Details of the employer

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Details of the employee

Title
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.

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

Details of the suspension of work

Is the employee expected to resume work?

Please note: As the employee is leaving the company permanently, his or her departure must be reported using the “Termination of Employment” form.

Please note: The employee’s return to work must be reported using the “Return to work” form.

Please note: The employee’s return to work must be reported using the “Return to work” form.

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Summary

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