LAA Accident declaration

Declaring a claim >> Accident LAA

Your email address*
Type
- Accident
- Dental injury
- Occupational illness
- Relapse
Statement of insurance informations
Insurance company
No of insurance policy
Employer
Name*
Address*
Street Address Street Address 2 City Postal Code Country
Insured person
Name*
First Name Last Name
Address*
Street Address Street Address 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 in training up to 25 years of age
Reimbursement of expenses
By
Name of the bank
IBAN
n° CCP
Commitment
Commitment*
DD slash MM slash YYYY
Position in the company*
Usual place of the insured*

business sector: reception, secretarial, IT, machine room, etc.
Position*
- Senior executive
- Middle Manager
- Employee/worker
- Apprentice
- Trainee
End date of the course
DD slash MM slash YYYY
Apprenticeship end date
DD slash MM slash YYYY
Contract of employment*
- Open-ended contract
- Fixed-term contract
- Terminated employment contract
until
DD slash MM slash YYYY
for the
DD slash MM slash YYYY
Contractual occupancy rate (%)*
Occupation
- Irregular
- Partial unemployment
Working hours of the insured person*

hour per week
Number of days per week*
Usual 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
Accident site
Where did the accident occur?*
Street Address Street Address 2 City Postal Code Country
Location (e.g. hotel XXX, workshop, street, garden, living room...)*
Accident description
Activity at the time of the accident*

(cycling, skiing, hiking...)
Accident sequence*
Persons, machines, objects, vehicles, products that played a role in the accident
Person(s) involved
- None
- Yes
If yes, name + address
Professional accident
Objects in issue*

E.g.: tool, vehicle, substance in question
Non-professional accident
When was the last time the injured person worked at the company before the accident?*
DD slash MM slash YYYY
Time

: Hours

Minutes
Reason for absence

holidays, sickness, on leave, end of work,...
Injury
Affected body part*

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

fracture, pain, sprain...
Incapacity to work
Work interrupted as a result of the accident?*
- Yes
- No
- Partially (%)
Partially (%)
If so, since when?
DD slash MM slash YYYY
Probable duration of incapacity for work
- More than 1 month
Has the work been resumed?
If yes, since when?
DD slash MM slash YYYY
partially (%)
Doctors' addresses
First aid by
Clinic / Hospital
Surname, First name of the doctor*
Address*
Street Address Street Address 2 City Postal code Country
Phone
Continuation of treatment by
Clinic / Hospital
Surname, First name of the doctor
Address
Street Address Street Address 2 City Postal code Country
AVS (Gross) Salary
Contactual base salary (gross) adjustement allowance included**
CHF per hour CHF per month CHF per year
Cost of living allowance included
Allowance for children, family
CHF per hour CHF per month CHF per year
Gratuities, 13th salary
CHF per hour CHF per month CHF per year
Indemnities for holidays, National holidays
CHF per hour CHF per month CHF per year
Other salary complements
CHF per hour CHF per month CHF per year
Type of salary supplement
Taxed at source
- Yes
- No
Payment details
Payment to
- Employer
- Insured person
To be paid on
- Bank account
- CCP
N° CCP
Name of the bank
Account holder
Clearing
IBAN
Possible comments
Comments
Date and place
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 LAA

Statement of insurance informations

Employer

Insured person

Commitment

Date of the Accident

Accident site

Accident description

Professional accident

Non-professional accident

Injury

Incapacity to work

Doctors' addresses

First aid by

Continuation of treatment by

AVS (Gross) Salary

Payment details

Possible comments

Date and place

Attach documents