DECISION No 153 of 7 October 1993 on the model forms necessary for the application of Council Regulation No (EEC) 1408/71 and (EEC) No 574/72 (E 001, E 103 to E 127) (Text with EEA relevance) (94/604/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 family 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 of March 1972, under which it is the duty of the Administrative Commission to draw up models of certificates, certifieds statements, declarations, applications and other documents necessary for the application of the Regulations,
Having regard to Decision No 130 of 17 October 1985 laying down and adapting the model forms necessary for the application of the Regulations,
Whereas these model forms should be adapted for the purpose of taking account of the amendments which have been introduced into the national legislation of Member States;
Whereas the Agreement on the European Economic Area of 2 May 1992, as adjusted by the Protocol of 17 March 1993, Annex VI, implements Council 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 Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 will be adapted and (EEC) No 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 with a view to the envisaged participation of Liechtenstein in the EEA at a later stage, these forms should also be adapted as regards Liechtenstein;
Whereas the language in which the forms should be drawn up has been decided by recommendation No 15 of the Administrative Commission,
HAS DECIDED AS FOLLOWS:
1. The model forms E 001, E 103 to E 127 printed in Decision No 130 shall be replaced by the models appended hereto.
2. The competent authorities of the Member States shall make available to the person concerned (rightful claimants, institutions, employers, etc.) the forms according to the attached 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 each person or body to which a form is addressed (rightful claimant, institution, employer, etc.) to receive the form printed in their own language.
4. This Decision shall be applicable from the first day of the month following its publication in the Official Journal of the European Communities.
The Chairman of the Administrative Commission Gabrielle CLOTUCHE
List of forms
E 001 - Request for information, communication of information, request for forms, reminder on an employed person a self-employed person, a frontier worker, a pensioner, an unemployed person, a dependant E 103 - Exercising the right of option E 104 - Certificate concerning the aggregation of periods of insurance, employment or residence E 105 - Certificate concerning the members of the family of an employed person or self-employed person to be taken into consideration for the calculation of cash benefits in the case of incapacity for work E 106 - Certificate of entitlement to sickness and maternity insurance benefits in kind for persons residing in a country other than the competent country E 107 - Application for a certificate of entitlement to benefits in kind E 108 - Notification of suspension or withdrawal of the right to sickness and maternity insurance benefits in kind E 109 - Certificate for the registration of members of the employed or self-employed person's family and the updating of lists E 110 - Certificate concerning employed persons in international transport E 111 - Certificate of entitlement to benefits in kind during a stay in a Member State E 112 - Certificate concerning the retention of the right to sickness or maternity benefits currently being provided E 113 - Hospitalization: notification of entering and leaving hospital E 114 - Granting of major benefits in kind E 115 - Claim for cash benefits for incapacity for work E 116 - Medical report relating to incapacity for work (sickness, maternity, accident at work, occupational disease) E 117 - Granting of cash benefits in the case of maternity and incapacity for work E 118 - Notification of non-recognition or of end of incapacity for work E 119 - Certificate concerning the entitlement of unemployed persons and the members of their family to sickness and maternity insurance benefits E 120 - Certificate of entitlement to benefits in kind for pension claimants and members of their family E 121 - Certificate for the registration of pensioners and the updating of lists E 122 - Certificate for the granting of benefits in kind to members of the family of pensioners E 123 - Certificate of entitlement to benefits in kind under insurance against accidents at work and occupational diseases E 124 - Claim for death grant E 125 - Individual record of actual expenditure E 126 - Rates for refund of benefits in kind E 127 - Individual record of monthly lump-sum payments
E 001
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Social Security Regulations EEA*on page 41&square;Request for information &square;Communication of information &square;Request for forms &square;Reminder &square;an employed person &square;a self-employed person &square;a frontier worker on&square;a pensioner &square;a pension claimant &square;an unemployed person &square;a dependant Reg. 1408/71: Art. 84 The sending institution should complete part A and send two copies of the form to the institution to which they are addressed. The latter institution should complete part B and return one copy to the sending institution. This form should be used to supplement the other forms or as a basis for exchanges between institutions not yet provided for in the forms currently in use. This form may not be used instead of a form of one of the other series.
