1n<\/option><option value='Bahamas' >Bahamas<\/option><option value='Bangladesh' >Bangladesh<\/option><option value='Barbados' >Barbados<\/option><option value='Bar\u00e9in' >Bar\u00e9in<\/option><option value='Belice' >Belice<\/option><option value='Benin' >Benin<\/option><option value='Bermuda' >Bermuda<\/option><option value='Bhut\u00e1n' >Bhut\u00e1n<\/option><option value='Bielorusia' >Bielorusia<\/option><option value='Bolivia' >Bolivia<\/option><option value='Bonaire, San Eustaquio y Saba' >Bonaire, San Eustaquio y Saba<\/option><option value='Bosnia y Herzegovina' >Bosnia y Herzegovina<\/option><option value='Botswana' >Botswana<\/option><option value='Brasil' >Brasil<\/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='B\u00e9lgica' >B\u00e9lgica<\/option><option value='Cabo Verde' >Cabo Verde<\/option><option value='Camboya' >Camboya<\/option><option value='Camer\u00fan' >Camer\u00fan<\/option><option value='Canada' >Canada<\/option><option value='Chad' >Chad<\/option><option value='Chequia' >Chequia<\/option><option value='Chile' >Chile<\/option><option value='China' >China<\/option><option value='Chipre' >Chipre<\/option><option value='Colombia' >Colombia<\/option><option value='Comoras' >Comoras<\/option><option value='Congo' >Congo<\/option><option value='Congo, Rep\u00fablica Democr\u00e1tica del' >Congo, Rep\u00fablica Democr\u00e1tica del<\/option><option value='Corea, Rep\u00fablica Popular Democr\u00e1tica de' >Corea, Rep\u00fablica Popular Democr\u00e1tica de<\/option><option value='Corea, Rep\u00fablica de' >Corea, Rep\u00fablica de<\/option><option value='Costa Rica' >Costa Rica<\/option><option value='Costa de Marfil' >Costa de Marfil<\/option><option value='Croacia' >Croacia<\/option><option value='Cuba' >Cuba<\/option><option value='Curazao' >Curazao<\/option><option value='Dinamarca' >Dinamarca<\/option><option value='Djibouti' >Djibouti<\/option><option value='Dominica' >Dominica<\/option><option value='Ecuador' >Ecuador<\/option><option value='Egipto' >Egipto<\/option><option value='El Salvador' >El Salvador<\/option><option value='Emiratos \u00c1rabes Unidos' >Emiratos \u00c1rabes Unidos<\/option><option value='Eritrea' >Eritrea<\/option><option value='Eslovaquia' >Eslovaquia<\/option><option value='Eslovenia' >Eslovenia<\/option><option value='Espa\u00f1a' >Espa\u00f1a<\/option><option value='Estados Unidos' >Estados Unidos<\/option><option value='Estonia' >Estonia<\/option><option value='Esuatini' >Esuatini<\/option><option value='Etiop\u00eda' >Etiop\u00eda<\/option><option value='Federaci\u00f3n Rusa' >Federaci\u00f3n Rusa<\/option><option value='Fiji' >Fiji<\/option><option value='Filipinas' >Filipinas<\/option><option value='Finlandia' >Finlandia<\/option><option value='Francia' >Francia<\/option><option value='Gab\u00f3n' >Gab\u00f3n<\/option><option value='Gambia' >Gambia<\/option><option value='Georgia' >Georgia<\/option><option value='Ghana' >Ghana<\/option><option value='Gibraltar' >Gibraltar<\/option><option value='Granada' >Granada<\/option><option value='Grecia' >Grecia<\/option><option value='Groenlandia' >Groenlandia<\/option><option value='Guadalupe' >Guadalupe<\/option><option value='Guam' >Guam<\/option><option value='Guatemala' >Guatemala<\/option><option value='Guayana' >Guayana<\/option><option value='Guayana Francesa' >Guayana Francesa<\/option><option value='Guernsey' >Guernsey<\/option><option value='Guinea' >Guinea<\/option><option value='Guinea Bissau' >Guinea Bissau<\/option><option value='Guinea Ecuatorial' >Guinea Ecuatorial<\/option><option value='Hait\u00ed' >Hait\u00ed<\/option><option value='Honduras' >Honduras<\/option><option value='Hong Kong' >Hong Kong<\/option><option value='Hungr\u00eda' >Hungr\u00eda<\/option><option value='India' >India<\/option><option value='Indonesia' >Indonesia<\/option><option value='Iraq' >Iraq<\/option><option value='Irlanda' >Irlanda<\/option><option value='Ir\u00e1n' >Ir\u00e1n<\/option><option value='Isla Bouvet' >Isla Bouvet<\/option><option value='Isla Norfolk' >Isla Norfolk<\/option><option value='Isla de Man' >Isla de Man<\/option><option value='Isla de Navidad' >Isla de Navidad<\/option><option value='Islandia' >Islandia<\/option><option value='Islas Caim\u00e1n' >Islas