{"id":1036,"date":"2023-09-26T11:18:58","date_gmt":"2023-09-26T15:18:58","guid":{"rendered":"https:\/\/quantum-staffing.com\/?page_id=1036"},"modified":"2025-07-16T10:16:54","modified_gmt":"2025-07-16T14:16:54","slug":"formulario-de-eleccion-de-beneficios","status":"publish","type":"page","link":"https:\/\/quantum-staffing.com\/es\/formulario-de-eleccion-de-beneficios\/","title":{"rendered":"FORMULARIO DE ELECCI\u00d3N DE BENEFICIOS"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1036\" class=\"elementor elementor-1036\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-1d61b440 e-flex e-con-boxed e-con e-parent\" data-id=\"1d61b440\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-394e9736 exad-sticky-section-no exad-glass-effect-no elementor-widget elementor-widget-text-editor\" data-id=\"394e9736\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t\n<h3 class=\"wp-block-heading\" style=\"text-align: center;\">Gu\u00eda de Inscripci\u00f3n al Plan de Seguro M\u00e9dico de Indemnizaci\u00f3n Fija, Productos Auxiliares y Cobertura Esencial M\u00ednima Autofi nanciada (MEC)<\/h3>\n\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-3ff9352 e-flex e-con-boxed e-con e-parent\" data-id=\"3ff9352\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-e72aed4 exad-sticky-section-no exad-glass-effect-no elementor-widget elementor-widget-shortcode\" data-id=\"e72aed4\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\"><a href=\"https:\/\/quantum-staffing.com\/wp-content\/uploads\/2023\/11\/BSP-EF-4EUSNADW-SP-FORMULARIO-DE-BENEFICIOS.-1.pdf\" class=\"pdfemb-viewer\" style=\"width: 800px; height: 600px; \" data-width=\"800\" data-height=\"600\" data-mobile-width=\"200\"  data-scrollbar=\"vertical\" data-download=\"off\" data-tracking=\"on\" data-newwindow=\"off\" data-pagetextbox=\"off\" data-scrolltotop=\"on\" data-startzoom=\"100\" data-startfpzoom=\"100\" data-toolbar=\"top\" data-toolbar-fixed=\"on\">BSP-EF-4EUSNADW-SP-FORMULARIO-DE-BENEFICIOS.-1<br\/><\/a><\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-85da534 e-flex e-con-boxed e-con e-parent\" data-id=\"85da534\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-67b724f exad-sticky-section-no exad-glass-effect-no elementor-widget elementor-widget-text-editor\" data-id=\"67b724f\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p class=\"has-text-align-center\"><strong>IMPORTANTE INFORMACI\u00d3N SOBRE EL PLAN:<\/strong>\u00a0Usted tiene dos opciones de planes m\u00e9dicos.<br \/>Puede registrarse en uno o en los dos. Hay m\u00e1s bene\ufb01 cios disponibles si se registra en el Plan de<br \/>seguro m\u00e9dico de indemnizaci\u00f3n \ufb01 ja (Fixed Indemnity Medical Insurance Plan).<\/p>\n<ol>\n<li>Usted\u00a0<strong>DEBE<\/strong>\u00a0completar el Formulario de registro como parte de su proceso de nuevo empleado.<\/li>\n<li>Elija o decline todos los bene\ufb01cios en el\u00a0<b>Formulario<\/b>\u00a0de\u00a0<b>registro<\/b>.<\/li>\n<li>Usted\u00a0<b>DEBE<\/b>\u00a0<b>Firmar<\/b>\u00a0y Fechar la parte inferior del formulario, aunque\u00a0<b>decline<\/b> la cobertura.<\/li>\n<\/ol>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-1896e90 exad-sticky-section-no exad-glass-effect-no elementor-widget elementor-widget-formidable\" data-id=\"1896e90\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"formidable.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_7_container\" data-token=\"713489598904863d5a1ec53fd4ba3e08\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form \" id=\"form_formulariodeeleccindebeneficios\" data-token=\"713489598904863d5a1ec53fd4ba3e08\">\n<div class=\"frm_form_fields \">\n<fieldset>\n<legend class=\"frm_screen_reader\">FORMULARIO DE ELECCI\u00d3N DE BENEFICIOS<\/legend>\r\n\r\n<div class=\"frm_fields_container\">\n<input type=\"hidden\" name=\"frm_action\" value=\"create\" \/>\n<input type=\"hidden\" name=\"form_id\" value=\"7\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_7\" id=\"frm_hide_fields_7\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"formulariodeeleccindebeneficios\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_7\" name=\"frm_submit_entry_7\" value=\"3a5dd2b2c1\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/es\/wp-json\/wp\/v2\/pages\/1036\" \/><div id=\"frm_field_64_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">A. INFORMACI\u00d3N REQUERIDA DEL EMPLEADO<\/h3>\r\n\r\n\r\n<div id=\"frm_field_65_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <div  id=\"field_6ywe9_label\" class=\"frm_primary_label\">Datos personales\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_6ywe9_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tDatos personales\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_65\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_65-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_6ywe9_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tNombre\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_6ywe9_first\" value=\"\" name=\"item_meta[65][first]\" data-sectionid=\"64\"  data-reqmsg=\"Datos personales no puede estar en blanco.\" aria-required=\"true\" data-invmsg=\"Datos personales no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_65_first_desc\">Nombre<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_65-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_6ywe9_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tApellidos\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_6ywe9_last\" value=\"\" name=\"item_meta[65][last]\" data-sectionid=\"64\"  data-reqmsg=\"Datos personales no puede estar en blanco.\" aria-required=\"true\" data-invmsg=\"Datos personales no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_65_last_desc\">Apellidos<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_66_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n    <label for=\"field_m94se\" id=\"field_m94se_label\" class=\"frm_primary_label\">Celular\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"tel\" id=\"field_m94se\" name=\"item_meta[66]\" value=\"\"  data-sectionid=\"64\"  data-reqmsg=\"Celular no puede estar en blanco.\" aria-required=\"true\" data-invmsg=\"Phone is invalid\" aria-invalid=\"false\" pattern=\"((\\+\\d{1,3}(-|.| )?\\(?\\d\\)?(-| |.)?\\d{1,5})|(\\(?\\d{2,6}\\)?))(-|.| )?(\\d{3,4})(-|.| )?(\\d{4})(( x| ext)\\d{1,5}){0,1}$\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_67_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n    <label for=\"field_zmqlo\" id=\"field_zmqlo_label\" class=\"frm_primary_label\">N\u00famero de Seguro Social\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_zmqlo\" name=\"item_meta[67]\" value=\"\"  data-sectionid=\"64\"  data-reqmsg=\"N\u00famero de Seguro Social no puede estar en blanco.