Part A 1Institution to which the form is addressed 1.1Name 1.2Address (2) 2Information concerning insured persons (3) 2.1Surname (4) 2.2Surname at birth (4) 2.3Forenames (5) 2.4Previous names (6) 2.5Sex (7) 3Nationality (8)D.N.I (9) 4Details of birth 4.1Date (10) 4.2Place of birth (11) 4.3Province, department or county (12) 4.4Country (13) 5Insurance No 5.1Insurance No at sending institution 5.2Insurance No at receiving institution 6Address (2) 7Information on the file 7.1Type of benefit 7.2Reference No of file at the institution sending the form 7.3Reference No of file at the institution to which the form is addressed ! 8Dependant (14) 8.1Surname (4) 8.2ForenamesSurname at birth (4) 8.3Place of birth (11)Date of birth 8.4SexNationalityD.N.I. (9) 8.5Address (2):
9&square;Request&square;Reminder of request (date) With reference to the person named in box&square;2&square;8,please send 9.1&square;the following forms 9.2&square;the following documents &square;
9.3&square;the following information &square;
9.4Reason for request 10Change in circumstances: the following changes have taken place 11Miscellaneous information 12Institution completing part A 12.1NameCode number (15) 12.2Address (2) 12.3Stamp 12.4Date 12.5Signature " Part B 13 In response to your request ofwe enclose 13.1&square;the following forms 13.2&square;the following documents &square;
13.3&square;the following information &square;
14 In response to your request of we regret that we are unable to forward 14.1&square;the following forms 14.2&square;the following documents 14.3&square;the following information 14.4&square;Reason &square;
&square;
15Miscellaneous information 16 &square;We acknowledge receipt of your form transmitted on the &square;which includes information in box 10 17Institution completing part B 17.1NameCode number (15) 17.2Address (2) 17.3Stamp 17.4Date 17.5Signature § 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.
NOTES *EEA Agreement on the European Economic Area, Annex VI, Social Security. For the purpose of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(1) Symbol of the country to which the institution belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(2) Street, number, post code, town, country.
(3) Headings 2.1 to 2.7 identifying the person concerned should be completed where appropriate.
(4) -For surname please state usual surname or surname acquired by marriage. If the form is being completed by a Netherlands institution in cases where the insured person or the rightful claimant is a married woman or a woman who was married before, put the present or last husband`s surname for current surname.
-The surname at birth must always be given; if same as current surname, put 'IDEM`. If the form is being completed by a Netherlands institution in cases where the insured person or the rightful claimant is a married woman or a woman who was married before, put maiden name for surname at birth.
-Explanations such as 'called . . .` or 'alias . . .` and all prefixes to surnames must be written in full in the order in which they appear on the birth certificate.
-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.
(5) Give all forenames in the order in which they appear on the birth certificate.
(6) Previous names should be stated particularly in the case of adoption or in the case of bynames in current use.
Explanations such as 'called . . .` or 'alias . . .` must be written in full in the order in which they appear on the birth certificate.
(7) Put 'M` for male and 'F` for female.
(8) Where appropriate, indicate the date of naturalization.
(9) In the case of Spanish nationals state the number appearing on the national identity card (D.N.I.), if it exists, even if the identity card is out of date. Failing this, indicate 'None`.
(10) The day and the month should be shown by two digits and the year by four digits (example: 1 August 1921 = 01. 08. 1921).
(11) For French towns comprising several arrondissements, please give the number of the arrondissement (example: Paris 14).
In the case of Portuguese districts, state also the parish and local authority.
(12) This information is obligatory for insured persons of Spanish, French or Italian nationality. The territorial divison in which the place of birth is located should be stated; for instance in the case of France if the commune of birth is Lille, the department of birth should be shown as 'Nord` followed by the department code if known to the insured person, in this case: 59. The complete entry should read: 'Nord 59`. In the case of persons born in Spain indicate only the province.
(13) Symbol of the insured person`s country of birth in accordance with the international motor vehicle registration code.
