Incident note

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

Employer & Policy

Employer

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Policy information


   
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Contact person

   
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Bank account

   
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Company details

   
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Insured person

Personal data

   
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Personal details

   
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Employment data

   
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Working time

   
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Further information

Further social insurance

Is the insured person already entitled to a daily allowance or pension from a health insurance, Swiss Accident Insurance Fund (Suva) or another compulsory accident insurance, disability insurance, old-age and survivors' insurance, occupational pension plan, military insurance, unemployment insurance or maternity indemnity?

   
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Accident report

Accident details

   
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Accident information

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Injury

Main Injury

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Treatment

Initial treatment by doctor/hospital


   
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Subsequent treatment by doctor/hospital


   
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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