Incident note

Fill in the following fields with your data in order to complete the incident note.

Insured person & Policy

Insured person

Bank account


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Policy information


   
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Insured person

Personal data


Bank account

   
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Personal details

   
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Further information

Further social insurance

Does the insured person receive a daily allowance or a pension?

   
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Incapacity to work

Incapacity to work


The percentage indicates the extent to which they are incapable of work.

PercentageStart dateFinish date
  

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Treatment

Initial treatment by doctor/hospital


   
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Subsequent treatment by doctor/hospital


   
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Comment

Comment for insurance

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Send and Print

          
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Submit attachment

Submit attachment

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Help for use

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Version: 24670