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<div style="page-break-inside: avoid;">
<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Son nom ou sa d&eacute;nomination sociale :</span></td>
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		<tr>
			<td>{% textarea_tag name=&quot;64fe2fbc&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Nom de l&#39;agence&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Nom de l&#39;agence&quot; data_textarea_value=&quot;INFO_CLIENT_enseigne&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">L&#39;adresse g&eacute;ographique de l&#39;&eacute;tablissement :&nbsp;</span></td>
		</tr>
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			<td>{% textarea_tag name=&quot;d345c4f5&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Adresse de l&#39;agence&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Adresse&quot; data_textarea_value=&quot;INFO_CLIENT_adresse&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Si elle est diff&eacute;rente, l&#39;adresse du si&egrave;ge social :</span></td>
		</tr>
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			<td>{% textarea_tag name=&quot;x345c4f5&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Adresse du si&egrave;ge social&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">E-mail :</span></td>
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			<td>{% textarea_tag name=&quot;9b4ce0de&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;E-mail de l&#39;agence&quot; data_map_field=&quot;nomap&quot; data_help=&quot;E-mail agence&quot; data_textarea_value=&quot;INFO_CLIENT_email&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">T&eacute;l :</span></td>
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			<td>{% textarea_tag name=&quot;5d9ed1ee&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;T&eacute;l&eacute;phone de l&#39;agence&quot; data_map_field=&quot;nomap&quot; data_help=&quot;T&eacute;l&eacute;phone agence&quot; data_textarea_value=&quot;INFO_CLIENT_telephone&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Autres canaux de communication digitale avec conservation des &eacute;changes (ex : Messagerie espace client, WhatsApp...) :</span></td>
		</tr>
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			<td>{% textarea_tag name=&quot;6f09b66c&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Autres canaux de communication digitale avec conservation des &eacute;changes&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>
</div>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Pour toute r&eacute;clamation, vous pouvez contacter :</span></td>
		</tr>
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			<td>{% textarea_tag name=&quot;4e2ed96e&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Pour toute r&eacute;clamation, vous pouvez contacter :&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Nom et coordonn&eacute;es du responsable de l&#39;agence :</span></td>
		</tr>
		<tr>
			<td>{% textarea_tag name=&quot;133f574e&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Nom et coordonn&eacute;es du responsable de l&#39;agence :&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Statut et forme juridique de l&#39;entreprise :</span></td>
		</tr>
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			<td>{% textarea_tag name=&quot;b29be734&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Statut et forme juridique de l&#39;entreprise :&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">N&deg;RCS :</span></td>
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			<td>{% textarea_tag name=&quot;ea7d320f&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;N&deg;RCS :&quot; data_textarea_value=&quot;INFO_CLIENT_rcs&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
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			<td colspan="2"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">N&deg; de la carte professionnelle, nom et adresse de l&#39;autorit&eacute; l&#39;ayant d&eacute;livr&eacute; :</span></td>
		</tr>
		<tr>
			<td style="width: 40%;">{% textinput_tag name=&quot;5c9f774f&quot; value=&quot;INFO_CLIENT_carte_professionnelle&quot; data_label=&quot;N&deg; de la carte professionnelle :&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td>{% textinput_tag name=&quot;1b48d947&quot; value=&quot;INFO_CLIENT_delivre_prefecture&quot; data_label=&quot; nom et adresse de l&#39;autorit&eacute; l&#39;ayant d&eacute;livr&eacute; :&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">N&deg; individuel d&#39;identification &agrave; la TVA intracommunautaire :</span></td>
		</tr>
		<tr>
			<td>{% textarea_tag name=&quot;f1edaa90&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;N&deg; individuel d&#39;identification &agrave; la TVA intracommunautaire :&quot; data_textarea_value=&quot;INFO_CLIENT_tva_intra&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Nom et adresse du garant financier :</span></td>
		</tr>
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			<td>{% textarea_tag name=&quot;45c8e5b3&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Nom et adresse du garant financier :&quot; data_map_field=&quot;nomap&quot; data_textarea_value=&quot;INFO_CLIENT_garantie_financiere&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Nom et adresse de l&#39;assureur responsabilit&eacute; civile professionnelle :</span></td>
		</tr>
		<tr>
			<td>{% textarea_tag name=&quot;e93009f2&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Nom et adresse de l&#39;assureur responsabilit&eacute; civile professionnelle :&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
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			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Ces garanties s&#39;appliquent aux sinistres survenus en France (&agrave; compl&eacute;ter &eacute;ventuellement) :</span></td>
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			<td>{% textarea_tag name=&quot;7ebccc3d&quot; data_width=&quot;100&quot; rows=&quot;1&quot; data_label=&quot;Ces garanties s&#39;appliquent aux sinistres survenus en France (&agrave; compl&eacute;ter &eacute;ventuellement) :&quot; data_map_field=&quot;nomap&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

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