DECISION No 166 of 2 October 1997 on the amending of forms E 106 and E 109 (Text with EEA relevance) (98/441/EC)
THE ADMINISTRATIVE COMMISSION OF THE EUROPEAN COMMUNITIES ON SOCIAL SECURITY FOR MIGRANT WORKERS,
Having regard to Article 81(a) of Council Regulation (EEC) No 1408/71 of 14 June 1971 on the application of social security schemes to employed persons, to self-employed persons and to members of their families moving within the Community, under which it is the duty of the Administrative Commission to deal with all administrative matters arising from Regulation (EEC) No 1408/71 and subsequent Regulations,
Having regard to Article 2(1) of Council Regulation (EEC) No 574/72 of 21 March 1972, under which it is the duty of the Administrative Commission to draw up models of certificates, certified statements, declarations, applications and other documents necessary for the application of the Regulations,
Having regard to Decision No 153 of 7 October 1993 on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 001, E 103 to E 127),
Whereas Council Regulation (EC) No 3095/95 of 22 December 1995 has amended Article 17(2) and Article 30(1) of Regulation (EEC) No 574/72 by limiting to one year the period of validity of forms E 106 and E 109 issued by German, Italian or Portuguese institutions;
Whereas forms E 106 and E 109 must therefore be adapted;
Whereas the Agreement of the European Economic Area of 2 May 1992, as amended by the Protocol of 17 March 1993, Annex VI, implements Regulations (EEC) No 1408/71 and (EEC) No 574/72 within the European Economic Area;
Whereas by Decision of the EEA Joint Committee the model forms necessary for the application of Regulation (EEC) No 1408/71 and Regulation (EEC) No 574/72 will be adapted and implemented within the European Economic Area;
Whereas for practical reasons identical forms should be used within the Community and within the European Economic Area;
Whereas the language in which forms should be issued is the subject of Recommendation No 15 of the Administrative Commission,
HAS DECIDED AS FOLLOWS:
1. The model forms E 106 and E 109 reproduced in Decision No 153 of 7 October 1993 shall be replaced by the models appended hereto.
2. The competent authorities of the Member States shall make the appended forms available to the persons concerned (rightful claimants, institutions, employers, etc.). However, the introduction of new model forms does not affect the validity of existing models.
3. Each form shall be available in the official languages of the Community and laid out in such manner that the different versions are perfectly superposable, thereby making it possible for all persons or bodies to whom a form is addressed (rightful claimants, institutions, employers, etc.) to receive the form printed in their own language.
4. This Decision shall be published in the Official Journal of the European Communities and shall be applicable from 1 January 1998.
Georges SCHROEDER
The Chairman of the Administrative Commission
START OF GRAPHIC
EUROPEAN COMMUNITIES
Social Security Regulations
EEA (*)
See Instructions on page 3
E 106
(1)
CERTIFICATE OF ENTITLEMENT TO SICKNESS AND MATERNITY INSURANCE BENEFITS IN KIND FOR PERSONS
RESIDING IN A COUNTRY OTHER THAN THE COMPETENT COUNTRY
Employed and self-employed persons and members of their families residing with them; members of the family of unemployed persons who were formerly employed
Regulation (EEC) No 1408/71: Article 19.1.a; Article 19.2; Article 25.3.i
Regulation (EEC) No 574/72: Article 17.1 and 4; Article 27.1 (first sentence)
The competent institution should complete Part A of the form and send two copies to the insured person, or send them - where necessary through the liaison body - to the institution in the place of residence if the form is drawn up at that institution's request. As soon as it has received the two copies, the latter institution should complete Part B and return one copy to the competent institution.
A. Notification of entitlement
1.Institution of the place of residence (2)
1.1.Name: ............... Code number (2a): .................
1.2.Address (3): ............................................
1.3.Reference: your E 107 form of ............................
2.
Employed person
Self-employed person
Unemployed person
Frontier worker (employed)
Frontier worker (self-employed)
2.1.Surname (3a) ..............................
