Unemployment insurance
Date of receipt
Employer’s certificate
Surname and first name
Personnel no.
AHV (Swiss old age and survivors’
insurance no.)
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
1
The form of employment immediately before leaving employment is decisive in answering
the following questions.
Fixed-term
Permanent
Type of employment
Work scheme for
Temping/agency work
On-call job
Full-time job
unemployed persons
Seasonal job
Temporary employment
Part-time job
Apprenticeship
Teleworking / working
from home
from
to
2
Length of employment
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.) ?
yes
no
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?
8
Was employment subject to a collective employment agreement?
yes
CEA
9
yes
no
no
Which AHV compensation fund is the company affiliated to?
(Name and number)
Termination of employment
When?
10 Who gave notice?
verbally
in writing (attach written notice)
For what date of
termination?
11 Duration of the statutory or contractual notice period?
13 Reason for notice
______________________________________________________________
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716.103 e 6.2008
0716103 – 004 – 06 - 2008
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
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
contributions
CHF
CHF
CHF
CHF
17 Earnings
THE PAY SLIPS OR PAYROLL REGISTERS OF THE LAST 12 MONTHS MUST BE INCLUDED WITH THE
EMPLOYER’S CERTIFICATE
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/
hours
CHF
Last hourly wages:
Vacation pay
Holiday pay
%
%
13th monthly
Total hourly
wage / bonus
wages
% CHF
18 Absences
Absences during the last 12
months on account of
Illness
from
to
from
to
from
to
Accident
Swiss military service, civil
protection or civilian service
Unpaid vacation
Other reasons
19 Is an annuity or pension being paid?
(attach supporting documents)
yes
CHF
per month
no
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
entitlements?
yes CHF
(attach supporting documents)
no
22 Were child and/or training allowances paid?
yes
Number of child allowances
Place and date:
Number of training allowances
Complete address / Valid signature / Company stamp
and
Tel.
Attached copies:
Letter of notice
Pay slips for the last 12 months (section 17)
Supporting documents according to sections 19 + 21
no