Unemployment insurance Date of receipt
Surname and first name Personnel no. AHV (Swiss old age and survivors’
Postcode, town, street, number Date of birth Marital status
Employers are required to provide truthful information and must maintain confidentiality vis-à-vis third parties (Art. 20,
88 AVIG; Art. 28 ATSG); they must in particular deliver the employer’s certificate to the insured person within a week of
said person’s request.
Form of employment The form of employment immediately before leaving employment is decisive in answering
the following questions.
1 Type of employment Fixed-term Permanent
Full-time job Temping/agency work On-call job Work scheme for
Part-time job Seasonal job Temporary employment unemployed persons
Teleworking / working Apprenticeship
2 Length of employment from to
3 Employed as
4 Does the insured person or his/her spouse or registered partner have a share in the business or hold a managerial
position (e.g. shareholder, board of directors in a plc or partner or MD in a private limited company, etc.) ?
5 Normal working hours in the business Hours per week
6 The insured person’s normal contractual working hours Hours per week
7 Was there a written employment contract? yes no
8 Was employment subject to a collective employment agreement?
yes CEA no
9 Which AHV compensation fund is the company affiliated to?
(Name and number)
Termination of employment
10 Who gave notice? When? For what date of
verbally in writing (attach written notice) termination?
11 Duration of the statutory or contractual notice period?
12 Was the insured person unable to work due to illness, accident, pregnancy, military service, civil protection or
civilian service at the time notice was given or during the notice period?
yes, due to from to no
13 Reason for notice ______________________________________________________________
0716103 – 004 – 06
14 Last day worked
15 Wages were paid until
Periods of employment in the last 2 years
16 Use a new line for each period of employment that follows a break in employment of at least one month.
from to Total earnings subject to AHV
THE PAY SLIPS OR PAYROLL REGISTERS OF THE LAST 12 MONTHS MUST BE INCLUDED WITH THE
Last monthly wages CHF
- The last time the ensured person received
a 13th monthly wage of CHF was on
a bonus of CHF was on
Basic wage/ Vacation pay Holiday pay 13th monthly Total hourly
Last hourly wages:
hours wage / bonus wages
CHF % % % CHF
Absences during the last 12
from to from to from to
months on account of
Swiss military service, civil
protection or civilian service
19 Is an annuity or pension being paid? yes CHF per month no
(attach supporting documents)
20 What pension fund are employees ensured with under the Federal Act
on Occupational Old Age, Survivors' and Invalidity Pension Provision?
21 On termination of employment, did you grant the insured person further financial benefits in addition to wage
yes CHF (attach supporting documents) no
22 Were child and/or training allowances paid?
yes Number of child allowances Number of training allowances no
Place and date: Complete address / Valid signature / Company stamp
Attached copies: Letter of notice
Pay slips for the last 12 months (section 17)
Supporting documents according to sections 19 + 21