\" aria-required=\"true\" data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_68_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm6 frm_first\">\r\n    <label for=\"field_re83v\" id=\"field_re83v_label\" class=\"frm_primary_label\">Fecha de nacimiento\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_re83v\" name=\"item_meta[68]\" value=\"--,--,---\"  data-sectionid=\"64\"  maxlength=\"10\" data-frmval=\"--,--,---\" data-reqmsg=\"Fecha de nacimiento no puede estar en blanco.\" aria-required=\"true\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_69_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 vertical_radio\">\r\n    <div  id=\"field_ptwyx_label\" class=\"frm_primary_label\">G\u00e9nero\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_ptwyx_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_69-64-0\">\t\t\t<label  for=\"field_ptwyx-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[69]\" id=\"field_ptwyx-0\" value=\"Hombre\"\n\t\t   data-sectionid=\"64\"  data-reqmsg=\"G\u00e9nero no puede estar en blanco.\" data-invmsg=\"G\u00e9nero no es v\u00e1lido\"  \/> Hombre<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_69-64-1\">\t\t\t<label  for=\"field_ptwyx-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[69]\" id=\"field_ptwyx-1\" value=\"Mujer\"\n\t\t   data-sectionid=\"64\"  data-reqmsg=\"G\u00e9nero no puede estar en blanco.\" data-invmsg=\"G\u00e9nero no es v\u00e1lido\"  \/> Mujer<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_70_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <div  id=\"field_15mju_label\" class=\"frm_primary_label\">Direcci\u00f3n\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_15mju_label\">\n<legend class=\"frm_screen_reader frm_hidden\">\n\tDirecci\u00f3n<\/legend>\n<div class=\"frm_combo_inputs_container\">\n<div id=\"frm_field_70-line1_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_15mju_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tDirecci\u00f3n\t<\/label>\n\t\t<input type=\"text\" id=\"field_15mju_line1\" value=\"\" name=\"item_meta[70][line1]\"  data-sectionid=\"64\"  data-reqmsg=\"Direcci\u00f3n no puede estar en blanco.\" aria-required=\"true\" data-invmsg=\"Direcci\u00f3n no es v\u00e1lido\" aria-invalid=\"false\"   autocomplete=\"address-line1\" \/>\n\t<\/div>\n<div id=\"frm_field_70-line2_container\" class=\"frm_form_field form-field \">\n\t<label for=\"field_15mju_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tDirecci\u00f3n\t<\/label>\n\t\t<input type=\"text\" id=\"field_15mju_line2\" value=\"\" name=\"item_meta[70][line2]\"  data-sectionid=\"64\"  data-reqmsg=\"Direcci\u00f3n no puede estar en blanco.\" aria-required=\"true\" data-invmsg=\"Direcci\u00f3n no es v\u00e1lido\" class=\"frm_optional\" aria-invalid=\"false\"   autocomplete=\"address-line2\" \/>\n\t<\/div>\n<div id=\"frm_field_70-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_15mju_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCiudad\t<\/label>\n\t\t<input type=\"text\" id=\"field_15mju_city\" value=\"\" name=\"item_meta[70][city]\"  data-sectionid=\"64\"  data-reqmsg=\"Direcci\u00f3n no puede estar en blanco.\" aria-required=\"true\" data-invmsg=\"Direcci\u00f3n no es v\u00e1lido\" aria-invalid=\"false\"   autocomplete=\"address-level2\" \/>\n\t<div class=\"frm_description\">Ciudad<\/div><\/div>\n<div id=\"frm_field_70-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_15mju_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tEstado\t<\/label>\n\t\t\t<select name=\"item_meta[70][state]\" id=\"field_15mju_state\"  data-sectionid=\"64\"  data-reqmsg=\"Direcci\u00f3n no puede estar en blanco.\" aria-required=\"true\" data-invmsg=\"Direcci\u00f3n no es v\u00e1lido\" aria-invalid=\"false\"   autocomplete=\"address-level1\">\n\t\t\t<option value=\"\" class=\"\">\n\t\t\t\t \t\t\t<\/option>\n\t\t\t<option  value=\"Alabama\">Alabama<\/option><option  value=\"Alaska\">Alaska<\/option><option  value=\"Arkansas\">Arkansas<\/option><option  value=\"Arizona\">Arizona<\/option><option  value=\"California\">California<\/option><option  value=\"Colorado\">Colorado<\/option><option  value=\"Connecticut\">Connecticut<\/option><option  value=\"Delaware\">Delaware<\/option><option  value=\"District of Columbia\">District of Columbia<\/option><option  value=\"Florida\">Florida<\/option><option  value=\"Georgia\">Georgia<\/option><option  value=\"Hawaii\">Hawaii<\/option><option  value=\"Idaho\">Idaho<\/option><option  value=\"Illinois\">Illinois<\/option><option  value=\"Indiana\">Indiana<\/option><option  value=\"Iowa\">Iowa<\/option><option  value=\"Kansas\">Kansas<\/option><option  value=\"Kentucky\">Kentucky<\/option><option  value=\"Louisiana\">Louisiana<\/option><option  value=\"Maine\">Maine<\/option><option  value=\"Maryland\">Maryland<\/option><option  value=\"Massachusetts\">Massachusetts<\/option><option  value=\"Michigan\">Michigan<\/option><option  value=\"Minnesota\">Minnesota<\/option><option  value=\"Mississippi\">Mississippi<\/option><option  value=\"Missouri\">Missouri<\/option><option  value=\"Montana\">Montana<\/option><option  value=\"Nebraska\">Nebraska<\/option><option  value=\"Nevada\">Nevada<\/option><option  value=\"New Hampshire\">New Hampshire<\/option><option  value=\"New Jersey\">New Jersey<\/option><option  value=\"New Mexico\">New Mexico<\/option><option  value=\"New York\">New York<\/option><option  value=\"North Carolina\">North Carolina<\/option><option  value=\"North Dakota\">North Dakota<\/option><option  value=\"Ohio\">Ohio<\/option><option  value=\"Oklahoma\">Oklahoma<\/option><option  value=\"Oregon\">Oregon<\/option><option  value=\"Pennsylvania\">Pennsylvania<\/option><option  value=\"Rhode Island\">Rhode Island<\/option><option  value=\"South Carolina\">South Carolina<\/option><option  value=\"South Dakota\">South Dakota<\/option><option  value=\"Tennessee\">Tennessee<\/option><option  value=\"Texas\">Texas<\/option><option  value=\"Utah\">Utah<\/option><option  value=\"Vermont\">Vermont<\/option><option  value=\"Virginia\">Virginia<\/option><option  value=\"Washington\">Washington<\/option><option  value=\"West Virginia\">West Virginia<\/option><option  value=\"Wisconsin\">Wisconsin<\/option><option  value=\"Wyoming\">Wyoming<\/option>\t\t<\/select>\n\t<div class=\"frm_description\">Estado<\/div><\/div>\n<div id=\"frm_field_70-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_15mju_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/C\u00f3digo Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_15mju_zip\" value=\"\" name=\"item_meta[70][zip]\"  data-sectionid=\"64\"  data-reqmsg=\"Direcci\u00f3n no puede estar en blanco.