2.2.Forenames / Previous names (3a) / Date of birth
............../ ..................../ .............
2.3. Address in the country of residence (3) ..................
2.4. Identification number (3b): ..............................
2.5. The insured person is / is not employed in a mine or similar place of employment
2.6. The insured person is covered by a scheme for self-employed persons as referred to in Annex 11 to Regulation (EEC) No 574/72 3.Member of the family (4)
3.1.Surname (3a) ...................................
3.2.Forenames / Previous names (3a) / Date of birth
............../ ..................../ .............
3.3.Address in the country of residence (3):..................
4.The abovementioned worker and the members of his family (5) residing with him
4.1.The members of the family (5) of the unemployed person mentioned above
5.are entitled to sickness and maternity insurance benefits in kind as from
6.
The persons concerned will retain their entitlement
6.1. until this certificate is cancelled
6.2. for a period of one year from the date specified in point 5 (6)
6.3. until ...................... inclusive (7)
E 106
7.
Competent institution for sickness and maternity insurance
7.1.Name: ............... Code number (7a): ...........
7.2.Address (3): .....................................
Téléphone ............... Télécopieur .................
7.3.Stamp
7.4.Date: ...................
7.5.Signature ...............
8.
Competent institution for non-occupational accidents (8) (8a) (10)
8.1.Name: ............... Code number (7a): ...................
8.2.Address (3): .................
Téléphone ................ Télécopieur ........................
8.3.Stamp
8.4.Date: ......................
8.5.Signature
B. Notification of registration (9)9.
9.1.The worker named in box 2 and the members of his family
9.2.The members of the family of the unemployed person named in box 2
9.3.were registered with us on9.4.cannot be registered with us because:
10.
Registered members of the family
10.1.Surname (3a)/Forenames/ Sex F/ M /Previous names/Date of birth
10.2............./........ / ...../.../............../ ............
10.3............./........./....../.../............../ ............
10.4............./........./....../.../............../ ............
10.5............./........./....../.../............../ ............
10.6............./........./....../.../............../ ............
10.7............./........./....../.../............../ ............
10.8............./........./....../.../............../ ............
10.9............./........./....../.../............../ ............
11.
Institution of the place of residence
11.1.Name: ................... 11.2.Address (3): ...........
Téléphone .................... Télécopieur ..................
11.3.Stamp
11.4.Date: .....................
11.5.Signature .................
E 106
INSTRUCTIONS
Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information
Information for the insured person
(a)This form entitles you to receive sickness and maternity insurance benefits in kind for yourself and the members of your family. If you are unemployed, this form is not intended for you; it is intended solely for members of your family who reside in a Member State other than the one where you are insured.
(b)The two copies of the form which are in your possession must be submitted as soon as possible to the sickness and maternity insurance institution in your place of residence. If you are unemployed, the form must be submitted by the members of your family to the sickness and maternity insurance institution in their place of residence.
(c)The sickness and maternity insurance institutions are:
in Belgium, the 'mutualité' (local sickness insurance fund) of your choice
in Denmark, the competent 'amtskommune' (local administration), in Copenhagen the 'magistrat' (municipal administration) and in Frederiksberg the 'Kommunalbestyrelse' (municipal administration)
in Germany, the 'Krankenkasse' (sickness fund) in the place of residence chosen by the person concerned
in Greece, normally the regional or local branch of the Social Insurance Institute (IKA). The branch office should issue the person concerned with a 'health book' without which no benefits in kind can be provided
in Spain, the 'Dirección Provincial del Instituto Nacional de la Seguridad Social' (Provincial Directorate of the National Social Security Institution) of the place of residence. If your require benefits you may apply to the medical and hospital service of the Spanish social security health system. You must submit the form together with a photocopy
in France, the Caisse primaire d'assurance-maladie (local sickness insurance fund). Where the answer to 2.5 is 'yes', the form may be sent to the 'Société de secours minière' (Miners Relief Society)
in Ireland, the Health Board in whose area the benefit is sought
in Italy, normally the 'Unità sanitaria locale' (USL, the local health administration unit) responsible for the area concerned; for mariners and for civilian aircrews, the 'ministero della Sanità - Ufficio di sanità marittima o aerea' (Ministry of Health, the navy or aviation health office)
in Luxembourg, the 'Caisse de maladie des ouvriers' (sickness fund for manual workers)
in the Netherlands, any sickness fund competent for the place of residence
in Austria, the 'Gebietskrankenkasse' (Regional Fund for Sickness Insurance) competent for the place of residence
in Portugal, for metropolitan Portugal: the 'Centro Regional de Segurança Social' (Regional Social Security Centre); for Madeira: the 'Direcção Regional de Segurança Social' (Regional Social Security Directorate) in Funchal; for the Azores: 'Direcção Regional de Segurança Social' (Regional Social Security Directorate) in Angra do Heroismo
in Finland, the local office of the 'Kansaneläkelaitos' (Social Insurance Institution)
in Sweden, 'försäkringskassan' (Social Insurance Office) in the place of residence
in the United Kingdom, the Department of Social Security, Benefits Agency, Overseas Benefits Directorate, Newcastle-upon-Tyne, or the Northern Ireland Social Security Agency, Overseas Branch, Belfast, as appropriate
in Iceland, the 'tryggingastofnun rikisins' (the State Social Security Institute), Reykjavik
in Liechtenstein, the 'Amt für Volkswirtschaft' (the Office of National Economy), Vaduz
in Norway, the 'lokale trygdekontor' (the local Insurance Office) in the place of residence.
(d)This form is valid from the date indicated in item 5 and for the period indicated in box 6 by the square marked with a cross.
(e)You or the members of your family must inform the insurance institution to which the form has been sent of any change of circumstances which might affect the right to benefits in kind, such as termination or change of employment, change of your place of residence or stay or of that of a member of your family.
E 106NOTES
(*)EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purpose of this Agreement the present form shall also apply to Iceland, Liechtenstein and Norway.
(1)Symbol of the country to which the institution completing Part A of the form belongs: B= Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = Netherlands; A = Austria; P = Portugal; FIN = Finland; S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway.
(2)Complete only if the form is drawn up at the request of the institution in the place of residence.
(2a)To be completed if it is known.
(3)Street, number, post code, town, country.
(3a)In the case of Spanish nationals, state both names at birth.
In the case of Portuguese nationals, state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.
(3b)For Italian nationals indicate, if possible, the insurance and/or the 'codice fiscale'.
(4)Complete only if the form relates to members of the family of an unemployed person.
Mention one member of the family only. The members of the family of the beneficiary will be specified in Part B of the form as they are designated by the institution of the place of residence.
(5)The legislation of the country of residence determines which members of the family are entitled to benefit.
(6)In the form is issued by a German, French, Italian or Portuguese institution.
(7)If the form is issued by a French institution for self-employed persons or a Greek or United Kingdom institution for employed persons or self-employed persons.
(7a)To be completed where this exists.
(8)To be completed for French institutions for self-employed workers.
(8a)If the form is completed by a Liechtenstein institution, the name of the competent accident insurer of the worker has to be inserted.
(9)If this form is issued in renewal of a certificate previously provided, part B need not be completed.
(10)Where Liechtenstein is the competent State, the cost of benfits in kind relating to a non-occupational accident to the worker are borne by the accident insurance institution shown in box 8.
