Formulaire

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

Cerfa 12040*04 (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.

    Fill out the form

    To whom shall I send this form ?

    For details, please use the practical information sheets :

    J'ai réalisé une démarche administrative

    Je donne mon avis sur Services Publics +. L'administration concernée me répondra.

    Je donne mon avis

    Émetteur du formulaire administratif : National Health Insurance Fund (Cnam)

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