\" aria-required=\"true\" data-invmsg=\"Direcci\u00f3n no es v\u00e1lido\" aria-invalid=\"false\"   autocomplete=\"postal-code\" \/>\n\t<div class=\"frm_description\">Zip\/C\u00f3digo Postal<\/div><\/div>\n<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_72_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">B. INFORMACI\u00d3N SOBRE MEDICARE<\/h3>\r\n\r\n\r\n<div id=\"frm_field_111_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_8ad2x_label\" class=\"frm_primary_label\">\u00bfUsted o uno de sus dependientes recibe Medicare?\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_8ad2x_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_111-72-0\">\t\t\t<label  for=\"field_8ad2x-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[111]\" id=\"field_8ad2x-0\" value=\"Si\"\n\t\t   data-sectionid=\"72\"  data-invmsg=\"\u00bfUsted o uno de sus dependientes recibe Medicare? no es v\u00e1lido\"  \/> Si<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_111-72-1\">\t\t\t<label  for=\"field_8ad2x-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[111]\" id=\"field_8ad2x-1\" value=\"No\"\n\t\t   data-sectionid=\"72\"  data-invmsg=\"\u00bfUsted o uno de sus dependientes recibe Medicare? no es v\u00e1lido\"  \/> No<\/label><\/div>\n<\/div>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_8ad2x\"> Si dijo \"S\u00ed\", llene el resto de esta secci\u00f3n.<\/div>\r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_119_container\" class=\"frm_form_field frm_section_heading form-field  frm12 frm_first\">\r\n<h3 class=\"frm_pos_top frm_section_spacing frm_trigger\" tabindex=\"0\" role=\"button\">Si dijo \"S\u00ed\", llene el resto de esta secci\u00f3n <svg  viewBox=\"0 0 20 20\" width=\"1em\" height=\"1em\" aria-expanded=\"false\" aria-label=\"Campos conmutadores\" class=\"frmsvg frm-svg-icon\">\n\t<path d=\"M5 6l5 5 5-5 2 1-7 7-7-7 2-1z\"><\/path>\n\n<\/svg><svg  viewBox=\"0 0 20 20\" width=\"1em\" height=\"1em\" aria-expanded=\"false\" aria-label=\"Campos conmutadores\" class=\"frmsvg frm-svg-icon\">\n\t<title>arrowup6<\/title>\n\t<path style=\"transform:rotate(180deg); transform-origin:center;\" d=\"M5 6l5 5 5-5 2 1-7 7-7-7 2-1z\"><\/path>\n<\/svg><\/h3>\r\n\r\n<div class=\"frm_toggle_container frm_grid_container\" style=\"display:none;\">\r\n<div id=\"frm_field_74_container\" class=\"frm_form_field form-field  frm_top_container frm6  frm12 frm_first\">\r\n    <label for=\"field_4oo2j\" id=\"field_4oo2j_label\" class=\"frm_primary_label\">Fecha efectiva de Medicare:\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_4oo2j\" name=\"item_meta[74]\" value=\"\"  data-sectionid=\"119\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_4oo2j\" \/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_4oo2j\">Nombres de las personas cubiertas: <\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_112_container\" class=\"frm_form_field form-field  frm_top_container frm6\">\r\n    <label for=\"field_sll0q\" id=\"field_sll0q_label\" class=\"frm_primary_label\">N\u00famero de reclamo al seguro de salud de Medicare (HICN):\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_sll0q\" name=\"item_meta[112]\" value=\"\"  data-sectionid=\"119\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_75_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first\">\r\n    <div  id=\"field_a7xsk_label\" class=\"frm_primary_label\">\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_a7xsk_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\t\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_75\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_75-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_a7xsk_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tNombre\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_a7xsk_first\" value=\"\" name=\"item_meta[75][first]\" data-sectionid=\"119\"  data-invmsg=\"Este campo no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_75_first_desc\">Nombre<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_75-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_a7xsk_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tApellido\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_a7xsk_last\" value=\"\" name=\"item_meta[75][last]\" data-sectionid=\"119\"  data-invmsg=\"Este campo no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_75_last_desc\">Apellido<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_76_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n    <div  id=\"field_ufvjl_label\" class=\"frm_primary_label\">\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_ufvjl_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\t\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_76\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_76-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_ufvjl_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tNombre\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_ufvjl_first\" value=\"\" name=\"item_meta[76][first]\" data-sectionid=\"119\"  data-invmsg=\"Este campo no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_76_first_desc\">Nombre<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_76-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_ufvjl_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tApellido\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_ufvjl_last\" value=\"\" name=\"item_meta[76][last]\" data-sectionid=\"119\"  data-invmsg=\"Este campo no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_76_last_desc\">Apellido<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_77_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm12\">\r\n    <div  id=\"field_ulsxp_label\" class=\"frm_primary_label\">\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_ulsxp_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\t\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_77\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_77-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_ulsxp_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tNombre\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_ulsxp_first\" value=\"\" name=\"item_meta[77][first]\" data-sectionid=\"119\"  data-invmsg=\"Este campo no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_77_first_desc\">Nombre<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_77-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_ulsxp_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tApellido\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_ulsxp_last\" value=\"\" name=\"item_meta[77][last]\" data-sectionid=\"119\"  data-invmsg=\"Este campo no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_77_last_desc\">Apellido<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<\/div>\n<\/div>\n<div id=\"frm_field_79_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing frm_trigger\" tabindex=\"0\" role=\"button\">C. INFORMACI\u00d3N REQUERIDA DE LOS DEPENDIENTES <svg  viewBox=\"0 0 20 20\" width=\"1em\" height=\"1em\" aria-expanded=\"false\" aria-label=\"Campos conmutadores\" class=\"frmsvg frm-svg-icon\">\n\t<path d=\"M5 6l5 5 5-5 2 1-7 7-7-7 2-1z\"><\/path>\n\n<\/svg><svg  viewBox=\"0 0 20 20\" width=\"1em\" height=\"1em\" aria-expanded=\"false\" aria-label=\"Campos conmutadores\" class=\"frmsvg frm-svg-icon\">\n\t<title>arrowup6<\/title>\n\t<path style=\"transform:rotate(180deg); transform-origin:center;\" d=\"M5 6l5 5 5-5 2 1-7 7-7-7 2-1z\"><\/path>\n<\/svg><\/h3>\r\n\r\n<div class=\"frm_toggle_container frm_grid_container\" style=\"display:none;\">\r\n<div id=\"frm_field_80_container\" class=\"frm_form_field form-field  frm_top_container frm6 frm_first\">\r\n    <div  id=\"field_p0oad_label\" class=\"frm_primary_label\">1). Datos personales \r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_p0oad_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\t1). Datos personales \t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_80\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_80-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_p0oad_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tNombre\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_p0oad_first\" value=\"\" name=\"item_meta[80][first]\" data-sectionid=\"79\"  data-invmsg=\"1). Datos personales  no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_80_first_desc\">Nombre<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_80-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_p0oad_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tApellido\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_p0oad_last\" value=\"\" name=\"item_meta[80][last]\" data-sectionid=\"79\"  data-invmsg=\"1). Datos personales  no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_80_last_desc\">Apellido<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_81_container\" class=\"frm_form_field form-field  frm_top_container frm6\">\r\n    <label for=\"field_yogvo\" id=\"field_yogvo_label\" class=\"frm_primary_label\">Fecha de nacimiento\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_yogvo\" name=\"item_meta[81]\" value=\"\"  data-sectionid=\"79\"  maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_82_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first\">\r\n    <label for=\"field_81ht3\" id=\"field_81ht3_label\" class=\"frm_primary_label\">N\u00famero de Seguro Social\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_81ht3\" name=\"item_meta[82]\" value=\"\"  data-sectionid=\"79\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_83_container\" class=\"frm_form_field form-field  frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_u96oq_label\" class=\"frm_primary_label\">G\u00e9nero\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_u96oq_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_83-79-0\">\t\t\t<label  for=\"field_u96oq-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[83]\" id=\"field_u96oq-0\" value=\"Hombre\"\n\t\t   data-sectionid=\"79\"  data-invmsg=\"G\u00e9nero no es v\u00e1lido\"  \/> Hombre<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_83-79-1\">\t\t\t<label  for=\"field_u96oq-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[83]\" id=\"field_u96oq-1\" value=\"Mujer\"\n\t\t   data-sectionid=\"79\"  data-invmsg=\"G\u00e9nero no es v\u00e1lido\"  \/> Mujer<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_84_container\" class=\"frm_form_field form-field  frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_xiawl_label\" class=\"frm_primary_label\">Relaci\u00f3n:\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_xiawl_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_84-79-0\">\t\t\t<label  for=\"field_xiawl-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[84][]\" id=\"field_xiawl-0\" value=\"Esposa\"  data-sectionid=\"79\"  data-invmsg=\"Relaci\u00f3n: no es v\u00e1lido\"   \/> Esposa<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_84-79-1\">\t\t\t<label  for=\"field_xiawl-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[84][]\" id=\"field_xiawl-1\" value=\"Hijo\/a\"  data-sectionid=\"79\"  data-invmsg=\"Relaci\u00f3n: no es v\u00e1lido\"   \/> Hijo\/a<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_84-79-2\">\t\t\t<label  for=\"field_xiawl-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[84][]\" id=\"field_xiawl-2\" value=\"Compa\u00f1ero dom\u00e9stico\"  data-sectionid=\"79\"  data-invmsg=\"Relaci\u00f3n: no es v\u00e1lido\"   \/> Compa\u00f1ero dom\u00e9stico<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_85_container\" class=\"frm_form_field form-field  frm_top_container frm6 frm_first\">\r\n    <div  id=\"field_r5c68_label\" class=\"frm_primary_label\">2). Datos personales \r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_r5c68_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\t2). Datos personales \t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_85\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_85-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_r5c68_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tNombre\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_r5c68_first\" value=\"\" name=\"item_meta[85][first]\" data-sectionid=\"79\"  data-invmsg=\"2). Datos personales  no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_85_first_desc\">Nombre<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_85-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_r5c68_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tApellido\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_r5c68_last\" value=\"\" name=\"item_meta[85][last]\" data-sectionid=\"79\"  data-invmsg=\"2). Datos personales  no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_85_last_desc\">Apellido<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_86_container\" class=\"frm_form_field form-field  frm_top_container frm6\">\r\n    <label for=\"field_xkt2k\" id=\"field_xkt2k_label\" class=\"frm_primary_label\">Fecha de nacimiento\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_xkt2k\" name=\"item_meta[86]\" value=\"\"  data-sectionid=\"79\"  maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_87_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first\">\r\n    <label for=\"field_1o5em\" id=\"field_1o5em_label\" class=\"frm_primary_label\">N\u00famero de Seguro Social\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_1o5em\" name=\"item_meta[87]\" value=\"\"  data-sectionid=\"79\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_88_container\" class=\"frm_form_field form-field  frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_aqdtf_label\" class=\"frm_primary_label\">G\u00e9nero\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_aqdtf_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_88-79-0\">\t\t\t<label  for=\"field_aqdtf-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[88]\" id=\"field_aqdtf-0\" value=\"Hombre\"\n\t\t   data-sectionid=\"79\"  data-invmsg=\"G\u00e9nero no es v\u00e1lido\"  \/> Hombre<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_88-79-1\">\t\t\t<label  for=\"field_aqdtf-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[88]\" id=\"field_aqdtf-1\" value=\"Mujer\"\n\t\t   data-sectionid=\"79\"  data-invmsg=\"G\u00e9nero no es v\u00e1lido\"  \/> Mujer<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_89_container\" class=\"frm_form_field form-field  frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_oi01j_label\" class=\"frm_primary_label\">Relaci\u00f3n:\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_oi01j_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_89-79-0\">\t\t\t<label  for=\"field_oi01j-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[89][]\" id=\"field_oi01j-0\" value=\"Esposa\"  data-sectionid=\"79\"  data-invmsg=\"Relaci\u00f3n: no es v\u00e1lido\"   \/> Esposa<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_89-79-1\">\t\t\t<label  for=\"field_oi01j-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[89][]\" id=\"field_oi01j-1\" value=\"Hijo\/a\"  data-sectionid=\"79\"  data-invmsg=\"Relaci\u00f3n: no es v\u00e1lido\"   \/> Hijo\/a<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_89-79-2\">\t\t\t<label  for=\"field_oi01j-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[89][]\" id=\"field_oi01j-2\" value=\"Compa\u00f1ero dom\u00e9stico\"  data-sectionid=\"79\"  data-invmsg=\"Relaci\u00f3n: no es v\u00e1lido\"   \/> Compa\u00f1ero dom\u00e9stico<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_90_container\" class=\"frm_form_field form-field  frm_top_container frm6 frm_first\">\r\n    <div  id=\"field_uhe31_label\" class=\"frm_primary_label\">3). Datos personales \r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_uhe31_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\t3). Datos personales \t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_90\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_90-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_uhe31_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tNombre\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_uhe31_first\" value=\"\" name=\"item_meta[90][first]\" data-sectionid=\"79\"  data-invmsg=\"3). Datos personales  no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_90_first_desc\">Nombre<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_90-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_uhe31_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tApellido\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_uhe31_last\" value=\"\" name=\"item_meta[90][last]\" data-sectionid=\"79\"  data-invmsg=\"3). Datos personales  no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_90_last_desc\">Apellido<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_91_container\" class=\"frm_form_field form-field  frm_top_container frm6\">\r\n    <label for=\"field_h3xuq\" id=\"field_h3xuq_label\" class=\"frm_primary_label\">Fecha de nacimiento\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_h3xuq\" name=\"item_meta[91]\" value=\"\"  data-sectionid=\"79\"  maxlength=\"10\" data-invmsg=\"Date is invalid\" class=\"frm_date\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_92_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first\">\r\n    <label for=\"field_95lp5\" id=\"field_95lp5_label\" class=\"frm_primary_label\">N\u00famero de Seguro Social\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/label>\r\n    <input  type=\"text\" id=\"field_95lp5\" name=\"item_meta[92]\" value=\"\"  data-sectionid=\"79\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_93_container\" class=\"frm_form_field form-field  frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_7t4gf_label\" class=\"frm_primary_label\">G\u00e9nero\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_7t4gf_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_93-79-0\">\t\t\t<label  for=\"field_7t4gf-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[93]\" id=\"field_7t4gf-0\" value=\"Hombre\"\n\t\t   data-sectionid=\"79\"  data-invmsg=\"G\u00e9nero no es v\u00e1lido\"  \/> Hombre<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_93-79-1\">\t\t\t<label  for=\"field_7t4gf-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[93]\" id=\"field_7t4gf-1\" value=\"Mujer\"\n\t\t   data-sectionid=\"79\"  data-invmsg=\"G\u00e9nero no es v\u00e1lido\"  \/> Mujer<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_94_container\" class=\"frm_form_field form-field  frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_40v89_label\" class=\"frm_primary_label\">Relaci\u00f3n:\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_40v89_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_94-79-0\">\t\t\t<label  for=\"field_40v89-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[94][]\" id=\"field_40v89-0\" value=\"Esposa\"  data-sectionid=\"79\"  data-invmsg=\"Relaci\u00f3n: no es v\u00e1lido\"   \/> Esposa<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_94-79-1\">\t\t\t<label  for=\"field_40v89-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[94][]\" id=\"field_40v89-1\" value=\"Hijo\/a\"  data-sectionid=\"79\"  data-invmsg=\"Relaci\u00f3n: no es v\u00e1lido\"   \/> Hijo\/a<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_94-79-2\">\t\t\t<label  for=\"field_40v89-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[94][]\" id=\"field_40v89-2\" value=\"Compa\u00f1ero dom\u00e9stico\"  data-sectionid=\"79\"  data-invmsg=\"Relaci\u00f3n: no es v\u00e1lido\"   \/> Compa\u00f1ero dom\u00e9stico<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<\/div>\n<div id=\"frm_field_96_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">D. REGISTRO EN LOS PLANES DE BENEFICIOS LIMITADOS (OBLIGATORIO)<\/h3>\r\n\r\n\r\n<div id=\"frm_field_97_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first vertical_radio\">\r\n    <div  id=\"field_txh6m_label\" class=\"frm_primary_label\">Usted DEBE seleccionar un nivel de cobertura antes de a\u00f1adir ning\u00fan beneficio. Su nivel de cobertura ser\u00e1 id\u00e9ntica para  cada beneficio. SELECCIONE NIVEL  DE COBERTURA\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_txh6m_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_97-96-0\">\t\t\t<label  for=\"field_txh6m-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[97][]\" id=\"field_txh6m-0\" value=\"S\u00f3lo empleado\"  data-sectionid=\"96\"  data-frmlimit=\"1\"  data-reqmsg=\"Usted DEBE seleccionar un nivel de cobertura antes de a\u00f1adir ning\u00fan beneficio. Su nivel de cobertura ser\u00e1 id\u00e9ntica para  cada beneficio. SELECCIONE NIVEL  DE COBERTURA cannot be blank.