Caim\u00e1n<\/option><option value='Islas Cocos' >Islas Cocos<\/option><option value='Islas Cook' >Islas Cook<\/option><option value='Islas Faroe' >Islas Faroe<\/option><option value='Islas Heard y McDonald' >Islas Heard y McDonald<\/option><option value='Islas Malvinas' >Islas Malvinas<\/option><option value='Islas Marianas del Norte' >Islas Marianas del Norte<\/option><option value='Islas Marshall' >Islas Marshall<\/option><option value='Islas Salom\u00f3n' >Islas Salom\u00f3n<\/option><option value='Islas Turcas y Caicos' >Islas Turcas y Caicos<\/option><option value='Islas Ultramarinas Menores de Estados Unidos' >Islas Ultramarinas Menores de Estados Unidos<\/option><option value='Islas V\u00edrgenes Brit\u00e1nicas' >Islas V\u00edrgenes Brit\u00e1nicas<\/option><option value='Islas V\u00edrgenes de los Estados Unidos' >Islas V\u00edrgenes de los Estados Unidos<\/option><option value='Islas \u00c5land' >Islas \u00c5land<\/option><option value='Israel' >Israel<\/option><option value='Italia' >Italia<\/option><option value='Jamaica' >Jamaica<\/option><option value='Jap\u00f3n' >Jap\u00f3n<\/option><option value='Jersey' >Jersey<\/option><option value='Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy' >Ji\u017en\u00ed Georgie a Ji\u017en\u00ed Sandwichovy ostrovy<\/option><option value='Jord\u00e1n' >Jord\u00e1n<\/option><option value='Kazajist\u00e1n' >Kazajist\u00e1n<\/option><option value='Kenia' >Kenia<\/option><option value='Kirguist\u00e1n' >Kirguist\u00e1n<\/option><option value='Kiribati' >Kiribati<\/option><option value='Kuwait' >Kuwait<\/option><option value='LIbia' >LIbia<\/option><option value='Lesoto' >Lesoto<\/option><option value='Liberia' >Liberia<\/option><option value='Liechtenstein' >Liechtenstein<\/option><option value='Lituania' >Lituania<\/option><option value='Lituania' >Lituania<\/option><option value='Luxemburgo' >Luxemburgo<\/option><option value='L\u00edbano' >L\u00edbano<\/option><option value='Macau' >Macau<\/option><option value='Macedonia del Norte' >Macedonia del Norte<\/option><option value='Madagascar' >Madagascar<\/option><option value='Malasia' >Malasia<\/option><option value='Malawi' >Malawi<\/option><option value='Maldivas' >Maldivas<\/option><option value='Mali' >Mali<\/option><option value='Malta' >Malta<\/option><option value='Marruecos' >Marruecos<\/option><option value='Martinica' >Martinica<\/option><option value='Mauricio' >Mauricio<\/option><option value='Mauritania' >Mauritania<\/option><option value='Mayotte' >Mayotte<\/option><option value='Micronesia' >Micronesia<\/option><option value='Moldavia' >Moldavia<\/option><option value='Monaco' >Monaco<\/option><option value='Mongolia' >Mongolia<\/option><option value='Montenegro' >Montenegro<\/option><option value='Montserrat' >Montserrat<\/option><option value='Mozambique' >Mozambique<\/option><option value='Myanmar' >Myanmar<\/option><option value='M\u00e9xico' >M\u00e9xico<\/option><option value='Namibia' >Namibia<\/option><option value='Nauru' >Nauru<\/option><option value='Nepal' >Nepal<\/option><option value='Nicaragua' >Nicaragua<\/option><option value='Nigeria' >Nigeria<\/option><option value='Niue' >Niue<\/option><option value='Noruega' >Noruega<\/option><option value='Nueva Caledonia' >Nueva Caledonia<\/option><option value='Nueva Zelanda' >Nueva Zelanda<\/option><option value='N\u00edger' >N\u00edger<\/option><option value='Om\u00e1n' >Om\u00e1n<\/option><option value='Paises Bajos' >Paises Bajos<\/option><option value='Pakist\u00e1n' >Pakist\u00e1n<\/option><option value='Palau' >Palau<\/option><option value='Palestina, Estado de' >Palestina, Estado de<\/option><option value='Panam\u00e1' >Panam\u00e1<\/option><option value='Pap\u00faa Nueva Guinea' >Pap\u00faa Nueva Guinea<\/option><option value='Paraguay' >Paraguay<\/option><option value='Per\u00fa' >Per\u00fa<\/option><option value='Pitcairn' >Pitcairn<\/option><option value='Polinesia Francesa' >Polinesia Francesa<\/option><option value='Polonia' >Polonia<\/option><option value='Portugal' >Portugal<\/option><option value='Puerto Rico' >Puerto Rico<\/option><option value='Qatar' >Qatar<\/option><option value='Reino Unido' >Reino Unido<\/option><option value='Rep\u00fablica Centroafricana' >Rep\u00fablica