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accident notification we are happy to assist.

We wish you a good and full recovery. If you have any questions about the form please contact our Admin Center.

please complete this form.

first name^*

last name^*

phone / mobile^*

date of birth^*

e-mail^*

did the accident happen at work or was it a non-occupational accident? ^*

if relapse - please state insurance and claim number incl. exact details of the 1st accident optional

when exactly did the accident take place?^*

at what time did the accident happen?^*

(HH:MM)

where did the accident take place?^*

(Street / ZIP / City)

how did it happen?^*

Please describe the exact circumstances

were other people involved? ^*

if yes, who? optional

(first name, last name)

did the police have to file a report? ^*

which body part is affected? ^*

is another body part affected? if yes, please choose. optional

what is the exact injury? ^*

when was the last time you worked before the accident?^*

(date and time)

were you absent from work? for how long?^*

at which location are you employed?^*

did you go back to work, and if so, when? optional

if yes, for what percentage of working time? optional

physician's details^*

(name and address)