{"id":1153,"date":"2023-10-03T15:44:02","date_gmt":"2023-10-03T19:44:02","guid":{"rendered":"https:\/\/quantum-staffing.com\/?page_id=1153"},"modified":"2023-10-03T15:44:39","modified_gmt":"2023-10-03T19:44:39","slug":"formulario-de-eleccion-de-beneficios-2","status":"publish","type":"page","link":"https:\/\/quantum-staffing.com\/es\/formulario-de-eleccion-de-beneficios-2\/","title":{"rendered":"FORMULARIO DE ELECCI\u00d3N DE BENEFICIOS"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"1153\" class=\"elementor elementor-1153\" 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\">\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-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\">\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-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\/09\/BSP-EF-4EUSNADW-SP-FORMULARIO-DE-BENEFICIOS.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<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\">\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-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-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_15_container\" data-token=\"78a2d716db4ce1f7066d8bcd91068e33\">\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form  frm_pro_form\" id=\"form_formulariodeeleccindebeneficios2\" data-token=\"78a2d716db4ce1f7066d8bcd91068e33\" action=\"\">\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=\"15\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_15\" id=\"frm_hide_fields_15\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"formulariodeeleccindebeneficios2\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_15\" name=\"frm_submit_entry_15\" value=\"c220548d1d\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/es\/wp-json\/wp\/v2\/pages\/1153\" \/><div id=\"frm_field_194_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_195_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <div  id=\"field_6ywe92_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_6ywe92_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_195\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_195-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_6ywe92_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_6ywe92_first\" value=\"\" name=\"item_meta[195][first]\" data-sectionid=\"194\"  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_195_first_desc\">Nombre<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_195-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_6ywe92_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_6ywe92_last\" value=\"\" name=\"item_meta[195][last]\" data-sectionid=\"194\"  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_195_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_196_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first\">\r\n    <label for=\"field_m94se2\" id=\"field_m94se2_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_m94se2\" name=\"item_meta[196]\" value=\"\"  data-sectionid=\"194\"  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_197_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6\">\r\n    <label for=\"field_zmqlo2\" id=\"field_zmqlo2_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_zmqlo2\" name=\"item_meta[197]\" value=\"\"  data-sectionid=\"194\"  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_198_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm6 frm_first\">\r\n    <label for=\"field_re83v2\" id=\"field_re83v2_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_re83v2\" name=\"item_meta[198]\" value=\"--,--,---\"  data-sectionid=\"194\"  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_199_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 vertical_radio\">\r\n    <div  id=\"field_ptwyx2_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_ptwyx2_label\" role=\"radiogroup\" aria-required=\"true\">\t\t<div class=\"frm_radio\" id=\"frm_radio_199-194-0\">\t\t\t<label  for=\"field_ptwyx2-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[199]\" id=\"field_ptwyx2-0\" value=\"Hombre\"\n\t\t   data-sectionid=\"194\"  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_199-194-1\">\t\t\t<label  for=\"field_ptwyx2-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[199]\" id=\"field_ptwyx2-1\" value=\"Mujer\"\n\t\t   data-sectionid=\"194\"  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_200_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <div  id=\"field_15mju2_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_15mju2_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_200-line1_container\" class=\"frm_form_field form-field\">\n\t<label for=\"field_15mju2_line1\" class=\"frm_screen_reader frm_hidden\">\n\t\tDirecci\u00f3n\t<\/label>\n\t\t<input type=\"text\" id=\"field_15mju2_line1\" value=\"\" name=\"item_meta[200][line1]\"  data-sectionid=\"194\"  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_200-line2_container\" class=\"frm_form_field form-field\">\n\t<label for=\"field_15mju2_line2\" class=\"frm_screen_reader