Centroafricana<\/option><option value='Rep\u00fablica Democr\u00e1tica Popular de Laos' >Rep\u00fablica Democr\u00e1tica Popular de Laos<\/option><option value='Rep\u00fablica Dominicana' >Rep\u00fablica Dominicana<\/option><option value='Rep\u00fablica \u00c1rabe de Siria' >Rep\u00fablica \u00c1rabe de Siria<\/option><option value='Reuni\u00f3n' >Reuni\u00f3n<\/option><option value='Ruanda' >Ruanda<\/option><option value='Ruman\u00eda' >Ruman\u00eda<\/option><option value='Sahara Occidental' >Sahara Occidental<\/option><option value='Samoa' >Samoa<\/option><option value='Samoa Americana' >Samoa Americana<\/option><option value='San Bartolom\u00e9' >San Bartolom\u00e9<\/option><option value='San Crist\u00f3bal y Nieves' >San Crist\u00f3bal y Nieves<\/option><option value='San Marino' >San Marino<\/option><option value='San Mart\u00edn' >San Mart\u00edn<\/option><option value='San Pedro y Miquel\u00f3n' >San Pedro y Miquel\u00f3n<\/option><option value='San Vicente y las Granadinas' >San Vicente y las Granadinas<\/option><option value='Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a' >Santa Elena, Ascensi\u00f3n y Trist\u00e1n de Acu\u00f1a<\/option><option value='Santa Luc\u00eda' >Santa Luc\u00eda<\/option><option value='Santa Sede' >Santa Sede<\/option><option value='Santo Tom\u00e9 y Principe' >Santo Tom\u00e9 y Principe<\/option><option value='Senegal' >Senegal<\/option><option value='Serbia' >Serbia<\/option><option value='Seychelles' >Seychelles<\/option><option value='Sierra Leona' >Sierra Leona<\/option><option value='Singapur' >Singapur<\/option><option value='Sint Maarten' >Sint Maarten<\/option><option value='Somalia' >Somalia<\/option><option value='Sri Lanka' >Sri Lanka<\/option><option value='Sud\u00e1frica' >Sud\u00e1frica<\/option><option value='Sud\u00e1n' >Sud\u00e1n<\/option><option value='Sud\u00e1n del Sur' >Sud\u00e1n del Sur<\/option><option value='Suecia' >Suecia<\/option><option value='Suiza' >Suiza<\/option><option value='Surinam' >Surinam<\/option><option value='Svalbard y Jan Mayen' >Svalbard y Jan Mayen<\/option><option value='Tailandia' >Tailandia<\/option><option value='Taiwan' >Taiwan<\/option><option value='Tanzania (Rep\u00fablica Unida de)' >Tanzania (Rep\u00fablica Unida de)<\/option><option value='Tayikist\u00e1n' >Tayikist\u00e1n<\/option><option value='Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico' >Territorio Brit\u00e1nico del Oc\u00e9ano \u00cdndico<\/option><option value='Tierras Australes y Ant\u00e1rticas Francesas' >Tierras Australes y Ant\u00e1rticas Francesas<\/option><option value='Timor Oriental' >Timor Oriental<\/option><option value='Togo' >Togo<\/option><option value='Tokelau' >Tokelau<\/option><option value='Tonga' >Tonga<\/option><option value='Trinidad y Tobago' >Trinidad y Tobago<\/option><option value='Turkmenist\u00e1n' >Turkmenist\u00e1n<\/option><option value='Turqu\u00eda' >Turqu\u00eda<\/option><option value='Tuvalu' >Tuvalu<\/option><option value='T\u00fanez' >T\u00fanez<\/option><option value='Ucrania' >Ucrania<\/option><option value='Uganda' >Uganda<\/option><option value='Uruguay' >Uruguay<\/option><option value='Uzbekist\u00e1n' >Uzbekist\u00e1n<\/option><option value='Vanuatu' >Vanuatu<\/option><option value='Venezuela' >Venezuela<\/option><option value='Vietnam' >Vietnam<\/option><option value='Wallis y Futuna' >Wallis y Futuna<\/option><option value='Yemen' >Yemen<\/option><option value='Zambia' >Zambia<\/option><option value='Zimbaue' >Zimbaue<\/option><\/select>\n                                        <label for='input_20_47_6' id='input_20_47_6_label' class='gform-field-label gform-field-label--type-sub '>Pa\u00eds<\/label>\n                                    <\/span>\n                    <div class='gf_clear gf_clear_complex'><\/div>\n                <\/div><\/fieldset><div id=\"field_20_48\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_48'>Tel\u00e9fono<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_48' id='input_20_48' type='tel' value='' class='large'  placeholder='Tel\u00e9fono' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_20_49\" class=\"gfield gfield--type-email gfield--input-type-email gfield--width-half gf_right_half gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_49'>Correo electr\u00f3nico<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_49' id='input_20_49' type='email' value='' class='large'   placeholder='Correo electr\u00f3nico' aria-required=\"true\" aria-invalid=\"false\"  \/>\n                        <\/div><\/div><div id=\"field_20_53\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Informaci\u00f3n sanitaria<\/h3><\/div><div id=\"field_20_51\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_51'>Altura (cm)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_51' id='input_20_51' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><div id=\"field_20_52\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_52'>Peso (kg)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_52' id='input_20_52' type='number' step='any'   value='' class='medium'     aria-required=\"true\" aria-invalid=\"false\"  \/><\/div><\/div><fieldset id=\"field_20_54\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >incapacitado<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_20_54'><div class='gchoice gchoice_20_54_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_54.1' type='checkbox'  value='Estoy incapacitado total o parcialmente, presento alg\u00fan defecto invalidante o he iniciado alg\u00fan tr\u00e1mite para obtenci\u00f3n de la incapacidad'  id='choice_20_54_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_54_1' id='label_20_54_1' class='gform-field-label gform-field-label--type-inline'>Estoy incapacitado total o parcialmente, presento alg\u00fan defecto invalidante o he iniciado alg\u00fan tr\u00e1mite para obtenci\u00f3n de la incapacidad<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_20_55\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_55'>Detalles<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_55' id='input_20_55' class='textarea medium'    placeholder='Detalles' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_20_56\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >actividad interrumpida<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_20_56'><div class='gchoice gchoice_20_56_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_56.1' type='checkbox'  value='Durante los 3 \u00faltimos a\u00f1os he interrumpido mi actividad como consecuencia de una enfermedad\/accidente por m\u00e1s de 10 d\u00edas seguidos'  id='choice_20_56_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_56_1' id='label_20_56_1' class='gform-field-label gform-field-label--type-inline'>Durante los 3 \u00faltimos a\u00f1os he interrumpido mi actividad como consecuencia de una enfermedad\/accidente por m\u00e1s de 10 d\u00edas seguidos<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_20_57\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_57'>Fecha<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_57' id='input_20_57' type='text' value='' class='datepicker gform-datepicker mdy datepicker_no_icon gdatepicker-no-icon'   placeholder='Fecha' aria-describedby=\"input_20_57_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_20_57_date_format' class='screen-reader-text'>MM barra DD barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_20_57' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_20_58\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_58'>Motivo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_58' id='input_20_58' class='textarea medium'    placeholder='Motivo' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_20_59\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >baja laboral<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_20_59'><div class='gchoice gchoice_20_59_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_59.1' type='checkbox'  value='Me encuentro en situaci\u00f3n de baja laboral o m\u00e9dica actualmente'  id='choice_20_59_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_59_1' id='label_20_59_1' class='gform-field-label gform-field-label--type-inline'>Me encuentro en situaci\u00f3n de baja laboral o m\u00e9dica actualmente<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_20_60\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_60'>Detalles<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_60' id='input_20_60' class='textarea