Incident note

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

Employer & policy

Employer

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Contact person

   
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Account details

If no details are provided, the contractually agreed payment details will be used.

   
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Insured person

Contact details

   
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Employment details

   
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Work place

 

Percentage breakdown of work

   
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Salary details

   
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Additional information

Does the insured person receive a pension or a daily allowance?

   
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Incapacity to work

Incapacity to work

   
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Resumption of work


   
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Treatment

First treating physician


   
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Subsequent treating physician


   
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Remarks

Remarks for the insurance provider

Characters remaining:

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Send and Print

          
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Under "Open PDF document" and "Download PDF", the claim number will only be visible after transmission of the data to the insurance provider.

Submit attachment

Submit attachment

Documents can only be sent after successful submission of the incident report.

Help for use

Do you have any questions about the software?

Sunet help desk 041 455 43 12
Mon-Fri: 8:00 - 12:00 and 13:00 - 17:00


Do you have any questions about Visana’s processing of claims? Forgotten policy no.?

Accident section:
Visana AIA/UVG Benefits Centre 031 357 87 87
(Mon-Fri 08:00 to 17:00)

Daily allowance section:
Visana Daily Allowance Centre 031 357 88 00
(Mon-Fri 08:00 to 17:00)

Version: 26401