{"id":2041,"date":"2024-03-27T06:57:16","date_gmt":"2024-03-27T06:57:16","guid":{"rendered":"https:\/\/fnblegal.com\/?page_id=2041"},"modified":"2024-03-27T06:57:16","modified_gmt":"2024-03-27T06:57:16","slug":"general-accident-form","status":"publish","type":"page","link":"https:\/\/fnblegal.com\/backup\/es\/general-accident-form\/","title":{"rendered":"Formulario general de accidentes"},"content":{"rendered":"<div id=\"modal-ready\"><h1 style=\"text-align: center;\">Formulario de admisi\u00f3n de nuevos clientes &#8211; Accidente general<\/h1>\n\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f2040-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"2040\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/backup\/es\/wp-json\/wp\/v2\/pages\/2041#wpcf7-f2040-o1\" method=\"post\" class=\"wpcf7-form init intake\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<div style=\"display: none;\">\n<input type=\"hidden\" name=\"_wpcf7\" value=\"2040\" \/>\n<input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.0.6\" \/>\n<input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/>\n<input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f2040-o1\" \/>\n<input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/>\n<input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/>\n<input type=\"hidden\" name=\"_wpcf7_recaptcha_response\" value=\"\" \/>\n<\/div>\n<div class=\"flex\">\n\t<div class=\"column one-second2\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"your-email\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Correo Electr\u00f3nico\" value=\"\" type=\"email\" name=\"your-email\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column one-second2\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"your-name\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Nombre Completo (Nombre, Segundo nombre, Apellido)\" value=\"\" type=\"text\" name=\"your-name\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex\">\n\t<div class=\"column one-second2\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"home-addr\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Direcci\u00f3n de Casa\" value=\"\" type=\"text\" name=\"home-addr\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column one-second2\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"mod-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Tel\u00e9fono M\u00f3vil\" value=\"\" type=\"text\" name=\"mod-phone\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex\">\n\t<div class=\"column one-second2\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"home-phone\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Tel\u00e9fono de Casa\" value=\"\" type=\"text\" name=\"home-phone\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column one-second2\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"date-birth\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Fecha de Nacimiento *\" value=\"\" type=\"text\" name=\"date-birth\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex\">\n\t<div class=\"column one-second2\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"soc-sec\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"N\u00famero de Seguro Social *\" value=\"\" type=\"text\" name=\"soc-sec\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column one-second2\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"date-accid\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Fecha del Accidente *\" value=\"\" type=\"text\" name=\"date-accid\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex\">\n\t<div class=\"column full\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"loc-accid\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Ubicaci\u00f3n del Accidente (Estado, Ciudad, Calle - nombre) *\" value=\"\" type=\"text\" name=\"loc-accid\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"injuries-accid\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Estoy experimentando dolor en \/ Sufri las siguientes lesiones... (lista partes del cuerpo) *\" value=\"\" type=\"text\" name=\"injuries-accid\" \/><\/span> <\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"column fullcolumn\">\n\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"brief-desc\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" placeholder=\"Breve Descripci\u00f3n del Accidente\" name=\"brief-desc\"><\/textarea><\/span> <\/label>\n\t<\/p>\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label>Fui al hospital como resultado del accidente *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"went-hospital\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"went-hospital\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"went-hospital\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label>He sido lesionado previamente en un accidente *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"previously-injured\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"previously-injured\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"previously-injured\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label>Soy Beneficiario de Medicare *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"medicare-beneficiary\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"medicare-beneficiary\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"medicare-beneficiary\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label> Soy Beneficiario de Medicaid *<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"medicaid-beneficiary\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"medicaid-beneficiary\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"medicaid-beneficiary\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label> Tengo Seguro de Salud<br \/>\n<span class=\"wpcf7-form-control-wrap\" data-name=\"health-insurance\"><span class=\"wpcf7-form-control wpcf7-radio\"><span class=\"wpcf7-list-item first\"><input type=\"radio\" name=\"health-insurance\" value=\"S\u00ed\" \/><span class=\"wpcf7-list-item-label\">S\u00ed<\/span><\/span><span class=\"wpcf7-list-item last\"><input type=\"radio\" name=\"health-insurance\" value=\"No\" checked=\"checked\" \/><span class=\"wpcf7-list-item-label\">No<\/span><\/span><\/span><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div style=\"clear:both\">\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label>Informe de Polic\u00eda \/ Accidente<br \/>\n<span class=\"wpcf7-form-control-wrap accident-repord\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-multifile\" multiple=\"multiple\" aria-invalid=\"false\" type=\"file\" name=\"accident-repord[]\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label>Im\u00e1genes del Accidente (ubicaci\u00f3n)<br \/>\n<span class=\"wpcf7-form-control-wrap accident-imageslocation\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-multifile\" multiple=\"multiple\" aria-invalid=\"false\" type=\"file\" name=\"accident-imageslocation[]\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label>Im\u00e1genes del Accidente (lesiones)<br \/>\n<span class=\"wpcf7-form-control-wrap accident-imagesinjuries\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-multifile\" multiple=\"multiple\" aria-invalid=\"false\" type=\"file\" name=\"accident-imagesinjuries[]\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex hals\">\n\t<div class=\"column\">\n\t\t<p><label>Tarjeta de Seguro de Salud<br \/>\n<span class=\"wpcf7-form-control-wrap health-insurancecart\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-multifile\" multiple=\"multiple\" aria-invalid=\"false\" type=\"file\" name=\"health-insurancecart[]\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<div class=\"flex oryoucan\">\n\t<div class=\"column one-second2\">\n\t\t<p>O puede adjuntar archivos a trav\u00e9s de Almacenamiento en la Nube\n\t\t<\/p>\n\t<\/div>\n\t<div class=\"column full one-second2\">\n\t\t<p><label> <span class=\"wpcf7-form-control-wrap\" data-name=\"cloud-link\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"Ingresar Enlace de Almacenamiento en la Nube\" type=\"text\" name=\"cloud-link\" \/><\/span><\/label>\n\t\t<\/p>\n\t<\/div>\n<\/div>\n<p><input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Enviar\" \/>\n<\/p><div 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