Report incapacity for work or to earn

Details of the employer

Company

Contract number

*Mandatory fields

Details of the employee

Policy no.

Title

First name

Last name

Street

No.

Postcode

Place

Country

Date of birth

Marital status

E-mail

Telephone no.

*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?

Annual salary

Degree of employment as %

Has the employment contract with the employee been terminated?

Date of termination of employment relationship

Is the employment contract expected to be terminated?

Date of planned termination of employment relationship

*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.

First name

Last name

E-mail

Telephone no.

*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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Document accepted

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?

The company will hand the necessary form out to the employee.
The employee should receive the form by e-mail.
The foundation should send the employee the form by post.

Employee’s private e-mail address

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.

Form for incapacity for work or incapacity to earn – employee section

Comments

Further comments

Confirmation

The company hereby confirms that all details are truthful and accurate.

*Mandatory fields

Summary

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Good to know

When should a case of incapacity for work or to earn be reported?

Information on waivers of contributions

During the first year from the start of incapacity for work, contributions are waived on the basis of the incapacity for work as certified by a doctor; thereafter, contributions are waived on the basis of the degree of disability set by the invalidity insurance scheme (IV).

The waiver of contributions is calculated according to the following scale:

A degree of incapacity for work of less than 40% does not confer any entitlement to benefits.
A medically certified incapacity for work of between 40% and 49% confers entitlement to a 25% waiver of contributions.
A medically certified incapacity for work of between 50% and 59% confers entitlement to a 50% waiver of contributions.
A medically certified incapacity for work of between 60% and 69% confers entitlement to a 75% waiver of contributions.
A medically certified incapacity for work of at least 70% confers entitlement to a 100% waiver of contributions.

Details of the employer

Details of the employee

Details of the employment relationship

Details of incapacity for work or to earn

In the case of illness

For the accident

Contact person details

Other details

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

Upload documents

Other details of the employee

Comments

Confirmation

Summary

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