frm_hidden\">\n\t\tDirecci\u00f3n\t<\/label>\n\t\t<input type=\"text\" id=\"field_15mju2_line2\" value=\"\" name=\"item_meta[200][line2]\"  data-sectionid=\"194\"  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_200-city_container\" class=\"frm_form_field form-field frm_third frm_first\">\n\t<label for=\"field_15mju2_city\" class=\"frm_screen_reader frm_hidden\">\n\t\tCiudad\t<\/label>\n\t\t<input type=\"text\" id=\"field_15mju2_city\" value=\"\" name=\"item_meta[200][city]\"  data-sectionid=\"194\"  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_200-state_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_15mju2_state\" class=\"frm_screen_reader frm_hidden\">\n\t\tEstado\t<\/label>\n\t\t\t<select name=\"item_meta[200][state]\" id=\"field_15mju2_state\"  data-sectionid=\"194\"  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_200-zip_container\" class=\"frm_form_field form-field frm_third\">\n\t<label for=\"field_15mju2_zip\" class=\"frm_screen_reader frm_hidden\">\n\t\tZip\/C\u00f3digo Postal\t<\/label>\n\t\t<input type=\"text\" id=\"field_15mju2_zip\" value=\"\" name=\"item_meta[200][zip]\"  data-sectionid=\"194\"  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_202_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_203_container\" class=\"frm_form_field form-field  frm_top_container vertical_radio\">\r\n    <div  id=\"field_8ad2x2_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_8ad2x2_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_203-202-0\">\t\t\t<label  for=\"field_8ad2x2-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[203]\" id=\"field_8ad2x2-0\" value=\"Si\"\n\t\t   data-sectionid=\"202\"  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_203-202-1\">\t\t\t<label  for=\"field_8ad2x2-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[203]\" id=\"field_8ad2x2-1\" value=\"No\"\n\t\t   data-sectionid=\"202\"  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_8ad2x2\"> Si dijo \"S\u00ed\", llene el resto de esta secci\u00f3n.<\/div>\r\n    \r\n<\/div>\n<\/div>\n<div id=\"frm_field_205_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_206_container\" class=\"frm_form_field form-field  frm_top_container frm6  frm12 frm_first\">\r\n    <label for=\"field_4oo2j2\" id=\"field_4oo2j2_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_4oo2j2\" name=\"item_meta[206]\" value=\"\"  data-sectionid=\"205\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_4oo2j2\" \/>\r\n    <div class=\"frm_description\" id=\"frm_desc_field_4oo2j2\">Nombres de las personas cubiertas: <\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_207_container\" class=\"frm_form_field form-field  frm_top_container frm6\">\r\n    <label for=\"field_sll0q2\" id=\"field_sll0q2_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_sll0q2\" name=\"item_meta[207]\" value=\"\"  data-sectionid=\"205\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_208_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first\">\r\n    <div  id=\"field_a7xsk2_label\" class=\"frm_primary_label\">\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_a7xsk2_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_208\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_208-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_a7xsk2_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_a7xsk2_first\" value=\"\" name=\"item_meta[208][first]\" data-sectionid=\"205\"  data-invmsg=\"Este campo no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_208_first_desc\">Nombre<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_208-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_a7xsk2_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_a7xsk2_last\" value=\"\" name=\"item_meta[208][last]\" data-sectionid=\"205\"  data-invmsg=\"Este campo no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_208_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_209_container\" class=\"frm_form_field form-field  frm_top_container frm4\">\r\n    <div  id=\"field_ufvjl2_label\" class=\"frm_primary_label\">\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_ufvjl2_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_209\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_209-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_ufvjl2_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_ufvjl2_first\" value=\"\" name=\"item_meta[209][first]\" data-sectionid=\"205\"  data-invmsg=\"Este campo no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_209_first_desc\">Nombre<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_209-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_ufvjl2_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_ufvjl2_last\" value=\"\" name=\"item_meta[209][last]\" data-sectionid=\"205\"  data-invmsg=\"Este campo no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_209_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_210_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm12\">\r\n    <div  id=\"field_ulsxp2_label\" class=\"frm_primary_label\">\r\n        <span