Declaration Accident Bagatelle LAA

Declaring a claim >> Accident Bagatelle LAA

Your email address*
Statement of insurance informations
Insurance company
No of insurance policy
Employer
Name*
Address
Street Adress Street Adress 2 City Postal Code Country
Insured person
Name*
First Name Last Name
Adress*
Street Adress Street Adress 2 City Postal Code Country
Date of birth*
DD slash MM slash YYYY
Civil status*
Nationality*
Phone*
No AVS*
Children under 18 years of age or still in education till 25 years
Reimbursement of expenses
By
Name of the bank
IBAN
N°CCP
Commitment
Commitment date*
DD slash MM slash YYYY
Position in the company*
Usual place of the insured*

business sector: reception, secretarial, IT, machine room, etc.
Function*
- Senior executive
- Middle management
- Employee/worker
- Apprentice
- Intern
End date of the course
DD slash MM slash YYYY
Apprenticeship end date
DD slash MM slash YYYY
Employment relationship*
- Permanent employment relationship
- Temporary employment relationship
- Terminated employment relationship
until
DD slash MM slash YYYY
for the
DD slash MM slash YYYY
Contractual occupancy rate (%)*
Occupation
- Temporary
- Part time
Work schedule of the insured person*

Hours per week
Number of days per week*
Standard working hours of the company*

Hours per week
Date of the accident
Date of the Accident*
DD slash MM slash YYYY
Time of Accident*

: Hours

Minutes
Location of the accident
Where did the accident happen?*
Street Address Street Address 2 City Postal Code Country
for ex. Hotel, XX, workshop, street, garden, sitting room….*
Description of the accident
Activity at the time of the accident*

(bike, Ski, Trekking, ...)
Accident course*
Persons, machines, objects, vehicles, products that played a role in the accident
Person(s) involved
- None
- Yes
If yes, name + address
Work-related accident
Involved items*

for ex: tools, vehicule, substance involved
Work-unrelated accident
Until when has the injured person worked for the last time in the company before the accident.*
DD slash MM slash YYYY
Hour

: Hours

Minutes
Cause of absence

Holidays, sickness, vacations, end of work,...
Injury
Part of the body affected*

hand, foot, elbow...
Affected body part(s)*
- Left
- Right
- Undetermined
Nature of the injury*

fracture, pain, sprain...
Doctors' addresses
First aid by
Clinic / Hospital
Name, surname of the doctor*
Address*
Street Address Street Address 2 City Postal Code Country
Phone
Following treatment by
Clinic / Hospital
Surname, First name of the doctorNom, Prénom du médecin
Address
Street Address Street Address 2 City Postal Code Country
Phone
Place and date
Location
Date
DD slash MM slash YYYY
Attach documents
Documents
Drop files here or

Accepted file types: iejpg, gif, png, pdf, Max. file size: 128 MB.

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Declaring a claim >> Accident Bagatelle LAA

Statement of insurance informations

Employer

Insured person

Commitment

Date of the accident

Location of the accident

Description of the accident

Work-related accident

Work-unrelated accident

Injury

Doctors' addresses

First aid by

Following treatment by

Place and date

Attach documents