Accident Notification

Accident reported by

Title

Injured person

Please answer all questions completely and accurately.

Format: 123.45.67.890.1

Injured person

Work details

If unemployed or if no longer gainfully employed as an employee (e.g. following a vacation, stay abroad, continuing education)

Average working hours per week?
Since then, have you received daily allowance from unemployment insurance?
Do you have an Insurance by Special Agreement?

No branch could be found. Please check your entry.

Format: 09:30

Is it a traffic accident?
Was a third party responsible for the accident?
Was a police report filed?

Injuries

Side of body
Are you unable to work?
Could the medical treatment be concluded in the meantime?

Additional questions regarding the traffic accident

Type (e.g. bicycle, moped, motorcycle, car)

War ein zweites Fahrzeug in den Unfall involviert?

Collision vehicle

Other insurances

By which of the insurances listed below are you insured against accidents, whether mandatory or supplementary, and to what extent?

Obligatory Accident Insurance (UVG/LAA/LAINF) of the employer

Coverage as per UVG/LAA/LAINF

Additional/Supplementary insurance to the Obligatory Accident Insurance (UVG/LAA/LAINF)
Coverage for medical expenses and/or daily allowance (loss of earnings)
Other accident insurance
Coverage
Are you receiving a pension from the Federal Disability Insurance, the Swiss National Accident Insurance Fund (SUVA) or the Swiss federal military insurance (MV/AM), a UVG/LAA/LAINF pension, or a pension from a private insurance?

General remarks