class=\"frm_required\" aria-hidden=\"true\"><\/span>\r\n    <\/div>\r\n    <fieldset aria-labelledby=\"field_ulsxp2_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_210\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_210-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_ulsxp2_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_ulsxp2_first\" value=\"\" name=\"item_meta[210][first]\" data-sectionid=\"205\"  data-invmsg=\"Este campo no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_210_first_desc\">Nombre<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_210-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_ulsxp2_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_ulsxp2_last\" value=\"\" name=\"item_meta[210][last]\" data-sectionid=\"205\"  data-invmsg=\"Este campo no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_210_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_212_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_213_container\" class=\"frm_form_field form-field  frm_top_container frm6 frm_first\">\r\n    <div  id=\"field_p0oad2_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_p0oad2_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_213\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_213-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_p0oad2_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_p0oad2_first\" value=\"\" name=\"item_meta[213][first]\" data-sectionid=\"212\"  data-invmsg=\"1). Datos personales  no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_213_first_desc\">Nombre<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_213-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_p0oad2_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_p0oad2_last\" value=\"\" name=\"item_meta[213][last]\" data-sectionid=\"212\"  data-invmsg=\"1). Datos personales  no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_213_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_214_container\" class=\"frm_form_field form-field  frm_top_container frm6\">\r\n    <label for=\"field_yogvo2\" id=\"field_yogvo2_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_yogvo2\" name=\"item_meta[214]\" value=\"\"  data-sectionid=\"212\"  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_215_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first\">\r\n    <label for=\"field_81ht32\" id=\"field_81ht32_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_81ht32\" name=\"item_meta[215]\" value=\"\"  data-sectionid=\"212\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_216_container\" class=\"frm_form_field form-field  frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_u96oq2_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_u96oq2_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_216-212-0\">\t\t\t<label  for=\"field_u96oq2-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[216]\" id=\"field_u96oq2-0\" value=\"Hombre\"\n\t\t   data-sectionid=\"212\"  data-invmsg=\"G\u00e9nero no es v\u00e1lido\"  \/> Hombre<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_216-212-1\">\t\t\t<label  for=\"field_u96oq2-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[216]\" id=\"field_u96oq2-1\" value=\"Mujer\"\n\t\t   data-sectionid=\"212\"  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_217_container\" class=\"frm_form_field form-field  frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_xiawl2_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_xiawl2_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_217-212-0\">\t\t\t<label  for=\"field_xiawl2-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[217][]\" id=\"field_xiawl2-0\" value=\"Esposa\"  data-sectionid=\"212\"  data-invmsg=\"Relaci\u00f3n: no es v\u00e1lido\"   \/> Esposa<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_217-212-1\">\t\t\t<label  for=\"field_xiawl2-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[217][]\" id=\"field_xiawl2-1\" value=\"Hijo\/a\"  data-sectionid=\"212\"  data-invmsg=\"Relaci\u00f3n: no es v\u00e1lido\"   \/> Hijo\/a<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_217-212-2\">\t\t\t<label  for=\"field_xiawl2-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[217][]\" id=\"field_xiawl2-2\" value=\"Compa\u00f1ero dom\u00e9stico\"  data-sectionid=\"212\"  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_218_container\" class=\"frm_form_field form-field  frm_top_container frm6 frm_first\">\r\n    <div  id=\"field_r5c682_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_r5c682_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_218\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_218-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_r5c682_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_r5c682_first\" value=\"\" name=\"item_meta[218][first]\" data-sectionid=\"212\"  data-invmsg=\"2). Datos personales  no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_218_first_desc\">Nombre<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_218-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_r5c682_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_r5c682_last\" value=\"\" name=\"item_meta[218][last]\" data-sectionid=\"212\"  