medium'    placeholder='Detalles' aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><fieldset id=\"field_20_61\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >alcohol<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_20_61'><div class='gchoice gchoice_20_61_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.1' type='checkbox'  value='Consumo alcohol'  id='choice_20_61_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_61_1' id='label_20_61_1' class='gform-field-label gform-field-label--type-inline'>Consumo de alcohol<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_20_62\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_62'>Cantidad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_62' id='input_20_62' type='text' value='' class='medium'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_20_63\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_63'>Tipo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_20_63' type='text' value='' class='medium'    placeholder='Tipo' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_20_64\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_64'>Frecuencia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_64' id='input_20_64' type='text' value='' class='medium'    placeholder='Frecuencia' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_20_65\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >tabaco<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_20_65'><div class='gchoice gchoice_20_65_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_65.1' type='checkbox'  value='Consumo tabaco'  id='choice_20_65_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_65_1' id='label_20_65_1' class='gform-field-label gform-field-label--type-inline'>Tabaco<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_20_66\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_66'>Cantidad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_66' id='input_20_66' type='text' value='' class='medium'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_20_67\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_67'>Tipo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_67' id='input_20_67' type='text' value='' class='medium'    placeholder='Tipo' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_20_68\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_68'>Frecuencia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_68' id='input_20_68' type='text' value='' class='medium'    placeholder='Frecuencia' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_20_69\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >drogas<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_20_69'><div class='gchoice gchoice_20_69_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_69.1' type='checkbox'  value='Consumo drogas'  id='choice_20_69_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_69_1' id='label_20_69_1' class='gform-field-label gform-field-label--type-inline'>Consumo de drogas<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_20_70\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_70'>Cantidad<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_20_70' type='text' value='' class='medium'    placeholder='Cantidad' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_20_71\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_71'>Tipo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_71' id='input_20_71' type='text' value='' class='medium'    placeholder='Tipo' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_20_72\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_72'>Frecuencia<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_72' id='input_20_72' type='text' value='' class='medium'    placeholder='Frecuencia' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_20_73\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >patologias<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_20_73'><div class='gchoice gchoice_20_73_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_73.1' type='checkbox'  value='Padezco o he padecido alguna de las siguientes enfermedades: card\u00edacas, circulatorias, respiratorias, neurol\u00f3gicas, mentales, hep\u00e1ticas, digestivas, reumatol\u00f3gicas, insuficiencia