Claim for Temporary Incapacity Allowance (Form 14103*01)

National Health Insurance Fund (Cnam) - Cerfa n° 14103*01
Autre numéro : S6110

Form posted online for information.

This form is given to the employee by the occupational doctor if the incapacity for his work may be linked to an accident or an occupational disease.

The employee must fill in the form provided by the occupational doctor.

Access to the explanatory leaflet.

Go to the online administrative form

Verified 22 March 2021 - Directorate for Legal and Administrative Information (Prime Minister)

To whom shall I send this form ?

J'ai réalisé une démarche administrative

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