Application form to determine social insurance liability in an EU or EFTA Member State after permanent departure from Switzerland

To be completed by the applicant

Date of leaving Switzerland*

. .

(Frontier workers: end of employment activity)

Last name*

Last name

Other last name

Forename*

Forename

Other forenames

Date of birth*

. .

Nationality

Personal identity document No.

AHV/AVS no. (Swiss OASI number)

Address in the EU / EFTA country*

Country

Last address in Switzerland

Telephone number

or e-mail
(for further questions)

Pension fund / Vested benefits foundation in Switzerland
(name and address)*

Contract number

Last employer in Switzerland (name and place)

The applicant confirms the correctness of the information above.

Place*

Date*

Contact