renal, urogenital, accidente cerebro-vascular, c\u00e1ncer\/tumor, enfermedad degenerativa del sistema .nervioso, s\u00edndrome o malformaci\u00f3n cong\u00e9nita, VIH\/Sida, hipertensi\u00f3n, colesterol, diabetes o hernia Padezco o he padecido alguna de las siguientes enfermedades insuficiencia cardiaca, circulatoria, respiratoria, neurol\u00f3gica, mental, hep\u00e1tica, digestiva, reumatol\u00f3gica, renal, urogenital, accidente cerebrovascular, c\u00e1ncer \/ tumor, enfermedad degenerativa del sistema nervioso, s\u00edndrome o malformaci\u00f3n cong\u00e9nita, VIH \/ SIDA, hipertensi\u00f3n, colesterol, diabetes o hernia;'  id='choice_20_73_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_73_1' id='label_20_73_1' class='gform-field-label gform-field-label--type-inline'>Padezco o he padecido alguna de las siguientes enfermedades: insuficiencia cardiaca, circulatoria, respiratoria, neurol\u00f3gica, mental, hep\u00e1tica, digestiva, reumatol\u00f3gica, renal, urogenital, accidente cerebrovascular, c\u00e1ncer \/ tumor, enfermedad degenerativa del sistema nervioso, s\u00edndrome o malformaci\u00f3n cong\u00e9nita, VIH \/ SIDA, hipertensi\u00f3n, colesterol, diabetes o hernia<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_20_74\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-no-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_74'>Fecha<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_74' id='input_20_74' type='text' value='' class='datepicker gform-datepicker dmy datepicker_no_icon gdatepicker-no-icon'   placeholder='Fecha' aria-describedby=\"input_20_74_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_20_74_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_20_74' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_20_75\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_75'>Patolog\u00eda<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_75' id='input_20_75' type='text' value='' class='medium'    placeholder='Patolog\u00eda' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_20_76\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_76'>Centro donde se recibi\u00f3 el tratamiento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_76' id='input_20_76' type='text' value='' class='large'    placeholder='Centro donde se recibi\u00f3 el tratamiento' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><\/div>\n                    <\/div>\n                    <div class='gform-page-footer gform_page_footer top_label'>\n                        <input type='button' id='gform_previous_button_20_87' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='button' id='gform_next_button_20_87' class='gform_next_button gform-theme-button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='next' value='Siguiente'  \/> \n                    <\/div>\n                <\/div>\n                <div id='gform_page_20_4' class='gform_page' data-js='page-field-id-87' style='display:none;'>\n                    <div class='gform_page_fields'>\n                        <div id='gform_fields_20_4' class='gform_fields top_label form_sublabel_below description_below validation_below'><fieldset id=\"field_20_77\" class=\"gfield gfield--type-radio gfield--type-choice gfield--input-type-radio gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label' >\u00bfExiste un pr\u00e9stamo hipotecario?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_radio'><div class='gfield_radio' id='input_20_77'>\n\t\t\t<div class='gchoice gchoice_20_77_0'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='Si'  id='choice_20_77_0' onchange='gformToggleRadioOther( this )' aria-describedby=\"gfield_description_20_77\"   \/>\n\t\t\t\t\t<label for='choice_20_77_0' id='label_20_77_0' class='gform-field-label gform-field-label--type-inline'>SI<\/label>\n\t\t\t<\/div>\n\t\t\t<div class='gchoice gchoice_20_77_1'>\n\t\t\t\t\t<input class='gfield-choice-input' name='input_77' type='radio' value='No'  id='choice_20_77_1' onchange='gformToggleRadioOther( this )'    \/>\n\t\t\t\t\t<label for='choice_20_77_1' id='label_20_77_1' class='gform-field-label gform-field-label--type-inline'>No<\/label>\n\t\t\t<\/div><\/div><\/div><div class='gfield_description' id='gfield_description_20_77'>Con esta cl\u00e1usula, el banco con el que se mantiene el cr\u00e9dito hipotecario es designado para el capital pendiente, y el resto, si lo hubiera, a los beneficiarios o herederos legales designados.