\" data-invmsg=\"Usted DEBE seleccionar un nivel de cobertura antes de a\u00f1adir ning\u00fan beneficio. Su nivel de cobertura ser\u00e1 id\u00e9ntica para  cada beneficio. SELECCIONE NIVEL  DE COBERTURA no es v\u00e1lido\"   aria-required=\"true\"  \/> S\u00f3lo empleado<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_97-96-1\">\t\t\t<label  for=\"field_txh6m-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[97][]\" id=\"field_txh6m-1\" value=\"Empleado + Hijo(s)\"  data-sectionid=\"96\"  data-frmlimit=\"1\"  data-reqmsg=\"Usted DEBE seleccionar un nivel de cobertura antes de a\u00f1adir ning\u00fan beneficio. Su nivel de cobertura ser\u00e1 id\u00e9ntica para  cada beneficio. SELECCIONE NIVEL  DE COBERTURA cannot be blank.\" data-invmsg=\"Usted DEBE seleccionar un nivel de cobertura antes de a\u00f1adir ning\u00fan beneficio. Su nivel de cobertura ser\u00e1 id\u00e9ntica para  cada beneficio. SELECCIONE NIVEL  DE COBERTURA no es v\u00e1lido\"   \/> Empleado + Hijo(s)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_97-96-2\">\t\t\t<label  for=\"field_txh6m-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[97][]\" id=\"field_txh6m-2\" value=\"Empleado + Esposa\/o\"  data-sectionid=\"96\"  data-frmlimit=\"1\"  data-reqmsg=\"Usted DEBE seleccionar un nivel de cobertura antes de a\u00f1adir ning\u00fan beneficio. Su nivel de cobertura ser\u00e1 id\u00e9ntica para  cada beneficio. SELECCIONE NIVEL  DE COBERTURA cannot be blank.\" data-invmsg=\"Usted DEBE seleccionar un nivel de cobertura antes de a\u00f1adir ning\u00fan beneficio. Su nivel de cobertura ser\u00e1 id\u00e9ntica para  cada beneficio. SELECCIONE NIVEL  DE COBERTURA no es v\u00e1lido\"   \/> Empleado + Esposa\/o<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_97-96-3\">\t\t\t<label  for=\"field_txh6m-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[97][]\" id=\"field_txh6m-3\" value=\"Empleado + Familia\"  data-sectionid=\"96\"  data-frmlimit=\"1\"  data-reqmsg=\"Usted DEBE seleccionar un nivel de cobertura antes de a\u00f1adir ning\u00fan beneficio. Su nivel de cobertura ser\u00e1 id\u00e9ntica para  cada beneficio. SELECCIONE NIVEL  DE COBERTURA cannot be blank.\" data-invmsg=\"Usted DEBE seleccionar un nivel de cobertura antes de a\u00f1adir ning\u00fan beneficio. Su nivel de cobertura ser\u00e1 id\u00e9ntica para  cada beneficio. SELECCIONE NIVEL  DE COBERTURA no es v\u00e1lido\"   \/> Empleado + Familia<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_97-96-4\">\t\t\t<label  for=\"field_txh6m-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[97][]\" id=\"field_txh6m-4\" value=\"NO a TODOS los bene\ufb01cios\"  data-sectionid=\"96\"  data-frmlimit=\"1\"  data-reqmsg=\"Usted DEBE seleccionar un nivel de cobertura antes de a\u00f1adir ning\u00fan beneficio. Su nivel de cobertura ser\u00e1 id\u00e9ntica para  cada beneficio. SELECCIONE NIVEL  DE COBERTURA cannot be blank.\" data-invmsg=\"Usted DEBE seleccionar un nivel de cobertura antes de a\u00f1adir ning\u00fan beneficio. Su nivel de cobertura ser\u00e1 id\u00e9ntica para  cada beneficio. SELECCIONE NIVEL  DE COBERTURA no es v\u00e1lido\"   \/> NO a TODOS los bene\ufb01cios<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_98_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 vertical_radio\">\r\n    <div  id=\"field_m32z6_label\" class=\"frm_primary_label\">PLAN M\u00c9DICO DE COMPENSACI\u00d3N FIJA\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_m32z6_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_98-96-0\">\t\t\t<label  for=\"field_m32z6-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[98][]\" id=\"field_m32z6-0\" value=\"S\u00ed\"  data-sectionid=\"96\"  data-frmlimit=\"1\"  data-reqmsg=\"PLAN M\u00c9DICO DE COMPENSACI\u00d3N FIJA cannot be blank.\" data-invmsg=\"PLAN M\u00c9DICO DE COMPENSACI\u00d3N FIJA no es v\u00e1lido\"   aria-required=\"true\"  \/> S\u00ed<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_98-96-1\">\t\t\t<label  for=\"field_m32z6-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[98][]\" id=\"field_m32z6-1\" value=\"No\"  data-sectionid=\"96\"  data-frmlimit=\"1\"  data-reqmsg=\"PLAN M\u00c9DICO DE COMPENSACI\u00d3N FIJA cannot be blank.\" data-invmsg=\"PLAN M\u00c9DICO DE COMPENSACI\u00d3N FIJA no es v\u00e1lido\"   \/> No<\/label><\/div>\n<\/div>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_m32z6\">Deducci\u00f3n semanal al cheque\u00a0de pago <br>\r\n$20.46  S\u00f3lo empleado <br>\r\n$26.65 Empleado + Hijo(s) <br> \r\n$28.90 Empleado + Esposa\/o <br>\r\n$34.80 Empleado + Familia.<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_99_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first vertical_radio\">\r\n    <div  id=\"field_us4xr_label\" class=\"frm_primary_label\">PLAN DENTAL\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_us4xr_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_99-96-0\">\t\t\t<label  for=\"field_us4xr-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[99][]\" id=\"field_us4xr-0\" value=\"S\u00ed\"  data-sectionid=\"96\"  data-frmlimit=\"1\"  data-reqmsg=\"PLAN DENTAL cannot be blank.\" data-invmsg=\"PLAN DENTAL no es v\u00e1lido\"   aria-required=\"true\"  \/> S\u00ed<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_99-96-1\">\t\t\t<label  for=\"field_us4xr-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[99][]\" id=\"field_us4xr-1\" value=\"No\"  data-sectionid=\"96\"  data-frmlimit=\"1\"  data-reqmsg=\"PLAN DENTAL cannot be blank.\" data-invmsg=\"PLAN DENTAL no es v\u00e1lido\"   \/> No<\/label><\/div>\n<\/div>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_us4xr\">Pagos semanal <br>\r\n$5.40 S\u00f3lo empleado <br>\r\n$14.58 Empleado + Hijo(s) <br>\r\n$10.80 Empleado + Esposa\/o <br>\r\n$20.52 Empleado + Familia.<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_100_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 vertical_radio\">\r\n    <div  id=\"field_cg77_label\" class=\"frm_primary_label\">ACCIDENTE\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_cg77_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_100-96-0\">\t\t\t<label  for=\"field_cg77-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[100][]\" id=\"field_cg77-0\" value=\"S\u00ed\"  data-sectionid=\"96\"  data-frmlimit=\"1\"  data-reqmsg=\"ACCIDENTE cannot be blank.