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

CONTACT DETAILS OF THE INSURED PERSON TO BE VERIFIED

POSSIBILITY OF CONTACTING THE INSURED PERSON TO BE CONTROLLED

I have the opportunity to get in touch with my employee (during the day)

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. *
No file chosen
Authorised exit *
Hospitalisation *

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