<\/div><\/fieldset><div id=\"field_20_79\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_79'>Entidad \/ Persona<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_79' id='input_20_79' type='text' value='' class='medium'    placeholder='Entidad \/ Persona' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_20_80\" class=\"gfield gfield--type-text gfield--input-type-text gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_80'>N\u00famero de pr\u00e9stamo<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_80' id='input_20_80' type='text' value='' class='medium'    placeholder='N\u00famero de pr\u00e9stamo' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_20_81\" class=\"gfield gfield--type-date gfield--input-type-date gfield--input-type-datepicker gfield--datepicker-default-icon gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_81'>Fecha de vencimiento<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_81' id='input_20_81' type='text' value='' class='datepicker gform-datepicker dmy datepicker_with_icon gdatepicker_with_icon'   placeholder='Fecha de vencimiento' aria-describedby=\"input_20_81_date_format\" aria-invalid=\"false\" aria-required=\"true\"\/>\n                            <span id='input_20_81_date_format' class='screen-reader-text'>DD barra MM barra AAAA<\/span>\n                        <\/div>\n                        <input type='hidden' id='gforms_calendar_icon_input_20_81' class='gform_hidden' value='https:\/\/insbrok.com\/wp-content\/plugins\/gravityforms\/images\/datepicker\/datepicker.svg'\/><\/div><div id=\"field_20_78\" class=\"gfield gfield--type-select gfield--input-type-select gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_78'>Designaci\u00f3n de beneficiarios<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_78' id='input_20_78' class='medium gfield_select'  aria-describedby=\"gfield_description_20_78\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Tipo de cl\u00e1usula<\/option><option value='Cla\u00fasula legal' >Cl\u00e1usula legal<\/option><option value='Cla\u00fasula nominativa' >Cl\u00e1usula nominativa<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_20_78'><strong><u>Cl\u00e1usula legal:<\/u><\/strong> El capital, en caso de no haber testamento, se repartir\u00eda entre los herederos legales seg\u00fan la ley.<\/span><br> <span><strong><u>Nominative Clause:<\/u><\/strong> The beneficiaries who will receive the compensation are expressly identified. Insured capital does not fall within the estate, so the beneficiaries will receive 100% of the contracted capital. <\/span><\/div><\/div><div id=\"field_20_82\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">A\u00f1adir un nuevo beneficiario<\/h3><\/div><div id=\"field_20_83\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_83'>Documento<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_83' id='input_20_83' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='' selected='selected' class='gf_placeholder'>Documento<\/option><option value='Pasaporte' >Pasaporte<\/option><option value='NIE' >NIE<\/option><option value='DNI' >DNI<\/option><\/select><\/div><\/div><div id=\"field_20_84\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required field_sublabel_below gfield--no-description field_description_below hidden_label field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_84'>n\u00famero<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_84' id='input_20_84' type='text' value='' class='large'    placeholder='N\u00famero de documento' aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_20_99\" class=\"gfield gfield--type-fileupload gfield--input-type-fileupload gfield--width-full gfield_contains_required field_sublabel_below gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_99'>Adjunta el pasaporte o NIE del beneficiario<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_fileupload'><input type='hidden' name='MAX_FILE_SIZE' value='5242880' \/><input name='input_99' id='input_20_99' type='file' class='large' aria-describedby=\"gfield_upload_rules_20_99 gfield_description_20_99\" onchange='javascript:gformValidateFileSize( this, 5242880 );'  \/><span class='gfield_description gform_fileupload_rules' id='gfield_upload_rules_20_99'>Tipos de archivos aceptados: jpg, jpeg, png, pdf, m\u00e1x. tama\u00f1o del archivo: 5 MB.