Accident at work Request for prior approval (sickness, maternity, occupational disease) (Form 12040*04)

National Health Insurance Fund (Cnam) - Cerfa n° 12040*04
Autre numéro : DIAD S3108f

Form template uploaded for information

For your gait, you must use the original form provided by the healthcare professional.

Contains leaflet 50556#05.

Go to the online administrative form

Verified 24 October 2023 - Directorate for Legal and Administrative Information (Prime Minister)

To whom shall I send this form ?

For details, please use the practical information sheets :

J'ai réalisé une démarche administrative

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