You are... *
What kind of claim does it concern ? *
How long lasted the incapacity of work?
Policy n° *
Your e-mail-address *
Reference n°
Language *
Language of the required forms
Date of accident
Date *
Time *
Place of accidentArea (name or postcode) and location (e.g. workshop, road) *
Facts
Activity at the time of the accident; how the accident happened, objects, vehicles involved *
Person(s) involved
Does a police report exist ?
What kind of claim does it concern ?
Injury
Address of medical practitioner
Postal account or bank account of the employee, for transfer of benefits
Bank account (IBAN) *
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4. Click on Next page or return to step 1 to upload an additional document
Where do you want to send your declaration ?
Adliswil
Nyon
Remarks