Details of the employer

*Mandatory fields

Details of the employee

Is the insured fully fit for work or capable of gainful employment? A person is considered to have a partial incapacity for work if, at the start of insurance, he/she has to be fully or partially absent from work for health reasons, is receiving daily sickness benefits as a result of accident or illness, can no longer be fully employed as befits his/her training and skills for health reasons or is disabled within the meaning of the Federal invalidity insurance, accident insurance or military insurance schemes, and/or is drawing benefits from one or more of these institutions (please attach pension decision).

Note: If we have not yet been notified of incapacity for work, the form "Incapacity to work or to earn" must be submitted.

*Mandatory fields


Please note: Salary adjustments and changes to the degree of employment which began more than 30 days ago may lead to the payment of accrued interest in certain circumstances. For that reason you should notify us of any changes which may affect premiums as soon as possible.

Please note: An increase in the degree of employment or salary is not possible for semi-retired employees. If you wish to report a reduction in the degree of employment in the context of semi-retirement, please use the “Flexible retirement” form.

Please note: Only possible as of 1.1. of the following year and provided the choice of plan is set out in the regulations.


This registration was entered by

*Mandatory fields






Protected by Google reCAPTCHA

Download PDF form

You can download a blank form in PDF format via the following link:

Download blank form


Download current interim status of the online form as PDF

Error during the generation of the intermediate status. Please try again.