EUROPEAN COMMUNITIES
Social security Regulations
EEA (*)
See Instructions on page 3
E 109
(1)
CERTIFICATE FOR THE REGISTRATION OF MEMBERS OF THE EMPLOYED OR SELF-EMPLOYED PERSON'S FAMILY AND
THE UPDATING OF LISTS
Regulation (EEC) No 1408/71: Article 19.2
Regulation (EEC) No 574/72: Article 17.1, 2, 3 and 4; Article 94.4
The competent institution should complete Part A of the form and send two copies to the insured person, or send them - where necessary through the liaison body - to the institution in the place of residence if the form is drawn up at that institution's request. Where the members of the insured person's family are resident in the United Kingdom, the competent institution should send the two copies to the Department of Social Security, Benefits Agency, Overseas Benefit Directorate, Newcastle-upon-Tyne. On receipt of the two copies, the institution of the place of residence should complete Part B and return one copy to the competent institution. Where the members of the family are resident in different countries, a separate certificate should be drawn up for each of these countries.
A. Notification of entitlement
1.
Institution in the place of residence (2)
1.1.Name: .........................
1.2.Address (3): ..................
1.3.Reference: your E 107 form of ...................... (date)
2.
Employed person
Self-employed person
Seasonally employed person
Frontier worker
2.1.Surname (3a) ...............
2.2.Forenames / Previous names (3a) / Date of birth
............../ ..................../ .............
2.3.Address (3): ..............................
2.4.Identification number (3b): ................
2.5.The insured person is / is not employed in a mine or similar place of employment
2.6.The insured person is covered by a scheme for self-employed persons as referred to in Annex 11 to Regulation (EEC) No 574/72
3.
Members of the family (4)
3.1.Surname (3a)
3.2.Forenames / Previous names / Date of birth
............../ .............../ .............
3.3.Address (3): .............................
4.The members of the family of the abovementioned insured person are entitled to sickness and maternity insurance benefits in kind unless they are already entitled to such benefits under the legislation of the country in which they reside (5)
they are pursuing a professional activity or trade (5)
5.This entitlement begins on ...............
6.
and continues
6.1.until this certificate is cancelled
6.2.for one year from the date specified in point 5 (6)6.3.until the date on which the seasonal work ends, i.e.
6.4.until (7) inclusive.
E 109
7.
Competent institution
7.1.Name ............. Code number (7a): .............
7.2.Address (3): .....................................
Téléphone ................. Télécopieur ..............
7.3.Stamp
7.4.Date: .....................
7.5.Signature .................
B. Notification of registration (8)
8.
(9)
8.1.The members of the family of the insured person named in box 2 have not been registered because
8.2.no member of the family is entitled to benefits
8.3.all the members of the family are entitled to benefits in kind under the legislation of our country
8.4.the spouse or the person caring for the children pursues a professional activity or trade in our country (10)
8.5.the required 'declaration of family status' has not been submitted
8.6.(11) 9.
(9)
9.1.The following members of the family of the insured person named in box 2 have been registered:
9.2.Surname (3a)/Forenames/SexF/M/Date of birth/Identification number (3b)
9.3............./ ......../.../../............./ .........................
9.4............./ ......../.../../............./ .........................
9.5............./ ......../.../../............./ .........................
9.6............./ ......../.../../............./ .........................
9.7............./ ......../.../../............./ .........................
9.8............./ ......../.../../............./ .........................
9.9............./ ......../.../../............./ .........................
9.10. The cost of these are payable by you; the date from which the lump sum referred to in Article 94 of (EEC) No 574/72 should be calculated is10.
Institution in the place of residence
10.
10.1.Name: ......................................
10.2.Address (3): ...............................
Téléphone ................ Télécopieur ..........
10.3.Stamp
10.4.Date: ......................
10.5.Signature ..................
E 109
INSTRUCTIONS
Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out even if it does not contain any relevant information
Information for the insured person
(a)This form enables the members of your family to receive benefits in kind in case of sickness or maternity in the country where they are resident and under the legislation of that country, unless they are already entitled to such benefits under that legislation.
