Incident note

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Employer & Policy

Employer

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Policy information

   
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Contact person

   
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Bank account

   
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Company details

   
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Insured person

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Personal details

   
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Employment data

   
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Working times

   
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Accident report

Accident details

   
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Until when did the insuree work in the company before the accident occured?

   
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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

Initial treatment by doctor/hospital


   
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Subsequent treatment by doctor/hospital


   
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Send and Print

          
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Version: 23480