\" data-invmsg=\"ACCIDENTE no es v\u00e1lido\"   aria-required=\"true\"  \/> S\u00ed<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_100-96-1\">\t\t\t<label  for=\"field_cg77-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[100][]\" id=\"field_cg77-1\" value=\"No\"  data-sectionid=\"96\"  data-frmlimit=\"1\"  data-reqmsg=\"ACCIDENTE cannot be blank.\" data-invmsg=\"ACCIDENTE no es v\u00e1lido\"   \/> No<\/label><\/div>\n<\/div>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_cg77\">Pagos semanal <br>\r\n$2.80 S\u00f3lo empleado <br>\r\n$6.74 Empleado + Hijo(s) <br>\r\n$4.42 Empleado + Esposa\/o <br>\r\n$10.02 Empleado + Familia.<\/div>\r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_102_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing frm_trigger\" tabindex=\"0\" role=\"button\">E. INFORMACI\u00d3N DEL BENEFICIARIO <svg  viewBox=\"0 0 20 20\" width=\"1em\" height=\"1em\" aria-expanded=\"false\" aria-label=\"Campos conmutadores\" class=\"frmsvg frm-svg-icon\">\n\t<path d=\"M5 6l5 5 5-5 2 1-7 7-7-7 2-1z\"><\/path>\n\n<\/svg><svg  viewBox=\"0 0 20 20\" width=\"1em\" height=\"1em\" aria-expanded=\"false\" aria-label=\"Campos conmutadores\" class=\"frmsvg frm-svg-icon\">\n\t<title>arrowup6<\/title>\n\t<path style=\"transform:rotate(180deg); transform-origin:center;\" d=\"M5 6l5 5 5-5 2 1-7 7-7-7 2-1z\"><\/path>\n<\/svg><\/h3>\r\n\r\n<div class=\"frm_toggle_container frm_grid_container\" style=\"display:none;\">\r\n<div id=\"frm_field_103_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <div  id=\"field_dyybc_label\" class=\"frm_primary_label\">Si seleccion\u00f3 el Accidente, escriba la informaci\u00f3n del  beneficiario del Accidente\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_dyybc_label\">\n\t<legend class=\"frm_screen_reader frm_hidden\">\n\t\tSi seleccion\u00f3 el Accidente, escriba la informaci\u00f3n del  beneficiario del Accidente\t<\/legend>\n\n\t<div  class=\"frm_combo_inputs_container\" id=\"frm_combo_inputs_container_103\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_103-first_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-first  frm6\"\n\t\t\t\tdata-sub-field-name=\"first\"\n\t\t\t>\n\t\t\t\t<label for=\"field_dyybc_first\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tNombre\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_dyybc_first\" value=\"\" name=\"item_meta[103][first]\" data-sectionid=\"102\"  data-invmsg=\"Si seleccion\u00f3 el Accidente, escriba la informaci\u00f3n del  beneficiario del Accidente no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_103_first_desc\">Nombre<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_103-last_container\"\n\t\t\t\tclass=\"frm_form_field form-field frm_form_subfield-last  frm6\"\n\t\t\t\tdata-sub-field-name=\"last\"\n\t\t\t>\n\t\t\t\t<label for=\"field_dyybc_last\" class=\"frm_screen_reader frm_hidden\">\n\t\t\t\t\tRelaci\u00f3n\t\t\t\t<\/label>\n\n\t\t\t\t<input  type=\"text\" id=\"field_dyybc_last\" value=\"\" name=\"item_meta[103][last]\" data-sectionid=\"102\"  data-invmsg=\"Si seleccion\u00f3 el Accidente, escriba la informaci\u00f3n del  beneficiario del Accidente no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_103_last_desc\">Relaci\u00f3n<\/div>\t\t\t<\/div>\n\t\t\t\t<\/div>\n<\/fieldset>\n\r\n    \r\n    \r\n<\/div>\n<\/div>\n<\/div>\n<div id=\"frm_field_105_container\" class=\"frm_form_field frm_section_heading form-field \">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">F. REGISTRO EN BENEFICIO DE MEC WELLNESS\/PREVENTIVE<\/h3>\r\n\r\n\r\n<div id=\"frm_field_106_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div  id=\"field_g4hvc_label\" class=\"frm_primary_label\">PLAN MEC Deducci\u00f3n semanal  al cheque de pago  83123700-M-BSP\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/div>\r\n    <div class=\"frm_opt_container\" aria-labelledby=\"field_g4hvc_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_106-105-0\">\t\t\t<label  for=\"field_g4hvc-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[106][]\" id=\"field_g4hvc-0\" value=\"$14.29 S\u00f3lo empleado\"  data-sectionid=\"105\"  data-reqmsg=\"PLAN MEC Deducci\u00f3n semanal  al cheque de pago  83123700-M-BSP cannot be blank.\" data-invmsg=\"PLAN MEC Deducci\u00f3n semanal  al cheque de pago  83123700-M-BSP no es v\u00e1lido\"   aria-required=\"true\"  \/> $14.29 S\u00f3lo empleado<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_106-105-1\">\t\t\t<label  for=\"field_g4hvc-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[106][]\" id=\"field_g4hvc-1\" value=\"$20.32 Empleado + Hijo(s)\"  data-sectionid=\"105\"  data-reqmsg=\"PLAN MEC Deducci\u00f3n semanal  al cheque de pago  83123700-M-BSP cannot be blank.\" data-invmsg=\"PLAN MEC Deducci\u00f3n semanal  al cheque de pago  83123700-M-BSP no es v\u00e1lido\"   \/> $20.32 Empleado + Hijo(s)<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_106-105-2\">\t\t\t<label  for=\"field_g4hvc-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[106][]\" id=\"field_g4hvc-2\" value=\"$18.99 Empleado + Esposa\/o\"  data-sectionid=\"105\"  data-reqmsg=\"PLAN MEC Deducci\u00f3n semanal  al cheque de pago  83123700-M-BSP cannot be blank.\" data-invmsg=\"PLAN MEC Deducci\u00f3n semanal  al cheque de pago  83123700-M-BSP no es v\u00e1lido\"   \/> $18.99 Empleado + Esposa\/o<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_106-105-3\">\t\t\t<label  for=\"field_g4hvc-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[106][]\" id=\"field_g4hvc-3\" value=\"$25.02 Empleado + Familia\"  data-sectionid=\"105\"  data-reqmsg=\"PLAN MEC Deducci\u00f3n semanal  al cheque de pago  83123700-M-BSP cannot be blank.\" data-invmsg=\"PLAN MEC Deducci\u00f3n semanal  al cheque de pago  83123700-M-BSP no es v\u00e1lido\"   \/> $25.02 Empleado + Familia<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_106-105-4\">\t\t\t<label  for=\"field_g4hvc-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[106][]\" id=\"field_g4hvc-4\" value=\"NO al Plan MEC\"  data-sectionid=\"105\"  data-reqmsg=\"PLAN MEC Deducci\u00f3n semanal  al cheque de pago  83123700-M-BSP cannot be blank.