Accident Notification

Accident reported by

Title

Injured person

Please answer all questions completely and accurately.

Format: 123.45.67.890.1

Injured person

Work details

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

Average working hours per week?
Since then, have you received daily allowance from unemployment insurance?
Do you have an Insurance by Special Agreement?

Format: 09:30

Is it a traffic accident?
Was a third party responsible for the accident?
Was a police report filed?

Injuries

Side of body
Are you unable to work?
Could the medical treatment be concluded in the meantime?

Additional questions regarding the traffic accident

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

War ein zweites Fahrzeug in den Unfall involviert?

Collision vehicle

Other insurances

By which of the insurances listed below are you insured against accidents, whether mandatory or supplementary, and to what extent?

Obligatory Accident Insurance UversG/OUFL of the employer

Coverage as per UVersG/OUFL

Additional/Supplementary Insurance to the Obligatory Accident Insurance UversG/OUFL
Coverage for medical expenses and/or daily allowance (loss of earnings)
Other accident insurance
Coverage
School accident insurance
Erhalten Sie eine Rente der Invalidenversicherung, der SUVA, UVersG/OUFL, MV oder Privatversicherung?

General remarks