LAA Accident declaration

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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