{"id":43,"date":"2011-06-18T20:15:57","date_gmt":"2011-06-18T19:15:57","guid":{"rendered":"http:\/\/mail.nemling.eu\/?page_id=43"},"modified":"2022-01-13T21:52:11","modified_gmt":"2022-01-13T20:52:11","slug":"rotary-registrierungsformular","status":"publish","type":"page","link":"https:\/\/nemling.eu\/rotary\/rotary-registrierungsformular","title":{"rendered":"Rotary Travel Insurance - Registration Form"},"content":{"rendered":"<div class=\"frm_forms  with_frm_style frm_style_formidable-style\" id=\"frm_form_3_container\" >\n<form enctype=\"multipart\/form-data\" method=\"post\" class=\"frm-show-form \" id=\"form_registration_en\" >\n<div class=\"frm_form_fields \">\n<fieldset>\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=\"3\" \/>\n<input type=\"hidden\" name=\"frm_hide_fields_3\" id=\"frm_hide_fields_3\" value=\"\" \/>\n<input type=\"hidden\" name=\"form_key\" value=\"registration_en\" \/>\n<input type=\"hidden\" name=\"item_meta[0]\" value=\"\" \/>\n<input type=\"hidden\" id=\"frm_submit_entry_3\" name=\"frm_submit_entry_3\" value=\"f22c5784e2\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/en\/wp-json\/wp\/v2\/pages\/43\" \/><div id=\"frm_field_14_container\" class=\"form-field frm_top_container\">\r\n<h2 class=\"frm_pos_ frm_primary_label[collapse_class]\">Insured person<\/h2>\r\n\r\n\r\n<\/div>\n<div id=\"frm_field_15_container\" class=\"form-field  frm_required_field frm_top_container\">\r\n    <label class=\"frm_primary_label\">name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_insuredpersonsname\" name=\"item_meta[15]\" value=\"\"  data-reqmsg=\"name cannot be blank\" aria-required=\"true\" data-invmsg=\"name is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_16_container\" class=\"form-field  frm_required_field frm_top_container\">\r\n    <label class=\"frm_primary_label\">sex\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    \t\t<select name=\"item_meta[16]\" id=\"field_sex\"  data-reqmsg=\"sex cannot be blank\" aria-required=\"true\" data-invmsg=\"sex is invalid\" aria-invalid=\"false\"  >\n\t\t<option  value=\"\" selected='selected'> <\/option><option  value=\"male\">male<\/option><option  value=\"female\">female<\/option>\t<\/select>\n\t\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_17_container\" class=\"form-field  frm_required_field frm_top_container\">\r\n    <label class=\"frm_primary_label\">address\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_address\" name=\"item_meta[17]\" value=\"\"  data-reqmsg=\"address cannot be blank\" aria-required=\"true\" data-invmsg=\"address is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_address\"\/>\r\n    <div id=\"frm_desc_field_address\" class=\"frm_description\">street<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_18_container\" class=\"form-field  frm_top_container\">\r\n    <label class=\"frm_primary_label\">address - 2nd line\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_hpq8ws\" name=\"item_meta[18]\" value=\"\"  data-invmsg=\"address - 2nd line is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_hpq8ws\"\/>\r\n    <div id=\"frm_desc_field_hpq8ws\" class=\"frm_description\">postal code, city, country<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_19_container\" class=\"form-field  frm_required_field frm_top_container\">\r\n    <label class=\"frm_primary_label\">date of birth\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_lm6yy0\" name=\"item_meta[19]\" value=\"\"  style=\"width:90px\" maxlength=\"10\" data-reqmsg=\"date of birth cannot be blank\" aria-required=\"true\" data-invmsg=\"date of birth is invalid\" class=\"auto_width\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_20_container\" class=\"form-field  frm_required_field frm_top_container\">\r\n    <label class=\"frm_primary_label\">place of birth\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_placeofbirth\" name=\"item_meta[20]\" value=\"\"  data-reqmsg=\"place of birth cannot be blank\" aria-required=\"true\" data-invmsg=\"place of birth is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_21_container\" class=\"form-field  frm_required_field frm_top_container\">\r\n    <label class=\"frm_primary_label\">nationality\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_insuredperson-citizenship\" name=\"item_meta[21]\" value=\"\"  data-reqmsg=\"nationality cannot be blank\" aria-required=\"true\" data-invmsg=\"nationality is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_22_container\" class=\"form-field  frm_top_container\">\r\n    <label class=\"frm_primary_label\">social insurance carrier\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_insuredperson-socialinsurance\" name=\"item_meta[22]\" value=\"\"  data-invmsg=\"social insurance carrier is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_23_container\" class=\"form-field  frm_top_container\">\r\n    <label class=\"frm_primary_label\">private health insurance policy number\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_insuredperson-privatehealthinsurancepol\" name=\"item_meta[23]\" value=\"\"  