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

Have you also taken out an accident insurance UVG contract with Baloise? If so, please enter this policy no. as well.
  • Supplementary accident insurance for companies
  • Collective accident insurance for persons not subject to the Swiss Federal Law on Accident Insurance (UVG)
  • Helpline
  • Case Management Plus
  • Agricultural accident insurance

   
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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

Is the insured person already entitled to a daily allowance or pension from a health insurance, Swiss Accident Insurance Fund (Suva) or another compulsory accident insurance, disability insurance, old-age and survivors' insurance, occupational pension plan, military insurance, unemployment insurance or maternity indemnity?

   
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Accident report

Accident details

   
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Accident information

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Incapacity to work

Incapacity to work



   
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Work resumption


   
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Injury

Main Injury

   
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Other injury 1

   
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Other injury 2

   
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Treatment

Initial treatment by doctor/hospital


   
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Subsequent treatment by doctor/hospital


   
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Send and Print

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

Submit attachment

Submit attachment

The document transmission is available only after successful sending of the incident.

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

Help for use

Do you have any questions?
 Please call us. We would be happy to help you.

Phone +41 58 285 97 30
Version: 24400