Accident report
All informations will of course be treated confidentially and forwarded directly to the accident
insurance company.
Please send the completed form by e-mail to HRMServices@equilas.ch
Surname, first name:
Company:
1. Type of accident: x Occupational accident (accident during work)
Non-occupational accident (private accident)
Type of damage: x Minor accident (no incapacity for work or such incapacity
for 3 calendar days at most)
Accident (incapacity to work for more than 3 calendar days)
Tooth damage
Occupational disease
Relapse
In the event of a relapse, only the following two details must be provided (if known):
Relapse date: Claim number:
2. Date of accident: 12.09.2024
3. Accident clock time: 0800
4. Description of the accident: Injury in the index finger of right foot.
5. Accident location (e.g. adress, town) / accident site (e.g. stairs, ski slope, etc.): Road sidewalk.
6. Persons / objects involved: Roadside stone.
7. Does a police report exist?:
yes x no
8. Last working day before the accident: 11.09.2024
9. Last working clock time: 1800
10. Reason for any absence before accident (not necessary in case of minor accident): NA
11. Work suspended as a result of the accident:
yes x no
If yes: Work suspended from
Date: Clock time:
12. Expected duration of incapacity to work longer than 1 month:
yes x no
13. Part of the body affected/injured: Index finger of right foot.
14. Side of the body (left/right): Right
15. Type of injury (e.g. fracture, bruise, etc.): Bruise and swelling due to broken tissues.
16. Did you obtain medication from the pharmacy?
x yes no
Doctor / Hospital Ortho-Notfall Klinik, Merian Iselin, Basel
Primary treating doctor / hospital: Dr. Med. Simon Karl Gratza / Merian Iselin
Address: Föhrenstrasse 2
Postcode / town: 4009 / Basel
Follow-up doctor / hospital: Dr. Med. Simon Karl Gratza / Merian Iselin
Address: Föhrenstrasse 2
Postcode / town: 4009 / Basel
Date: 12.09.2024
