Mandatory accident insurance (AIA)

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 n°*

Please enter the policy no.

1. Employer

First name*

Please enter your first name.

Surname*

Please enter your surname.

Street*

Please specify.

House number*

Please specify.

Postcode*

Please enter the postcode.

Location*

Please enter the location.

E-mail

Please specify.

Phone no.*

Please enter a valid phone no. +41791234567

2. Injured person

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

Please specify.

Profession carried out*

Please specify.

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 your e-mail address.

Phone no.*

Please enter a valid phone no. +41791234567

Date of birth*

Please state the date of birth.

AVS number*

Please state the AVS number.

Nationality*

Please specify.

Work/residence permit (foreigners only)

Other

Please specify.

Marital status*

Please specify.

Children up to the age of 18 or in education up to the age of 25*

Yes

Please specify.

Number of children

Please specify.

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 explain.

6. Facts (description of accident, suspected occupational illnesses)

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

characters remaining

Please explain.

Person(s) involved*

Please enter the name.

Does a police report exist ?*

Yes

Unknown

Please tick an answers.

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.

10. Disability

Stopped work as a consequence of the accident?*

Yes

Please tick an answers.

If yes, as of when?

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

Yes

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.

Anticipated duration of working incapacity longer than 1 month?*

Yes

Please tick an answers.

If work has been resumed: From?

Full-time

Partially

11. Address of medical practitioner

Initial treating doctor or hospital/clinic*

Please state the doctor or hospital/clinic.

Subsequent treatment (doctor and/or hospital/clinic)

12. Salary

Basic contractual salary incl. inflation allowance (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 allowance

Child/family allowances*

Please state the wage.

Child/family allowances*

CHF per hour

CHF per month

CHF per year

Please state the wage.

Holiday/public holiday compensation

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.

Gratification/13th monthly wage (and others)

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. piece rates, commission, payment in kind, shift allowance)

Other wage supplements

CHF per hour

CHF per month

CHF per year

Please state the wage.

Designation

13. Special cases

Voluntary insurance for entrepreneurs

Family members, partner

Subject to withholding tax

Other employer(s)

14. Compensation to be paid to bank/post account (number and name of the bank):

IBAN*

Please enter the IBAN.

Name of the account holder*

Please specify.

15. Other social insurance benefits

Is the insured already entitled to daily sickness benefits or a pension payments from any of the following: health insurer, Suva or other compulsory accident insurance company, old age and survivors insurance (AVS), professional provident institution, military insurance scheme, unemployment fund?

If yes, from which?

Name of compulsory health insurer

16. Name of Occupational Benefit Plan (Pension Fund)

Name of Occupational Benefit Plan*

Please enter the name of the occupational 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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Accident report mandatory accident insurance (AIA)