Kvg Questionnaire For Employees Form – Fill Out and Use This PDF

Questionnaire for employees - family Insurance

Personal details of member

Surname, First name	………………………………………………….………………………...
Address	……………………………………………………….…….…..…………
Additional address details	..…………………………………………….……….……..….…………
Country/Postal Code/Town	...…………………………………………………………..…..…………
Date of birth	………………………………………………………..………..…………
Insurance no. abroad	………….…..……………………….……………………………………
Telephone no./E-Mail	…………………..…..…/…………………………………...……………
IBAN and BIC	……….……………………………………………………………………

Name and address of bank ……….……………………………………………………………………

Account holder	…………………………………….………………………………………
(and address if different from above)
Civil status:
 single	 married	 widowed  divorced since ..…………..……

separated  registered partnership (please enclose document of registration in Switzerland)

Gainful employment:	I am employed	 yes	 no
In (country) …….…… 	with (employer) ……………………………			self-employed
In (country) …….…… 	with (employer) ……………………………			self-employed
In (country) …….…… 	with (apprenticeship) ……………………..
as  frontier worker	 posted worker	 employee of embassy or consulate

on legal parental leave until ………………………………..

Pension: I draw an official pension		 yes	 no
In (country) …………………….. since/per		……………….……
In (country) …………………….. since/per		……………….……
Details of the Swiss Health Insurance:
I am insured with a Swiss Health Insurance:		 basic	 complementary  no
Name of Health Insurance:	.………….………………………………………………………….

In case you have been exempted from the Swiss compulsory Health Insurance by the authorities of your Canton of domicile, please send us a copy of the exemption document.

Family details

	Spouse/Father/		1st child*		2nd child*		3rd child*
	mother of
	children
Surname
First name
Date of birth
Insurance no. abroad
Address if different from
above
Name and address of
Health Insurance
Pension	 yes	 no	 yes	 no	 yes	 no	 yes	 no
In (country)	………………….		……………….		……………….		……………….
	………………….		……………….		……………….		……………….
Gainful employment or	 yes	 no	 yes	 no	 yes	 no	 yes	 no
apprenticeship	……………….….		…………….….		…………….….		…………….….
In (country)	…………………..		………………..		………………..		………………..
Employer:	……………….….		…………….….		…………….….		…………….….
Scholar/Student			 yes	 no	 yes	 no	 yes	 no
Probably until			……………….		……………….		……………….

*Only to be completed if children are dependent family members. If mother/father from former partnership, please indicate custody.

I, hereby, confirm that the above statements have been truthfully made and that I have read the Information sheet for benefits assistance in Switzerland (responsibilities and consequences of non-compliance; please see on the back).

……………………………………..…	…………………………………………………….
Place, date	Signature

Your personal details are necessary for us in order to clarify the conditions in respect of the claim for mutual benefits assistance. The legal basis for this can be found in Art. 84 KVG of the Federal Law regarding health insurance.

Information sheet for benefits assistance in Switzerland (responsibilities and consequences of non-compliance)

Please pay careful attention to the following information. With your signature on the questionnaire you confirm that you have answered the questions completely and truthfully and that you have read and understood this information sheet.

Why a questionnaire?

By means of the details you have given us on your questionnaire, we will assess whether benefits assistance in respect of illness, recreational accident and maternity is possible for you or whether an obligation to be insured in Switzerland exists. For example, an obligation to be insured in Switzerland exists if you are employed in Switzerland or draw a Swiss pension – independent of the amount of your income. Children have to be insured in Switzerland if at least one parent is obliged to be insured in Switzerland because he/she is employed here.

Benefits assistance for children is possible until the age of 18 unless they have taken up further education in which case it is extended to the age of 25. In exceptional cases this can be extended further. We reserve the right to request details of further education.

What happens if an obligation to be insured in Switzerland exists?

Should the registration for benefits assistance have to be denied, the responsible cantonal authority will be informed. Basically, the responsibility to ensure the adherence to insurance requirements lies with this authority (Art. 6 KVG).

Why do I have to communicate changes immediately?

In Switzerland it is only possible to take out health insurance retrospectively for a maximum of three months. Therefore, it is important for you to inform us about changes without delay.

What happens if I communicate changes too late?

If you do not duly inform us, you risk an insurance gap between the end of your health insurance abroad and the beginning of your insurance cover in Switzerland. This can lead to a situation where you will have to pay for medical costs yourself which occur during the insurance gap.

Even without medical treatment during the time in question, an interruption of your insurance protection can have considerable consequences in respect of future claims to benefits or insurance cover.

Legal basis:

Art. 28 par. 1 and 2 ATSG (Federal law concerning general conditions of social insurance), art. 31 par. 1 ATSG, art. 25 par. 1 and 2 ATSG, art. 92 par. 1 lit. a and b KVG (Federal law concerning health insurance), art. 93 par. 1 lit. a KVG and art. 76 par. 4 decree (EG) Nr. 883/2004.