Incident note

Fill in the following fields with your data in order to complete the incident note.

Employer & Policy

Employer

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Policy information

   
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Contact person

Personal details will be sent to the contact person listed above. Therefore, please provide us with the contact details of an authorised person.

   
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Company details

   
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Insured person

Personal data

Necessary for obtaining additional data or documents directly from the employee (e.g. power of attorney).

   
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Personal details

   
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Employment data


   
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Working time

We request you to submit to us the time sheets including the pay slips for the last 12 months prior to the date of the accident.

   
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Basic contractual wage

   
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Further information

Further social insurance

Does the insured person receive a daily allowance or a pension?

   
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Incapacity to work

Incapacity to work

   
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Work resumption


   
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Treatment

Initial treatment by doctor/hospital


   
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Subsequent treatment by doctor/hospital


   
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Comment

Comment for insurance

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Send and Print

          
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Submit attachment

Submit attachment

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Information on data protection can be found in our privacy policy.

Help for use

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Version: 24400