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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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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Basic contractual wage

   
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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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Until when did the insuree work in the company before the relapse occured?

   
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Accident information

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Incapacity to work

Incapacity to work



   
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Work resumption


   
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Injury

Main Injury

   
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Other injury 1

   
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Other injury 2

   
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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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Version: 25180