data-invmsg=\"private health insurance policy number is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_24_container\" class=\"frm_form_field form-field  frm_required_field frm_top_container\">\r\n    <label class=\"frm_primary_label\">inception date\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_in55sd\" name=\"item_meta[24]\" value=\"\"  style=\"width:90px\" maxlength=\"10\" data-reqmsg=\"inception date cannot be blank\" aria-required=\"true\" data-invmsg=\"inception date is invalid\" class=\"auto_width\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_25_container\" class=\"form-field  frm_required_field frm_top_container\">\r\n    <label class=\"frm_primary_label\">Email\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"email\" id=\"field_mj2cma\" name=\"item_meta[25]\" value=\"\"  data-reqmsg=\"Email cannot be blank\" aria-required=\"true\" data-invmsg=\"Email is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_mj2cma\"\/>\r\n    <div id=\"frm_desc_field_mj2cma\" class=\"frm_description\">a copy of submitted data will be sent to this account<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_26_container\" class=\"frm_form_field form-field  frm_top_container\">\n\t<label for=\"field_cm184\" id=\"field_cm184_label\" class=\"frm_primary_label\">Endabschnitt\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input type=\"text\" id=\"field_cm184\" name=\"item_meta[26]\" value=\"\"  data-invmsg=\"Endabschnitt is invalid\" aria-invalid=\"false\"  \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_27_container\" class=\"form-field frm_top_container\">\r\n<h2 class=\"frm_pos_ frm_primary_label[collapse_class]\">Payor details<\/h2>\r\n\r\n\r\n<\/div>\n<div id=\"frm_field_28_container\" class=\"form-field  frm_required_field frm_top_container\">\r\n    <label class=\"frm_primary_label\">name\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_payor-name\" name=\"item_meta[28]\" value=\"\"  data-reqmsg=\"name cannot be blank\" aria-required=\"true\" data-invmsg=\"name is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_29_container\" class=\"form-field  frm_top_container\">\r\n    <label class=\"frm_primary_label\">e-mail\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_payor-e-mail\" name=\"item_meta[29]\" value=\"\"  data-invmsg=\"e-mail is invalid\" aria-invalid=\"false\"  \/>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_30_container\" class=\"frm_form_field form-field  frm_top_container\">\n\t<label for=\"field_cm1842\" id=\"field_cm1842_label\" class=\"frm_primary_label\">Endabschnitt\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input type=\"text\" id=\"field_cm1842\" name=\"item_meta[30]\" value=\"\"  data-invmsg=\"Endabschnitt is invalid\" aria-invalid=\"false\"  \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_31_container\" class=\"form-field frm_top_container\">\r\n<h2 class=\"frm_pos_ frm_primary_label[collapse_class]\">Calculation of applicable fee<\/h2>\r\n\r\n\r\n<\/div>\n<div id=\"frm_field_32_container\" class=\"form-field  frm_required_field frm_top_container\">\r\n    <label class=\"frm_primary_label\">premium\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"number\" id=\"field_insurance-days\" name=\"item_meta[32]\" value=\"\"  data-reqmsg=\"premium cannot be blank\" aria-required=\"true\" data-invmsg=\"premium is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_insurance-days\" min=\"0\" max=\"9999\" step=\"1\"\/>\r\n    <div id=\"frm_desc_field_insurance-days\" class=\"frm_description\">term of insurance in days (min. 31 days - \u20ac 40,30) by 1,30 daily rate<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_33_container\" class=\"form-field  frm_required_field frm_top_container\">\r\n    <label class=\"frm_primary_label\">bank transfer fees\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"number\" id=\"field_insurance-banktransferfees\" name=\"item_meta[33]\" value=\"\"  data-reqmsg=\"bank transfer fees cannot be blank\" aria-required=\"true\" data-invmsg=\"bank transfer fees is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_insurance-banktransferfees\" min=\"0\" max=\"9999\" step=\"1\"\/>\r\n    <div id=\"frm_desc_field_insurance-banktransferfees\" class=\"frm_description\">Latin America 26 \u20ac, overseas and Europe(non SEPA countries) 16 \u20ac, SEPA countries 2\u20ac<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_34_container\" class=\"form-field  frm_top_container\">\r\n    <label class=\"frm_primary_label\">total fee\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_insurance-totalfee\" name=\"item_meta[34]\" value=\"\"  data-invmsg=\"total fee is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_insurance-totalfee\"\/>\r\n    <div id=\"frm_desc_field_insurance-totalfee\" class=\"frm_description\">premium plus bank fees<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_35_container\" class=\"frm_form_field form-field  frm_top_container\">\n\t<label