<\/span><div class='gfield_description validation_message gfield_validation_message validation_message--hidden-on-empty' id='live_validation_message_20_99'><\/div> <\/div><div class='gfield_description' id='gfield_description_20_99'>Por favor, adjunte un escaneo o una foto de buena calidad del documento<\/div><\/div><fieldset id=\"field_20_85\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Nombre<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><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_20_85'>\n                            \n                            <span id='input_20_85_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_85.3' id='input_20_85_3' value=''   aria-required='true'     \/>\n                                                    <label for='input_20_85_3' class='gform-field-label gform-field-label--type-sub '>Nombre<\/label>\n                                                <\/span>\n                            \n                            <span id='input_20_85_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                    <input type='text' name='input_85.6' id='input_20_85_6' value=''   aria-required='true'     \/>\n                                                    <label for='input_20_85_6' class='gform-field-label gform-field-label--type-sub '>Apellidos<\/label>\n                                                <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_20_86\" class=\"gfield gfield--type-number gfield--input-type-number gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_20_86'>Porcentaje de participaci\u00f3n (%)<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/label><div class='ginput_container ginput_container_number'><input name='input_86' id='input_20_86' type='number' step='any' min='1' max='100' value='' class='small'     aria-required=\"true\" aria-invalid=\"false\" aria-describedby=\"gfield_instruction_20_86\" \/><div class='gfield_description instruction ' id='gfield_instruction_20_86'>Por favor, escribe un n\u00famero entre <strong>1<\/strong> y <strong>100<\/strong>.<\/div><\/div><\/div><fieldset id=\"field_20_96\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield_contains_required field_sublabel_below gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Condiciones de uso<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_asterisk\">*<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_20_96'><div class='gchoice gchoice_20_96_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_96.1' type='checkbox'  value='He le\u00eddo y aceptado la &lt;a href=&quot;https:\/\/insbrok.com\/personal-data-protection-policy\/&quot; target=&quot;_blank&quot;&gt;pol\u00edtica de protecci\u00f3n de datos&lt;\/a&gt;'  id='choice_20_96_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_20_96_1' id='label_20_96_1' class='gform-field-label gform-field-label--type-inline'>He le\u00eddo y aceptado la <a href=\"https:\/\/insbrok.com\/personal-data-protection-policy\/\" target=\"_blank\">pol\u00edtica de protecci\u00f3n de datos<\/a><\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><\/div><\/div>\n        <div class='gform-page-footer gform_page_footer top_label'><input type='submit' id='gform_previous_button_20' class='gform_previous_button gform-theme-button gform-theme-button--secondary button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='previous' value='Anterior'  \/> <input type='submit' id='gform_submit_button_20' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' value='Enviar'  \/> \n            <input type='hidden' class='gform_hidden' name='gform_submission_method' data-js='gform_submission_method_20' value='postback' \/>\n            <input type='hidden' class='gform_hidden' name='gform_theme' data-js='gform_theme_20' id='gform_theme_20' value='gravity-theme' \/>\n  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