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Forms

All the forms for your insurances gathered here.

Occupational incapacity insurance

Fill in this form, sign it and return it AG Employee Benefits to the attention of your plan manager at Boulevard Emile Jacqmain 53, 1000 Brussels.

New enrolment       
Use the application for enrolment form to enrol a new employee (except the Evolulife plan).  
EN - FR - NL - DE
                                              
                                 
Occupational incapacity
                                                                                                                                    

If the invalidity coverage is provided use the Claim Notification and Medical Certificate forms to report the occupational incapacity of an affiliate.

As soon as the required waiting period is over or you know that it is about to be exceeded, ask the affiliate: 
to complete the Claim Notification form and sign it, 
to have their physician complete and sign the Medical Certificate form, 
to have their sickness fund complete and sign the certificate for the first year of occupational incapacity. The certificate must only be completed when the benefits paid for under the incapacity benefit coverage take into account the contribution by the sickness fund and affiliates benefit from a contribution by the sickness fund of 55%. Without the certificate, payment will be based on a 60% contribution by the sickness fund.

Please also send a photocopy of the extension certificates and of any return-to-work certificate to your manager.

After one year of occupational incapacity:
At the end of the first year of incapacity, or as soon as you know that they will be disabled for more than a year and if the benefits paid under the incapacity benefit coverage take into account the contribution by the sickness fund, request that the affiliate on occupational incapacity leave

have their sickness fund complete and sign the occupational incapacity certificate after a year 
send the certificate to AG Insurance - AG Employee Benefits to the attention of the claim manager of your plan at Boulevard Emile Jacqmain 53, 1000 Brussels.

The certificate will enable us to calculate the amount of the compensation starting in the second year given the change in the contribution by the sickness fund starting in the second year of occupation incapacity.


Claim notification      
EN FR - NL - DE                                                                      
                                       
Medical certificate
EN FR - NL - DE
                   

The information required by the Verwilghen Act
(healthcare insurance and income protection)                                                                                 
                                                                                                                                                                                     

Pre-financing information document
The pre-financing information document must be provided by the employer to all of their insured employees and whenever a new person is hired. This ensures that the employer fulfils his information obligation under the Verwilghen Act. Given the severe sanctions, it is recommended that an acknowledgement of receipt be signed by the employees. 
For group hospitalisation, the employer must also provide the AG Care Vision form.
EN FR - NL - DE

Request for individual continuation coverage
This document must be provided to the employee at the latest 30 days after the end of affiliation or the loss of group healthcare insurance or income protection coverage. The document consists of two parts:
The first must be completed by the employer.
The second is for the employee requesting individual continuation coverage.
The two documents must be sent to the employee.
EN - FRNL - DE