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NOTIFICATION OF A CASE OF DEATH

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PASSAGE ST-ANTOINE 7 | CP | CH – 1800 VEVEY 1 T 021 924 87 40 | F 021 924 87 07 COPRE@COPRE.CH | WWW.COPRE.CH

LA COLLECTIVE DE PRÉVOYANCE D E P U I S 1 974

Company :

Contract n° :

Personal data of the insured(s) Name and first name :

Date of birth :

AVS N° :

Sex :

Civil status :

bachelor

married

bound by a registered partnership

masculine

divorced

feminine

widow(er)

dissolved partnership

If married or bound by a registered partnership, date of marriage/partnership : First name of spouse/partner :

Date of birth :

If divorced or partnership dissolved, date of the divorce/dissolution of the partnership : Children (if under 25 years of age) :

First name

Date of birth

Had the person, to your knowledge, already been divorced once, or had already experienced a dissolved partnership ?

yes

no

Details concerning the death a) Date of death : b) Cause of death, if known:  

infectious disease

road accident

cancer

other accidents, homicide

failure of the respiratory system

suicide

failure of the digestive system

AIDS

illness of the respiratory system

drugs

metabolic disease

anther cause :

c) Did the person have a lack of earning capacity more than three months before his death ? yes, at

% from the

(Please attach the medical certificate)

non d) If possible, name and address of the doctor : who recorded the death family doctor attending physician e) Is there an existing obligation to pay the salary after death ?

yes

no

If in the affirmative, for how long ?

Notification of a case of death | January 2014 | page 1/2

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co re LA COLLECTIVE DE PRÉVOYANCE D E P U I S 1 974

Enclosures

official death certificate

complete copy of the family record book or family certificate or extract from the registry office

(useless for bachelors without children)

medical certificate/medical report

Address of the survivors (if known)

Comments

Place and date :

Notification of a case of death  |   January 2014  |  page 2/2

Stamp, signature of employer : 

Notification of a case of death  
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