PSPI : Reporting Loss of income in case of illness to your broker

Loss of income

in case of illness

Your email address*
Sickness*
- Sickness
- Maternity
- Death
Date of birth
DD slash MM slash YYYY
Death on
DD slash MM slash YYYY
Insurance information
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
Address*
Street Address Street Address 2 City Postal Code Country
Date of birth*
DD slash MM slash YYYY
Marital status*
Nationality*
Phone*
No AVS*
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 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
Incapacity to work
Stopped working due to illness as of*
DD slash MM slash YYYY
*
- Completely
- Partly
Partially to (in %)
Expected duration of absence
- Supérieure à 1mois
Has the work been resumed?
If so, since when?
DD slash MM slash YYYY
partially (%)
Do you consider patient monitoring necessary?
- Yes
- No
Treating doctor/hospital
Name*
Address*
Street Address Street Address 2 City Postal Code Country
Phone
Salary
According to AVS or policy if agreed differently
Gross basic pay before the beginning of the incapacity for work or the average of the last 12 months in the case of irregular periods of work or strong variations*
CHF per hour CHF per Month CHF per Year
Child and family allowances
Gratuity, 13" month's salary (and subsequent)*.
CHF per hour CHF per Month CHF per Year
Holiday and public holiday pay
Other salary complements
Type of salary supplement
Taxed at source
- Yes
- No
No RCE
Payment details
Payment to
- Employer
- Insured person
To be paid on
- Bank account
- CCP
N° CCP
Name of the bank
Account holder
IBAN
Bank address
Street Address City Postal Code Country
Clearing
Possible comments
Comments
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.
Email
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Geneva

10 Rue du Prince,
1204 Geneva, Switzerland

T: +41 22 317 78 50
E: client@pspi.ch

Trade register:
CHE-114.803.069. FINMA : 28838

Megeve

T: +41 22 317 78 50
E: client@pspi.ch

Liechtenstein

T: +41 22 317 78 50
E: client@pspi.ch

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Loss of income

Insurance information

Employer

Insured person

Commitment

Incapacity to work

Treating doctor/hospital

Salary

Payment details

Possible comments

Place and date

Attach documents

Geneva

Megeve

Liechtenstein