Accident Notification

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Metadata

User Id

Form Uuid

Language

Webmail2Id

mailTo

Bcc

formType

resourceDownloadUrl

onServer

Accident reported by

Title

Mrs./Ms.

Mr.

First name

Last name

Injured person

Please answer all questions completely and accurately.

First name

Last name

Street, n°

Postcode

Town

Telephone n° (private)

Telephone n° (business)

Insurance number

Format: 123.45.67.890.1

AHV number

Date of birth

Injured person

child

Pupil

Student

Trainee

Employee

Self-employed

Not gainfully employed

Retired

Other

Beschreibung andere

Work details

Name and address of employer at time of accident

Days per week

Hours per week

If unemployed or if no longer gainfully employed as an employee (e.g. following a vacation, stay abroad, continuing education)

For whom did you last work before the accident, and until when?

Average working hours per week?

Less than 8 hours

8 hours or more

Since then, have you received daily allowance from unemployment insurance?

Yes

from

until

Do you have an Insurance by Special Agreement?

Yes

from

until

Additional questions regarding the traffic accident

Vehicle used by you

Type (e.g. bicycle, moped, motorcycle, car)

Vehicle licence plate

Halter/Eigentümer (Name und Adresse)

Driver (name and address)

Third party liability insurance, policy n°

Passenger insurance/ pillion passenger insurance policy n°

War ein zweites Fahrzeug in den Unfall involviert?

Yes

Collision vehicle

Vehicle licence plate

Halter/Eigentümer (Name und Adresse)

Driver (name and address)

Third party liability insurance, policy n°

Passenger insurance/ pillion passenger insurance policy n°

Accident Notification

Metadata

Accident reported by

Injured person

Work details

Injuries

Additional questions regarding the traffic accident

Collision vehicle

Other insurances

General remarks