for=\"field_cm1843\" id=\"field_cm1843_label\" class=\"frm_primary_label\">Endabschnitt\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input type=\"text\" id=\"field_cm1843\" name=\"item_meta[35]\" value=\"\"  data-invmsg=\"Endabschnitt is invalid\" aria-invalid=\"false\"  \/>\n\t\n\t\n<\/div>\n<div id=\"frm_field_36_container\" class=\"form-field frm_top_container\">\r\n<h2 class=\"frm_pos_ frm_primary_label[collapse_class]\">Payment details<\/h2>\r\n\r\n\r\n<\/div>\n<div id=\"frm_field_37_container\" class=\"form-field  frm_top_container\">\r\n    <label class=\"frm_primary_label\">transferring institution\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_payment-\" name=\"item_meta[37]\" value=\"\"  data-invmsg=\"transferring institution is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_payment-\"\/>\r\n    <div id=\"frm_desc_field_payment-\" class=\"frm_description\">for easier payment processing please provide your bank's name<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_38_container\" class=\"form-field  frm_required_field frm_top_container\">\r\n    <label class=\"frm_primary_label\">date of transfer\r\n        <span class=\"frm_required\">*<\/span>\r\n    <\/label>\r\n    <input type=\"text\" id=\"field_payment-dateoftransfer\" name=\"item_meta[38]\" value=\"\"  data-reqmsg=\"date of transfer cannot be blank\" aria-required=\"true\" data-invmsg=\"date of transfer is invalid\" aria-invalid=\"false\"   aria-describedby=\"frm_desc_field_payment-dateoftransfer\"\/>\r\n    <div id=\"frm_desc_field_payment-dateoftransfer\" class=\"frm_description\">please provide the date when the transfer was performed<\/div>\r\n    \r\n<\/div>\n<div id=\"frm_field_39_container\" class=\"form-field  frm_top_container\">\r\n    <label class=\"frm_primary_label\">whaterver is on your mind\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <textarea name=\"item_meta[39]\" id=\"field_whaterverisonyourmind\" rows=\"5\"  data-invmsg=\"whaterver is on your mind is invalid\" aria-invalid=\"false\"  ><\/textarea>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_40_container\" class=\"form-field  frm_hidden_container\">\r\n    <label class=\"frm_primary_label\">Untitled\r\n        <span class=\"frm_required\"><\/span>\r\n    <\/label>\r\n    <div  id=\"field_zo6syg\" class=\"frm-g-recaptcha\" data-sitekey=\"6LfNxasjAAAAABm-2prdXGWmwz4nr2sR0e_vjMYr\" data-size=\"invisible\" data-theme=\"light\"><\/div>\r\n    \r\n    \r\n<\/div>\n<div id=\"frm_field_41_container\" class=\"frm_form_field form-field  frm_top_container\">\n\t<label for=\"field_cm1844\" id=\"field_cm1844_label\" class=\"frm_primary_label\">Endabschnitt\n\t\t<span class=\"frm_required\" aria-hidden=\"true\"><\/span>\n\t<\/label>\n\t<input type=\"text\" id=\"field_cm1844\" name=\"item_meta[41]\" value=\"\"  data-invmsg=\"Endabschnitt is invalid\" aria-invalid=\"false\"  \/>\n\t\n\t\n<\/div>\n\t<input type=\"hidden\" name=\"item_key\" value=\"\" \/>\n\t\t\t<div id=\"frm_field_197_container\">\n\t\t\t<label for=\"field_71071\" >\n\t\t\t\tIf you are human, leave this field blank.\t\t\t<\/label>\n\t\t\t<input  id=\"field_71071\" type=\"text\" class=\"frm_form_field form-field frm_verify\" name=\"item_meta[197]\" value=\"\"  \/>\n\t\t<\/div>\n\t\t<input name=\"frm_state\" type=\"hidden\" value=\"r8F0WES1qN2wqIMsOn+oLob+hzecJNfTRlW0\/\/N0tgM=\" \/><div class=\"frm_submit\">\r\n\r\n<input type=\"submit\" value=\"Submit\"  \/>\r\n<img class=\"frm_ajax_loading\" src=\"https:\/\/nemling.eu\/wp-content\/plugins\/formidable\/images\/ajax_loader.gif\" alt=\"Wird gesendet\" style=\"visibility:hidden;\" \/>\r\n\r\n<\/div><\/div>\n<\/fieldset>\n<\/div>\n\n<\/form>\n<\/div>\n\n<p>&nbsp;<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Insured person name * sex * malefemale address * street address &#8211; 2nd line postal code, city, country date of birth * place of birth * nationality * social insurance carrier private health insurance policy number inception date * Email &hellip; <a href=\"https:\/\/nemling.eu\/rotary\/rotary-registrierungsformular\">Continue reading <span class=\"meta-nav\">&rarr;<\/span><\/a><\/p>\n","protected":false},"author":1,"featured_media":0,"parent":23,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":[],"_links":{"self":[{"href":"https:\/\/nemling.eu\/wp-json\/wp\/v2\/pages\/43"}],"collection":[{"href":"https:\/\/nemling.eu\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/nemling.eu\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/nemling.eu\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/nemling.eu\/wp-json\/wp\/v2\/comments?post=43"}],"version-history":[{"count":5,"href":"https:\/\/nemling.eu\/wp-json\/wp\/v2\/pages\/43\/revisions"}],"predecessor-version":[{"id":402,"href":"https:\/\/nemling.eu\/wp-json\/wp\/v2\/pages\/43\/revisions\/402"}],"up":[{"embeddable":true,"href":"https:\/\/nemling.eu\/wp-json\/wp\/v2\/pages\/23"}],"wp:attachment":[{"href":"https:\/\/nemling.eu\/wp-json\/wp\/v2\/media?parent=43"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}