Request for a control of an insured person who is unable to work

Fields marked with an asterisk (*) are mandatory.

CONTACT DETAILS OF THE EMPLOYER REQUESTING THE CONTROL

Employer's name*

Name and position of the declarant*

Employer's insurance number*

Email of the declarant*

Declarant's telephone number*

This form is to be completed by the employer or his duly authorised representative. *

CONTACT DETAILS OF THE INSURED PERSON TO BE VERIFIED

Name of the insured person to be controlled*

First name of the insured person to be controlled*

Insured person's insurance number*

Address*

Postal code*

City*

Country

POSSIBILITY OF CONTACTING THE INSURED PERSON TO BE CONTROLLED

I have the opportunity to get in touch with my employee (during the day) Yes No

DATA RELATING TO INCAPACITY FOR WORK OF THE INSURED PERSON TO BE CONTROLLED

The current absence of the insured person is covered by a medical certificate of incapacity for work. * Yes No

Attach a copy of the medical certificate (PDF format, less than 5 MB) No file chosen

Is this the first request for a control for this insured person? If not, when was the last one?

Start date of the certificate of incapacity*

End date of the medical certificate of incapacity for work*

Authorised exit * Yes No

Hospitalisation * Yes No

Reasons for the request

Details of non-observance of statutory provisions (exit times, frequenting a drinking establishment, etc.)

Please note that this request and the result, if applicable, on the ability to work do not exempt the employer and his duly authorised representative, or the employee, from complying with the provisions of Article L.121-6 of the Labour Code concerning ‘protection in the event of incapacity for work of the employee’. *

With link for the article:

https://legilux.public.lu/eli/etat/leg/code/travail/20240804