data-invmsg=\"2). Datos personales  no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_218_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_219_container\" class=\"frm_form_field form-field  frm_top_container frm6\">\r\n    <label for=\"field_xkt2k2\" id=\"field_xkt2k2_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_xkt2k2\" name=\"item_meta[219]\" value=\"\"  data-sectionid=\"212\"  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_220_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first\">\r\n    <label for=\"field_1o5em2\" id=\"field_1o5em2_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_1o5em2\" name=\"item_meta[220]\" value=\"\"  data-sectionid=\"212\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_221_container\" class=\"frm_form_field form-field  frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_aqdtf2_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_aqdtf2_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_221-212-0\">\t\t\t<label  for=\"field_aqdtf2-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[221]\" id=\"field_aqdtf2-0\" value=\"Hombre\"\n\t\t   data-sectionid=\"212\"  data-invmsg=\"G\u00e9nero no es v\u00e1lido\"  \/> Hombre<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_221-212-1\">\t\t\t<label  for=\"field_aqdtf2-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[221]\" id=\"field_aqdtf2-1\" value=\"Mujer\"\n\t\t   data-sectionid=\"212\"  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_222_container\" class=\"frm_form_field form-field  frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_oi01j2_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_oi01j2_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_222-212-0\">\t\t\t<label  for=\"field_oi01j2-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[222][]\" id=\"field_oi01j2-0\" value=\"Esposa\"  data-sectionid=\"212\"  data-invmsg=\"Relaci\u00f3n: no es v\u00e1lido\"   \/> Esposa<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_222-212-1\">\t\t\t<label  for=\"field_oi01j2-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[222][]\" id=\"field_oi01j2-1\" value=\"Hijo\/a\"  data-sectionid=\"212\"  data-invmsg=\"Relaci\u00f3n: no es v\u00e1lido\"   \/> Hijo\/a<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_222-212-2\">\t\t\t<label  for=\"field_oi01j2-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[222][]\" id=\"field_oi01j2-2\" value=\"Compa\u00f1ero dom\u00e9stico\"  data-sectionid=\"212\"  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_223_container\" class=\"frm_form_field form-field  frm_top_container frm6 frm_first\">\r\n    <div  id=\"field_uhe312_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_uhe312_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_223\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_223-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_uhe312_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_uhe312_first\" value=\"\" name=\"item_meta[223][first]\" data-sectionid=\"212\"  data-invmsg=\"3). Datos personales  no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_223_first_desc\">Nombre<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_223-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_uhe312_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_uhe312_last\" value=\"\" name=\"item_meta[223][last]\" data-sectionid=\"212\"  data-invmsg=\"3). Datos personales  no es v\u00e1lido\" aria-invalid=\"false\"  \/><div class=\"frm_description\" id=\"frm_field_223_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_224_container\" class=\"frm_form_field form-field  frm_top_container frm6\">\r\n    <label for=\"field_h3xuq2\" id=\"field_h3xuq2_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_h3xuq2\" name=\"item_meta[224]\" value=\"\"  data-sectionid=\"212\"  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_225_container\" class=\"frm_form_field form-field  frm_top_container frm4 frm_first\">\r\n    <label for=\"field_95lp52\" id=\"field_95lp52_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_95lp52\" name=\"item_meta[225]\" value=\"\"  data-sectionid=\"212\"  data-invmsg=\"Text is invalid\" aria-invalid=\"false\"   \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_226_container\" class=\"frm_form_field form-field  frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_7t4gf2_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_7t4gf2_label\" role=\"radiogroup\">\t\t<div class=\"frm_radio\" id=\"frm_radio_226-212-0\">\t\t\t<label  for=\"field_7t4gf2-0\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[226]\" id=\"field_7t4gf2-0\" value=\"Hombre\"\n\t\t   data-sectionid=\"212\"  data-invmsg=\"G\u00e9nero no es v\u00e1lido\"  \/> Hombre<\/label><\/div>\n\t\t<div class=\"frm_radio\" id=\"frm_radio_226-212-1\">\t\t\t<label  for=\"field_7t4gf2-1\">\n\t\t\t\t\t<input