Apply for benefits: Daily sickness allowance insurance

Employer

Insured person

Date of Birth *

DD.MM.YYYY

AHV/AVS number *

Marital status *

Nationality *

Employment

Profession carried out *

Date of employment *

DD.MM.YYYY

Position *

Employment contract *

Insured person's working hours *

Hours/week

Normal company working hours *

Hours/week

Contractual degree of employement *

Percent

Salary

Basic contractual AHV/AVS salary incl. inflation allowance (gross)*

Child/family allowances

Compensation for vacation/public holidays

Bonus/13th month's salary (and other)

Other AHV/AVS liable salary allowance (e.g. piece rates, commission, payment in kind, shift allowance)

Insured person subject to withholding tax ?

Postal account or bank account of the company, for transfer of benefits

Bank account (IBAN)

Postal account

Bank account (IBAN) *

Summary
Claim notification
Policy n°	undefined
Start of incapacity to work	29.07.2025

Creator of the report
You are...	Client
Your e-mail-address	undefined

Employer
Last name	undefined
Address	undefined
Postcode	undefined
City	undefined
Postal account or bank account of the employee, for transfer of benefits

Insured person
Last name
First name
Address
Postcode
City
Phone n°
Date of Birth	false
AHV/AVS number
Marital status	Unmarried
Nationality	CH
Profession carried out
Date of employment	false
Employment contract	Permanent empl. contract
Insured person's working hours	undefined
Normal company working hours	undefined
Contractual degree of employement	undefined

Insured salary
Basic contractual AHV/AVS salary incl. inflation allowance (gross)	/ CHF per month

Illness related loss of earning insurance