(b)As soon as you have received the two copies of the form, you should send them to the members of your family, who should submit them immediately to the sickness and maternity insurance institution in their place of residence, i.e.:
in Belgium, the 'mutualité' (local sickness insurance fund) of your choice
in Denmark, the competent 'amtskommune' (local administration), in Copenhagen the 'magistrat' (municipal administration) and in Frederiksberg the 'Kommunalbestyrelse' (municipal administration)
in Germany, the 'Krankenkasse' (sickness fund) in the place of residence chosen by the person concerned
in Greece, normally the regional or local branch of the Social Insurance Institute (IKA). The branch office should issue the person concerned with a 'health book' without which no benefits in kind can be provided
in Spain, the 'Dirección Provincial del Instituto Nacional de la Seguridad Social' (Provincial Directorate of the National Social Security Institution)
in France, the Caisse primaire d'assurance-maladie (local sickness insurance fund). Where the answer to 2.5 is 'yes', the form may be sent to the 'Société de secours minière' (Miners' Relief Society)
in Ireland, the Health Board in whose area the benefit is sought
in Italy, normally the 'Unità sanitaria locale' (USL, the local health administration unit) responsible for the area concerned
in Luxembourg, the 'Caisse de maladie des ouvriers' (sickness fund for manual workers)
in the Netherlands, any sickness fund competent for the place of residence
in Austria, the 'Gebietskrankenkasse' (Regional Fund for Sickness Insurance) competent for the place of residence
in Portugal, for metropolitan Portugal: the 'Centro Regional de Segurança Social' (Regional Social Security Centre); for Madeira: the 'Direcção Regional de Segurança Social' (Regional Social Security Directorate) in Funchal; for the Azores: the 'Direcção Regional de Segurança Social' (Regional Social Security Directorate) in Angra do Heroismo
in Finland, the local office of the 'Kansaneläkelaitos' (Social Insurance Institution)
in Sweden, 'försäkringskassan' (Social Insurance Office) in the place of residence
in Iceland, the 'Tryggingastofnun rikisins' (the State Social Security Institute), Reykjavik
in Liechtenstein, the 'Amt für Volkswirtschaft' (the Office of National Economy), Vaduz
in Norway, the 'lokale trygdekontor' (the local Insurance Office) in the place of residence.
(c)This form is valid from the date indicated in item 5 and for the period indicated in box 6 by the square marked with a cross.
(d)You or the members of your family must inform the institution of any change of circumstances which might affect the right to benefits in kind (such as termination or change of employment, change of your place or residence or stay or of that of a member of your family).
E 109NOTES
(*)EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purpose of this Agreement the present form shall also apply to Iceland, Liechtenstein and Norway.
(1)Symbol of country to which the institution completing Part A of the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = Netherlands; A = Austria; P = Portugal; FIN = Finland; S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway.
(2)Complete only if the form is drawn up at the request of the institution in the place of residence.
(3)Street, number, post code, town, country.
(3a)In the case of Spanish nationals, state both names at birth.
In the case of Portuguese nationals, state all names (forenames, surname, maiden name) in the order of civil status in which they appear on the identity card or passport.
(3b)For Italian nationals indicate, if possible, the insurance and/or the 'codice fiscale'.
(4)Mention one member of the family only. The members of the family of the beneficiary will be specified in Part B of the form as they are designated by the institution for the place of residence.
(5)Put a cross in the preceding square if the form is addressed to a Danish, Irish, Italian, Portuguese, United Kingdom, Finnish, Icelandic, Norwegian or Swedish institution.
(6)If the form is issued by a German, French, Italian or Portuguese institution.
(7)If the form is issued by a French institution for self-employed persons or by a Greek or United Kingom institution for employed persons or self-employed persons.
(7a)To be completed where this exists.
(8)If this certificate is issued in renewal of a previously issued certificate which has expired, the institution of the place of residence need not complete Part B.
(9)Complete box 8 or box 9 as applicable and put a cross in the corresponding square.
(10)Where appropriate, put a cross in the preceding square if part B has been completed by a Danish, Irish, United Kingdom, Finnish, Icelandic, Norwegian or Swedish institution.
(11)Other reasons.
END OF GRAPHIC