type=\"radio\" name=\"item_meta[226]\" id=\"field_7t4gf2-1\" value=\"Mujer\"\n\t\t   data-sectionid=\"212\"  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_227_container\" class=\"frm_form_field form-field  frm_top_container frm4 vertical_radio\">\r\n    <div  id=\"field_40v892_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_40v892_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_227-212-0\">\t\t\t<label  for=\"field_40v892-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[227][]\" id=\"field_40v892-0\" value=\"Esposa\"  data-sectionid=\"212\"  data-invmsg=\"Relaci\u00f3n: no es v\u00e1lido\"   \/> Esposa<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_227-212-1\">\t\t\t<label  for=\"field_40v892-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[227][]\" id=\"field_40v892-1\" value=\"Hijo\/a\"  data-sectionid=\"212\"  data-invmsg=\"Relaci\u00f3n: no es v\u00e1lido\"   \/> Hijo\/a<\/label><\/div>\n\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_227-212-2\">\t\t\t<label  for=\"field_40v892-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[227][]\" id=\"field_40v892-2\" value=\"Compa\u00f1ero dom\u00e9stico\"  data-sectionid=\"212\"  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_229_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_230_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first vertical_radio\">\r\n    <div  id=\"field_txh6m2_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_txh6m2_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_230-229-0\">\t\t\t<label  for=\"field_txh6m2-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[230][]\" id=\"field_txh6m2-0\" value=\"S\u00f3lo empleado\"  data-sectionid=\"229\"  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_230-229-1\">\t\t\t<label  for=\"field_txh6m2-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[230][]\" id=\"field_txh6m2-1\" value=\"Empleado + Hijo(s)\"  data-sectionid=\"229\"  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_230-229-2\">\t\t\t<label  for=\"field_txh6m2-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[230][]\" id=\"field_txh6m2-2\" value=\"Empleado + Esposa\/o\"  data-sectionid=\"229\"  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_230-229-3\">\t\t\t<label  for=\"field_txh6m2-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[230][]\" id=\"field_txh6m2-3\" value=\"Empleado + Familia\"  data-sectionid=\"229\"  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_230-229-4\">\t\t\t<label  for=\"field_txh6m2-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[230][]\" id=\"field_txh6m2-4\" value=\"NO a TODOS los bene\ufb01cios\"  data-sectionid=\"229\"  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_231_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 vertical_radio\">\r\n    <div  id=\"field_m32z62_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_m32z62_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_231-229-0\">\t\t\t<label  for=\"field_m32z62-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[231][]\" id=\"field_m32z62-0\" value=\"S\u00ed\"  data-sectionid=\"229\"  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_231-229-1\">\t\t\t<label  for=\"field_m32z62-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[231][]\" id=\"field_m32z62-1\" value=\"No\"  data-sectionid=\"229\"  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_m32z62\">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_232_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 frm_first vertical_radio\">\r\n    <div  id=\"field_us4xr2_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_us4xr2_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_232-229-0\">\t\t\t<label  for=\"field_us4xr2-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[232][]\" id=\"field_us4xr2-0\" value=\"S\u00ed\"  data-sectionid=\"229\"  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_232-229-1\">\t\t\t<label  for=\"field_us4xr2-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[232][]\" id=\"field_us4xr2-1\" value=\"No\"  data-sectionid=\"229\"  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_us4xr2\">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_233_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm6 vertical_radio\">\r\n    <div  id=\"field_cg772_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_cg772_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_233-229-0\">\t\t\t<label  for=\"field_cg772-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[233][]\" id=\"field_cg772-0\" value=\"S\u00ed\"  data-sectionid=\"229\"  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_233-229-1\">\t\t\t<label  for=\"field_cg772-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[233][]\" id=\"field_cg772-1\" value=\"No\"  data-sectionid=\"229\"  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_cg772\">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_235_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_236_container\" class=\"frm_form_field form-field  frm_top_container\">\r\n    <div  