Accident Notification

Accident reported by

Title

Injured person

Please answer all questions completely and accurately.

Format: 123.45.67.890.1

Work details

Were you employed or undergoing professional training at the time of the accident?
Average working hours per week?
Were you employed in the last 2 years before the accident?
Average working hours per week?
Since then, have you received daily allowance from unemployment insurance?
Do you have an Insurance by Special Agreement?
If you were not employed at the time of the accident, please check the relevant box:

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
How were you treated?
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)

Was a second vehicle involved in the accident?

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
Other accident insurance

z. E.g. school accident insurance, military insurance, other health insurance, private insurance, travel insurance, etc.

Coverage
In the event of an accident abroad: Was the trip paid for by credit card?

General remarks