Loss of earnings due to illness

Have you suffered a loss or damage? You can report any loss or damage and claim benefits, quickly and easily.

Fields marked * must be completed.

You are

You are...*

Client

Europ Assistance

Agency GENERALI

Other person

Please specify.

Policy n°*

Please enter the policy no.

First name*

Please enter your first name.

Surname*

Please enter your surname.

E-mail*

Please enter a valid e-mail address.

1. Employer

First name*

Please enter your first name.

Surname*

Please enter your surname.

Street*

Please enter the street name.

House number*

Please enter your house number.

Postcode*

Please enter the postcode.

Location*

Please enter the location.

Phone no.*

Please enter a valid phone no. +41791234567

E-mail

Please enter a valid e-mail address.

2. Insured person

First name*

Please enter your first name.

Surname*

Please enter your surname.

Street*

Please enter the street name.

House number*

Please enter your house number.

Postcode*

Please enter the postcode.

Location*

Please enter the location.

Phone no.*

Please enter a valid phone no. +41791234567

E-mail

Please enter a valid e-mail address.

Date of birth*

Please enter a valid date.

Marital status*

Please enter the marital status.

Nationality*

Please specify the nationality.

AVS number (13 digits)*

Please specify the AVS number. 756.XXXX.XXXX.XX

Work permit (for foreigners)

B

C

G

other

Other work permit

3. Employment

Normal occupation*

Please specify.

Starting date of employment*

Please enter a valid date.

Insured person's working hours*

Bitte geben Sie die Anzahl Stunden ein.

Company's working hrs full time*

Bitte geben Sie die Betriebsübliche Vollarbeitszeit ein.

Contractual degree of employment*

Please specify.

Employment contract:*

permanent contract

temporary contract

contract terminated as of

Please select the contractual relationship.

contract terminated as of:

Please enter a valid date.

4. Start of incapacity to work

Start of incapacity to work*

Please enter a valid date.

If work resumed, from when?

Please enter a valid date.

Here you can add certificates, medical certificates or medical findings; max. 20 MB (Files must be .pdf, .jpg or .png only).

Yes

No

Please transmit all relevant documents, max. 20 MB (e.g. certificates, medical reports or medical findings).

The maximum size of all files is 20MB.

Files must be .pdf, .jpg or .png only.

No file selected.

This file is infected.

5. Doctors' addresses

Doctor or hospital/clinic*

characters remaining

Please enter name and adress.

6. Salary

Insured person subject to tax at source?*

Yes

No

Please indicate if insured is subject to tax at source.

Contractual basic salary incl. cost of living bonus (gross)

Basic contractual salary (gross)*

Please state the wage.

Basic contractual salary*

CHF per hour

CHF per month

CHF per year

Please state the wage.

Child/family allowances

Child/family allowances*

Please state the wage.

Child/family allowances*

CHF per hour

CHF per month

CHF per year

Please state the wage.

Compensation for vacation/public holidays

Compensation for vacation/public holidays*

Please state the wage.

Compensation for vacation/public holidays*

% in percent

CHF per hour

CHF per month

CHF per year

Please state the wage.

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

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

Please state the wage.

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

% in percent

CHF per hour

CHF per month

CHF per year

Please state the wage.

Other wage supplements (e.g. settlement/commission/payment in kind/shift premium)

Other wage supplements

CHF per hour

CHF per month

CHF per year

Description

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

Postal account or bank account of the company:*

characters remaining

Please enter the account.

8. Other insurance benefits

Is the insured person already entitled to a daily allowance or pension from: health insurance, Suva or another compulsory accident insurance, disability insurance, old age or survivors' insurance, occupational benefit plans, military insurance, unemployment insurance?*

Yes

No

Please indicate whether the insured person already is entitled to a daily allowance or pension.

If so, to which one(s)?

Please specify.

Does the insured event give rise to benefits from other GENERALI Insurance policies?*

Yes

No

Please specify.

If so, policy no.?

Has the event been reported to the Federal Disability Insurance for early registration?*

Yes

No

Please specify.

9. Name of Occupational Benefit Plan (Pension Fund)

Name of Benefit Plan

Please enter the name of Benefit Plan

Data protection*

I accept that the entered personal data will be sent in the form of a confirmation email to the email address I have provided.

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