Name Address
Postcode / locality Tel./fax
Insurance contract no. (e.g. 123456 5630) 2. Insured person
Last name, first name Address
Postcode / locality Date of birth and gender Marital status
AHV/AVS number Tel. home/mobile E-mail
Postal cheque account or bank account
□ Male □ Female
□ Single □ Married □ Divorced □ Separated □ Widowed
3. Contract of employment Work and occupation Date of recruitment
If employment has been terminated, date of termination
If employed on a temporary basis, end date
4. If employee is a foreign national: Nationality
Work permit, permanent residence permit (A,B,C,F,G,L,N)
Subject to withholding tax □ Yes □ Nono. If yes: commercial liability insurance 5. Incapacity for work
Date of cessation of work Date of return to work (if known) Nature of health impairment Since when (first occurrence)
Last name, first name, locality of first doctor
Is the condition the result of an accident? Doctor
providing treatment
(if different): Last name, first name, locality
Date of first consultation
Return to work: %
□ Yes □ No
6. Weekly working time
In days In hours In hours spent at
workplace Employment
status:
□ Regular □ Irregular □ Partially unemployed □ Fully unemployed
7. Salary CHF per hour day month year Basic salary gross (including cost-of-living
allowances) Shift/commission
Child, family allowances
Holiday pay, compensation for public holidays (% or CHF)
Bonus /13th monthly salary (% or CHF) Other allowances - type:
Benefits in kind - type:
8. Benefits from other social insurance schemes
Is the insured person already entitled to daily benefits or a pension from a social insurance scheme: health, accident, disability, pension, military or unemployment insurance?
9. Procedure in the event of sickness:
The insured person, their employer or representatives of either must complete this sickness notification form and return it to the VAUDOISE GENERAL, Insurance Company Ltd agency as soon as possible.
On the occasion of each visit or consultation, the insured person must present the incapacity checklist to the doctor providing treatment so that he/she can enter the necessary details. Once the case has been concluded, the insured person hands the incapacity checklist over to his/her employer. The employer enters the date of return to work and returns the checklist to the VAUDOISE GENERAL, Insurance Company Ltd agency without delay.
If the incapacity persists for more than one month, a copy of the checklist must be sent to the VAUDOISE GENERAL, Insurance Company Ltd agency at the end of each month.
10. Processing of personal data:
The insured person hereby authorizes VAUDOISE GENERAL, Insurance Company Ltd, where necessary, to share all information on his/her case of illness with other insurers in Switzerland or abroad, including in particular co-insurers and reinsurers.
VAUDOISE GENERAL, Insurance Company Ltd may also obtain information from such insurers and gain access to files held by official bodies or the courts.
This agreement is independent of any recognition of entitlement to insurance benefits. 11. Right to access information:
The insured person releases hospitals, doctors, authorities, insurance companies or institutions, including in particular Federal Disability Insurance and occupational pension providers, from their duty to maintain confidentiality and authorizes them to provide
VAUDOISE GENERAL, Insurance Company Ltd with all requested information in connection with a claim.
12. Overinsurance:
Under the contractual provisions, the insured person authorizes VAUDOISE GENERAL, Insurance Company Ltd to reclaim directly from social security institutions (disability
insurance, occupational pension funds, accident insurance, unemployment insurance, federal military insurance) all or part of any benefits provided by those institutions if the benefits in question were provided concurrently with the daily benefits paid by VAUDOISE GENERAL, Insurance Company Ltd.
13. Right of free transfer:
Under certain conditions, the insured person has the right to transfer to individual insurance. To be valid, a written request to this effect must be submitted by the insured person within 30 days of their employment relationship coming to an end.
14. Additional copies
Additional copies of this form can be downloaded from the website
http://www.vaudoise.ch/fileadmin/documents/vaudoise.ch/formulaires/iiiDeclaration_Mal_F.pdf under claims (Schaden).
The insured person and the employer confirm that they have answered the questions on this form with due care and have taken note of the above-mentioned.
The employer hands over a copy of this form to the insured person.
If the form is transmitted by electronic means, VAUDOISE GENERAL, Insurance Company Ltd waives the requirement for handwritten signatures.
Place and date: Signature of insured person: Signature of employer: 1. Insured person
Last name, first name Address
Postcode / locality
Date of birth and gender □ Male □ Female
2. Claim
Date of accident or sickness VAUDOISE GENERAL, Insurance Company Ltd. claim file ref.
□ Accident □ Sickness 3. Doctor l Consultations: date and time Incapacity for work Signature of doctor 1 2 3 4 5 6 7 8 9 10
Next Took place on % Starting on
Medical treatment ended on: Doctor's stamp
4. Employer Name
Address
Postcode / locality
Insurance contract no. (e.g. 123456.5630) Date of return to work
Place and date
Signature of employer
5. Notes for the insured person:
This incapacity checklist is retained by the insured person.
It must be presented to the doctor providing treatment on the occasion of each visit, so that he/she can complete section 3.
Once the medical treatment has come to an end, the insured person submits this checklist to his/her employer. The employer enters the date of the return to work and forwards the checklist to the VAUDOISE GENERAL, Insurance Company Ltd agency without delay. If the incapacity persists for more than one month, a copy of the checklist must be sent to the
VAUDOISE GENERAL, Insurance Company Ltd agency at the end of each month. 6. Notes for the doctor providing treatment:
Regular updating of this checklist will normally enable VAUDOISE GENERAL, Insurance Company Ltd to dispense with interim and final reports except in special cases.
