Declaration of work disability - Employee

Instructions:

Before reporting a disability, we ask you to have the following documents digitally available:

• Medical certificate form - to be completed by the treating physician (Optional for pregnancy)
• Insured person's declaration form - to be completed by the insured
• Disability certificates (Optional for pregnancy)
• Medical reports (e.g. operation reports, hospitalization reports, specialist progress reports, etc.)
• Letter confirming contribution by the health fund, with start date and end date (pregnancy only)
• Copy/ scan of your ID-card
• Copy/ scan of your bank card or bank statement

You can download the first two documents here:

• Medical certificate form - to be completed by the attending physician
• Insured person's declaration form - to be completed by the insured person

Once you have filled out and have these documents available, you can proceed to the next step.

"By completing this form, you expressly authorise NN Insurance Belgium SA/NV (AvenueFonsny38, 1060 Brussels), in its capacity as data controller, to process your health data, which you communicate to us in the context of the processing of your "disability file”.