Notification of withdrawal

Details of the insured person

Form of address *

First name *

Last name *

Street and house number  *

Postcode *

Place *

Country *

Telephone *

E-mail *

Date of birth *

Insured person’s AHV/AVS number  *

Please enter the AHV/AVS number (e.g. 756.1234.5678.90).

Is the insured person fully capable of working? *

Yes

Answer “no” if at least one of the following statements applies. The insured person: a) is considered disabled under Federal disability insurance, accident insurance or military insurance and/or is receiving benefits from at least one of these institutions; b) has been absent from work for more than three weeks prior to leaving this employer; c) is permanently restricted in their capacity to work for medical reasons.

Employment details

Company  *

Contract number  *

Date of withdrawal *

Additional question for insured persons who are 58 or older.

Early retirement? *

Yes

When an insured person who is 58 years of age or older leaves the company, this question must be answered.

Official identification document of the insured person *

Select file

Copy of an official document containing the signature of the insured person (passport, ID). Possible file formats: .pdf, .jpg, .png, .gif, .tiff, .doc, .docx, max 5 MB

Please let us know who we can contact.

Details of the contact person who entered this report and confirms the accuracy of the information.

Form of address *

First name *

Last name *

E-mail *

E-mail address for any queries regarding this report.

Telephone *

Comments (e.g. availability by telephone)

Fields marked with * must be completed.

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