QUESTIONNAIRE FOR THE REVISION OF THE DISABILITY PAYMENT

Please return to : DI Office for people living abroad OAIE, Av. Edmond-Vaucher 18, POB 3100, 1211 Geneva 2, Switzerland

Name : Our ref. :

DOB :

Important :

Please fill in the questionnaire completely and precisely. Please print clearly, sign and date.

Insuree’s phone number: ___________________________________________________ E-mail address: ___________________________________________________________

1. MEDICAL INFORMATION SINCE THE LAST REVISION / SINCE APPROVAL OF DI BENEFITAre you currently undergoing medical treatment? If so, which treatment by which doctor? Please add complete doctor’s address.

2. ECONOMIC INFORMATION SINCE THE LAST REVISION/SINCE APPROVAL OF DI BENEFITa) Have you been or are you currently gainfully employed/self-employed after ?

No (You may date and sign the questionnaire directly in Section 3 and return it to us.)

Yes : Beginning of contract/work on dd.mm.YYYY End of contract/work on dd.mm.YYYY or contract not terminated.

Work(ed) as Employee Self-Employed/independent Volunteer / in sheltered workshop

Percentage of activity : __ % full-time part-time

..........................

Federal Department of Finance FDF

Central Compensation Office CCO Disability insurance Office for insured people living abroad

If part-time, what was the reason?

b) Working hours and revenue :

Daily working hours : __________________________ Weekly working hours : _________________

Gross hourly wages : __________________________ Gross monthly wages : __________________

c) Briefly describe your activity and then answer the additional questions at the end of thisquestionnaire:

d) Name and address of the employer (Street/Street number, postal code, town/city, E-mail address :

e) If you were forced to interrupt your activity due to sickness or accident, please indicate how and forwhich period your activity was affected (please send attestation)

f) Have you given up your activity due to these interruptions? Since when?

Federal Department of Finance FDF

Central Compensation Office CCO Disability insurance Office for insured people living abroad

3. OTHER REMARKS :

The insuree declares to have completely and truthfully answered the questions on this questionnaire.

Place and date : Signature :

Federal Department of Finance FDF

Central Compensation Office CCO Disability insurance Office for insured people living abroad

4. ADDITIONAL QUESTIONS : DESCRIPTION OF THE INDIVIDUAL ACTIVITY

The information you are giving us is extremely important. Indeed it will allow the medical service to optimally evaluate your situation.

For the following questions, please indicate the main tasks given to you as accurately as possible. Include a job description and what the requirements are to fulfill this job.

Which tasks make/made part of your job ? What is the frequency of these tasks to be performed properly? (on the basis of 8 hours/day)

up to ½ h bet. ½h to 3h bet. 3h to 5¼ h seldom occasionally often

What requirements were you faced with concerning What is the frequency these requirements were needed? the physical/intellectual workload? (on the basis of 8 hours/day)

up to ½ h bet. ½h to 3h bet. 3h to 5¼ h Physical seldom occasionally oftenseated

walking

standing

Lifting and carrying (light: 0–10 kg)

Lifting and carrying (medium: 10–25 kg)

Lifting and carrying (heavy: more than 25 kg)

other

The daily demand is Intellectual high moderate light concentration/attention to detail

endurance

Attention to detail

Ability to understand

other

Federal Department of Finance FDF

Central Compensation Office CCO Disability insurance Office for insured people living abroad

Other requirements :

Please indicate any additional information that you may find useful in giving us a more realistic picture of the work you are carrying out.

Federal Department of Finance FDF

Central Compensation Office CCO Disability insurance Office for insured people living abroad

Insurees phone number: Email address: Employee: OffSelfEmployedindependent: OffVolunteer in sheltered workshop: Offcontract not terminated: Offfulltime: Offparttime: OffDaily working hours: Weekly working hours: Gross hourly wages: Gross monthly wages: DOB: Our ref: Name: wich treatment by wich doctor ?: No: OffYes: Offreason: your activity: Name and address of the employer: How and for wich period your activity was affected: since when ?: Other remarks: Place and date: Text11: Check Box12: OffCheck Box11: OffCheck Box13: OffText14: Check Box15: OffCheck Box16: OffCheck Box17: OffText18: Check Box19: OffCheck Box20: OffCheck Box21: OffText22: Check Box23: OffCheck Box24: OffCheck Box25: OffText26: Check Box27: OffCheck Box28: OffCheck Box29: OffText30: Check Box31: OffCheck Box32: OffCheck Box33: OffCheck Box34: OffCheck Box35: OffCheck Box36: OffCheck Box37: OffCheck Box38: OffCheck Box39: OffCheck Box40: OffCheck Box41: OffCheck Box42: OffCheck Box43: OffCheck Box44: OffCheck Box45: OffCheck Box46: OffCheck Box47: OffCheck Box48: OffCheck Box49: OffCheck Box50: OffCheck Box51: OffCheck Box52: OffCheck Box53: OffCheck Box54: OffCheck Box55: OffCheck Box56: OffCheck Box57: OffCheck Box58: OffCheck Box59: OffCheck Box60: OffCheck Box61: OffCheck Box62: OffCheck Box63: OffCheck Box64: OffCheck Box65: OffCheck Box66: OffCheck Box67: OffCheck Box68: OffCheck Box69: Offadditional information: percentage: Date of the last questionnaire for the revision of the disability benefit: