AIA MINOR ACCIDENT REPORT

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.

What kind of claim does it concern?*

Occupational accident

Non-occupational accident

Dental claim

Occup. disease

Relapse

Please tick an answers.

You are

You are...*

Client

Europ Assistance

Agency GENERALI

Other person

Please specify.

First name*

Please enter your first name.

Surname*

Please enter your surname.

E-mail*

Please enter a valid e-mail address.

Policy nr.*

Please enter the policy no.

1. Employer

First name*

Please enter your first name.

Surname*

Please enter your surname.

Street*

Please enter your street name.

House number*

Please enter your house number.

Postcode*

Please enter the postcode.

Location*

Please enter the location.

E-mail

Please enter a valid e-mail address.

Phone no.*

Please enter a valid phone no. +41791234567

2. Injured person

Profession carried out*

Please specify.

Normal place of work of the injured person (branch of business)

Bitte geben Sie den Arbeitsplatz ein.

First name*

Please enter your first name.

Surname*

Please enter your surname.

Street name*

Please enter your street name.

House number*

Please enter your house number.

Postcode*

Please enter the postcode.

Location*

Please enter the location.

E-mail

Please enter a valid e-mail address.

Phone no.*

Please enter a valid phone no. +41791234567

Date of birth*

Please indicate the date of birth.

AVS number (13 digits)

Marital status*

Please specify.

Nationality*

Please specify.

Work/residence permit (foreigners only)

A

B

C

Other

Please specify.

Other work/residence permit

Other employer(s)

3. Employment

Date of commencement*

Please indicate the date.

Employment contract*

Permanent empl. contract

Temporary empl. contract

Terminated empl. contract

Please tick an answers.

Insured person's working hours: hours/week*

Please specify.

Contractual degree of employment in per cent*

Please specify.

Normal company working hours: hours/week*

Please specify.

Employment

irregular

Short-time working

Please specify.

4. Date of injury

Day Month Year*

Please indicate the date.

Time (HH, MM)*

Please indicate the time.

5. Place of accident

Area (name or postcode) and location (e.g. workshop, road)*

characters remaining

Please specify.

6. Facts (description of accident)

Activity at the time of the accident; how the accident happened; objects involved; vehicles*

characters remaining

Please explain.

Person(s) involved*

Please specify.

Does a police report exist ?*

Yes

No

Unknown

Please specify.

7. Occupational accident

Objects involved (e.g. machines, tools, vehicles, materials; please describe exactly)

characters remaining

8. Non-occupational accident

Please specify the last date on which the injured person last worked at the company before the accident (weekday, date, time).

Reason for absence

characters remaining

9. Injury

Affected part of the body*

Please indicate which body part is affected.

Type of injury*

Please indicate the type of injury.

Affected body part*

Left

Right

Both sides

Undetermined

Please tick an answers.

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.

10. Address of medical practitioner

First treatment (doctor and/or hospital/clinic)*

Please specify.

Subsequent treatment (doctor and/or hospital/clinic)

11. If you require reimbursement for bills you have already paid, please enclose the receipts and specify the account to be credited

Bank/postal account

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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