\" data-invmsg=\"PLAN MEC Deducci\u00f3n semanal  al cheque de pago  83123700-M-BSP no es v\u00e1lido\"   \/> NO al Plan MEC<\/label><\/div>\n<\/div>\r\n    \r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_108_container\" class=\"frm_form_field frm_section_heading form-field  frm12 frm_first\">\r\n<h3 class=\"frm_pos_top frm_section_spacing\">G. FIRMA REQUERIDA<\/h3>\r\n\r\n\r\n<div id=\"frm_field_109_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first\">\r\n    <label for=\"field_97jt6\" id=\"field_97jt6_label\" class=\"frm_primary_label\">DEBE FIRMAR Y PONER LA FECHA AUNQUE DECLINE LA COBERTURA\r\n        <span class=\"frm_required\" aria-hidden=\"true\">*<\/span>\r\n    <\/label>\r\n    <div class=\"sigPad\" id='sigPad109' style=\"max-width:400px;\">\n\t<div class=\"sig sigWrapper\" style=\"height:150px;border-color:#BFC3C8;--bg-color:#ffffff;--active:#579AF6;--inactive:#eaeaea;--active-text:#ffffff;--inactive-text:#3f4b5b;--button-margin:22px;--button-size:20px;--button-padding:10px;--button-side-margin:22px;--icon:20px\">\n\n\t\t<ul class=\"sigNav\">\n\t\t\t\t<li class=\"drawIt\"><a href=\"#\" class=\"frm-active-sig-type\" title=\"Draw It\" aria-label=\"Draw It\"><i class=\"frm_icon_font frm_signature_icon\" aria-hidden><\/i><\/a><\/li>\n\t\t\t\t<li class=\"typeIt\"><a href=\"#\" class=\"\" title=\"Type It\" aria-label=\"Type It\"><i class=\"frm_icon_font frm_keyboard_icon\" aria-hidden><\/i><\/a><\/li>\n\t\t<\/ul>\n\n\t\t<span class=\"frm-typed-drawline\"><\/span>\n\n\t\t<div class=\"typed\">\n\t\t\t<input type=\"text\" name=\"item_meta[109][typed]\" class=\"name\" id=\"field_97jt6\" autocomplete=\"off\" value=\"\"  data-sectionid=\"108\"  style=\"width:400px\" maxlength=\"150\" data-reqmsg=\"DEBE FIRMAR Y PONER LA FECHA AUNQUE DECLINE LA COBERTURA cannot be blank.\" aria-required=\"true\" class=\"auto_width\" aria-invalid=\"false\"   \/>\n\t\t<\/div>\n\n\t\t<canvas class=\"pad\" data-fieldid=\"109\" data-fieldname=\"item_meta[109]\" width=\"396\" height=\"150\"><\/canvas>\n\t\t<div class=\"clearButton\"><a href=\"#clear\">Clear<\/a><\/div>\n\n\t\t<input type=\"hidden\" name=\"item_meta[109][output]\" class=\"output\" value=\"\" \/>\n\t<\/div>\n<\/div>\n\r\n    <div class=\"frm_description\" id=\"frm_desc_field_97jt6\">Al firmar, confirmo que le\u00ed el Resumen de beneficios y las Limitaciones y exclusiones de los planes de beneficios \r\nrecomendados; que me ofrecieron una cobertura que cumple la ley ACA (MEC Wellness\/Preventive) con fondos propios y que \r\nel per\u00edodo de registro est\u00e1 disponible por un tiempo limitado. Tambi\u00e9n entiendo que no hacer una selecci\u00f3n de benefi cios es \r\nrechazar la cobertura y que la cobertura de benefi cios s\u00f3lo est\u00e1 disponible para empleados mayores de 18 a\u00f1os con un N\u00famero \r\nde Seguro Social (SSN) v\u00e1lido.<\/div>\r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_509_container\" class=\"frm_form_field form-field \">\n\t<div class=\"frm_submit\">\r\n\r\n<button class=\"frm_button_submit frm_final_submit\" type=\"submit\"  >ENVIAR <\/button>\r\n\r\n\r\n<\/div>\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_609_container\">\n\t\t\t<label for=\"field_kpqr0\" >\n\t\t\t\tSi eres humano, deja este campo en blanco.\t\t\t<\/label>\n\t\t\t<input  id=\"field_kpqr0\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[609]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"GwgXazH29cO0EZ0puQ69WlporPJScM0dr4D8C4Ske15QLr9mWkD8b8e9GnRwCiK6\" \/><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<div class=\"elementor-element elementor-element-7663161 exad-sticky-section-no exad-glass-effect-no elementor-widget elementor-widget-text-editor\" data-id=\"7663161\" data-element_type=\"widget\" data-e-type=\"widget\" data-settings=\"{&quot;ekit_we_effect_on&quot;:&quot;none&quot;}\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<div class=\"meSK8 M7eMe\" style=\"font-family: docs-Roboto, Helvetica, Arial, sans-serif; font-size: medium; line-height: 24px; color: #202124; white-space-collapse: collapse;\" role=\"heading\" aria-level=\"2\">\n<blockquote>\n<p><span style=\"font-size: revert; color: #202124; font-family: Roboto, Arial, sans-serif;\">\u2705 Al enviar este formulario, confirmas tu acuerdo con nuestras pr\u00e1cticas de tratamiento de datos personales.<\/span><\/p>\n<p style=\"margin-right: 0px; margin-left: 0px;\"><b><i>T<\/i><\/b><b><i>ratamiento de Datos Personales: <\/i><\/b><span style=\"font-family: Roboto, Arial, sans-serif; font-size: 11pt;\">Tu privacidad es importante para nosotros. Al completar este formulario y proporcionar tus datos, est\u00e1s aceptando que tratemos tus datos de acuerdo con nuestra <\/span><a style=\"color: #1155cc;\" href=\"https:\/\/quantum-staffing.com\/privacy-policy\/\">Pol\u00edtica de Privacidad<\/a><span style=\"font-family: Roboto, Arial, sans-serif; font-size: 11pt;\">. Los datos recopilados se utilizar\u00e1n solo para fines relacionados con el cumplimiento de obligaciones legales. Para m\u00e1s detalles, consulta nuestra pol\u00edtica completa en el enlace proporcionado. Si tienes preguntas, cont\u00e1ctanos a trav\u00e9s de <\/span><a style=\"color: #1155cc;\" href=\"mailto:contact@quantum-staffing.com\">contact@quantum-staffing.com<\/a><span style=\"font-family: Roboto, Arial, sans-serif; font-size: 11pt;\">.<\/span><\/p>\n<\/blockquote>\n<\/div>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Gu\u00eda de Inscripci\u00f3n al Plan de Seguro M\u00e9dico de Indemnizaci\u00f3n Fija, Productos Auxiliares y Cobertura Esencial M\u00ednima Autofi nanciada (MEC) IMPORTANTE INFORMACI\u00d3N SOBRE EL PLAN:\u00a0Usted tiene dos opciones de planes m\u00e9dicos.Puede registrarse en uno o en los dos. Hay m\u00e1s bene\ufb01 cios disponibles si se registra en el Plan deseguro m\u00e9dico de indemnizaci\u00f3n \ufb01 ja&#8230;<\/p>","protected":false},"author":21,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"inline_featured_image":false,"_kad_blocks_custom_css":"","_kad_blocks_head_custom_js":"","_kad_blocks_body_custom_js":"","_kad_blocks_footer_custom_js":"","_kad_post_transparent":"","_kad_post_title":"","_kad_post_layout":"","_kad_post_sidebar_id":"","_kad_post_content_style":"","_kad_post_vertical_padding":"","_kad_post_feature":"","_kad_post_feature_position":"","_kad_post_header":false,"_kad_post_footer":false,"footnotes":""},"class_list":["post-1036","page","type-page","status-publish","hentry"],"featured_image_src_large":false,"author_info":{"display_name":"Jose Pertuz","author_link":"https:\/\/quantum-staffing.com\/es\/author\/jose-pertuz\/"},"comment_info":0,"taxonomy_info":[],"_links":{"self":[{"href":"https:\/\/quantum-staffing.com\/es\/wp-json\/wp\/v2\/pages\/1036","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/quantum-staffing.com\/es\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/quantum-staffing.com\/es\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/quantum-staffing.com\/es\/wp-json\/wp\/v2\/users\/21"}],"replies":[{"embeddable":true,"href":"https:\/\/quantum-staffing.com\/es\/wp-json\/wp\/v2\/comments?post=1036"}],"version-history":[{"count":27,"href":"https:\/\/quantum-staffing.com\/es\/wp-json\/wp\/v2\/pages\/1036\/revisions"}],"predecessor-version":[{"id":13888,"href":"https:\/\/quantum-staffing.com\/es\/wp-json\/wp\/v2\/pages\/1036\/revisions\/13888"}],"wp:attachment":[{"href":"https:\/\/quantum-staffing.com\/es\/wp-json\/wp\/v2\/media?parent=1036"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}