Incident note

Fill in the following fields with your data in order to complete the incident note.

Policyholder & policy

Policyholder

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Policy information

   
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Contact person

   
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Company details

   
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Insured person

Personal data

Bank account

Bank account information is required for direct payments to the insured or if the employment contract has been terminated.

   
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Personal details


   
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Employment data

   
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Working time

   
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Further information

Further social insurance

Does the insured person receive a pension or daily benefit (e.g. accident, BVG/OPA, daily sickness benefit, unemployment, foreign insurance scheme)? Which insurer and reference number (if known)?

   
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Accident report

Accident details

   
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Accident information

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Injury

Main Injury

   
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Other injury 1

   
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Other injury 2

   
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Treatment

Doctor / hospital that provided initial treatment


   
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Subsequent treatment by doctor/hospital


   
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Send and Print

          
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The PDF contains the key details on the registered incident report. For technical reasons, not all details entered can be seen in the PDF.
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Help for use

Do you have technical questions about BBTClaims?
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Version: 25151