Details of the employer

*Mandatory fields

Details of the employee


*Mandatory fields

Details of the employment relationship

What was the annual salary and degree of employment at or just before the onset of the incapacity for work or to earn?

Has the employment contract with the employee been terminated?
Is the employment contract expected to be terminated?

*Mandatory fields

Details of incapacity for work or to earn

What type of incapacity for work or to earn do you wish to report?
How was the incapacity for work or to earn triggered?

During which period and to what degree was the insured person unable to work or earn an income?

Insurance institutions involved in this case:

In the case of illness

Contact person

For the accident

Contact person

Has a report been submitted to Federal invalidity insurance for early detection purposes?
Is a report for early detection purposes planned?
Is Military insurance involved?

*Mandatory fields

Contact person details

For further information please provide your contact details or the contact details of the responsible contact person at your employer’s company.

*Mandatory fields

Other details

Daily benefits statements of loss of earnings insurer(s) providing benefits

Please enclose copies of daily benefits statements from the onset of the incapacity for work until today.

Upload documents

You can upload the documents as a file here.

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or click to select it (10 MB; jpg, png oder pdf)*
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Other details of the employee

    Note: In order to definitively enter the incapacity for work or incapacity to earn you reported, we need additional information from the employee concerned.

    How should the employee receive the relevant form?

    Please give the following form to your employee for further details of the incapacity for work or to earn. This form must be completed and signed by your employee and then returned to us.



    *Mandatory fields






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    Download PDF form

    You can download blank forms as a PDF via the following links:

    1. PDF form for the employer
    2. PDF form for the employee


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