id=\"field_dyybc2_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_dyybc2_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_236\" data-name-layout=\"first_last\">\n\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_236-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_dyybc2_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_dyybc2_first\" value=\"\" name=\"item_meta[236][first]\" data-sectionid=\"235\"  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_236_first_desc\">Nombre<\/div>\t\t\t<\/div>\n\t\t\t\t\t\t<div\n\t\t\t\tid=\"frm_field_236-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_dyybc2_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_dyybc2_last\" value=\"\" name=\"item_meta[236][last]\" data-sectionid=\"235\"  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_236_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_238_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_239_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container vertical_radio\">\r\n    <div  id=\"field_g4hvc2_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_g4hvc2_label\" role=\"group\">\t\t<div class=\"frm_checkbox\" id=\"frm_checkbox_239-238-0\">\t\t\t<label  for=\"field_g4hvc2-0\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[239][]\" id=\"field_g4hvc2-0\" value=\"$14.29 S\u00f3lo empleado\"  data-sectionid=\"238\"  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_239-238-1\">\t\t\t<label  for=\"field_g4hvc2-1\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[239][]\" id=\"field_g4hvc2-1\" value=\"$20.32 Empleado + Hijo(s)\"  data-sectionid=\"238\"  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_239-238-2\">\t\t\t<label  for=\"field_g4hvc2-2\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[239][]\" id=\"field_g4hvc2-2\" value=\"$18.99 Empleado + Esposa\/o\"  data-sectionid=\"238\"  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_239-238-3\">\t\t\t<label  for=\"field_g4hvc2-3\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[239][]\" id=\"field_g4hvc2-3\" value=\"$25.02 Empleado + Familia\"  data-sectionid=\"238\"  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_239-238-4\">\t\t\t<label  for=\"field_g4hvc2-4\">\n\t\t\t<input type=\"checkbox\" name=\"item_meta[239][]\" id=\"field_g4hvc2-4\" value=\"NO al Plan MEC\"  data-sectionid=\"238\"  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_241_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_242_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container frm12 frm_first\">\r\n    <label for=\"field_97jt62\" id=\"field_97jt62_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='sigPad242' 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[242][typed]\" class=\"name\" id=\"field_97jt62\" autocomplete=\"off\" value=\"\"  data-sectionid=\"241\"  style=\"width:400px\" maxlength=\"150\" data-reqmsg=\"DEBE FIRMAR Y PONER LA FECHA AUNQUE DECLINE LA COBERTURA cannot be blank.\" aria-required=\"true\" aria-invalid=\"false\"   \/>\n\t\t<\/div>\n\n\t\t<canvas class=\"pad\" data-fieldid=\"242\" data-fieldname=\"item_meta[242]\" 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[242][output]\" class=\"output\" value=\"\" \/>\n\t<\/div>\n<\/div>\n\r\n    <div class=\"frm_description\" id=\"frm_desc_field_97jt62\">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\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_605_container\">\n\t\t\t<label for=\"field_m6e03\" >\n\t\t\t\tSi eres humano, deja este campo en blanco.\t\t\t<\/label>\n\t\t\t<input  id=\"field_m6e03\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[605]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"GwgXazH29cO0EZ0puQ69WhsHWYMbC+GnCv\/07q\/jJw31ojlCi+7UUmrazRSOQvWt\" \/><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><\/div>\n<\/fieldset>\n<\/div>\n\n<input type=\"hidden\" name=\"trp-form-language\" value=\"es\"\/><\/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-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\/es\/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>","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":2,"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-1153","page","type-page","status-publish","hentry"],"featured_image_src_large":false,"author_info":{"display_name":"Quantum Staffing Group","author_link":"https:\/\/quantum-staffing.com\/es\/author\/mauricio-camargohomeseacontainers-com\/"},"comment_info":0,"taxonomy_info":[],"_links":{"self":[{"href":"https:\/\/quantum-staffing.com\/es\/wp-json\/wp\/v2\/pages\/1153","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\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/quantum-staffing.com\/es\/wp-json\/wp\/v2\/comments?post=1153"}],"version-history":[{"count":4,"href":"https:\/\/quantum-staffing.com\/es\/wp-json\/wp\/v2\/pages\/1153\/revisions"}],"predecessor-version":[{"id":1160,"href":"https:\/\/quantum-staffing.com\/es\/wp-json\/wp\/v2\/pages\/1153\/revisions\/1160"}],"wp:attachment":[{"href":"https:\/\/quantum-staffing.com\/es\/wp-json\/wp\/v2\/media?parent=1153"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}