(14) Complete where appropriate.
(15) To be completed where this exists.
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Social Security Regulations EEA*on page 31EXERCISING THE RIGHT OF OPTION Reg. 1408/71: Art. 16.2 and 3 Reg. 574/72: Art. 13.2 and 3; Art. 14.1 and 2 After having completed part A of the form in accordance with points (a) and (b) of the instructions, the worker should hand it over or dispatch it in accordance with points (a) and (c) of the instructions. The institution receiving the form should complete part B and return one copy to the worker.
A. Option 1The undersigned 1.1Surname (1a) 1.2ForenamesPrevious names (1a) 1.3Date of birthNationalityD.N.I. (1b):
1.4Address (2):
1.5Identification No (1c):
2employed since 2.1(3) &square;asby the diplomatic mission or consular post named hereafter 2.2(3) &square;as (4) in the private staff of the following employer (5) agent of the diplomatic mission or consular post named hereafter 2.3(3) &square;as a member of the auxiliary staff of the European Communities,
3hereby opts to be subject to the social security legislation 3.1(6) &square;of the State of which he is a national 3.2(6) &square;of the State to whose legislation he was last subject, viz. the legislation of (6) &square;Belgium&square;Denmark&square;Germany&square;Greece&square;Spain (6) &square;France&square;Ireland&square;Italy&square;Luxembourg&square;the Netherlands (6) &square;Portugal&square;the United Kingdom (6) &square;Austria&square;Finland&square;Iceland&square;Liechtenstein&square;Norway (6) &square;Sweden 4Place and date 5Signature 6Authority of the European Communities which has concluded the contract with the member of the auxiliary staff 6.1Name 6.2Address (2) 6.3Stamp 6.4Date 6.5Signature ! B. Declaration 7We have taken note of the fact that the worker mentioned in box 1 above is subject to the legislation of (6) &square;Belgium&square;Denmark&square;Germany&square;Greece&square;Spain (6) &square;France&square;Ireland&square;Italy&square;Luxembourg&square;the Netherlands (6) &square;Portugal&square;the United Kingdom (6) &square;Austria&square;Finland&square;Iceland&square;Liechtenstein&square;Norway (6) &square;Sweden 7.1as from 7.2for the period during which he is engaged in the employment indicated in part A of this form (7) 8Institution designated by the authority 8.1Name 8.2Address (2) 8.3Stamp 8.4Date 8.5Signature " INSTRUCTIONS Please complete three copies of this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information.
To the staff of diplomatic missions or consular posts and their private domestic staff (a)After having completed part A of the form, excluding box 6, you should give one copy of the form to your employer and send two copies to the institution designated by the competent authority of the State for whose legislation you have opted, i.e.:
in Belgium, the 'Office national de sécurité sociale` (National Office for Social Security), Brussels;
in Denmark, 'Direktoratet for Social Sikring og Bistand` (National Directorate for Social Security and Assistance) Copenhagen;
in Germany, 'the Allgemeine Ortskrankenkasse Bonn` (AOK, local general sickness fund), Bonn;
in Greece, the regional or local branch of the Social Insurance Institute (IKA);
in Spain, the 'Tesoreria General de la Securidad Social - Ministerio de Trabajo y Seguridad Social` (Central Treasury for Social Security - Ministry of Labour and Social Security), Madrid;
in France, the 'Caisse primaire d'assurance maladie de Paris` (Sickness insurance fund);
in Ireland, the Department of Social Welfare, Dublin;
in Italy, the competent local office of the 'Istituto nazionale della previdenza sociale (INPS)` (National Social Welfare Institution);
in Luxembourg, the 'Inspection générale de la sécurité sociale` (General Social Security Inspectorate), Luxembourg;
in the Netherlands, the 'Sociale verzekeringsraad` (Social Insurance Council), Zoetermeer;
in Portugal, the 'Departamento de Relações Internacionais e Convenções de Segurança Social` (Department of International Relations and Social Security Conventions), Lisbon;
in the United Kingdom, the Department of Social Security, Contributions Agency, Overseas Contributions, Newcastle Upon Tyne, or the Northern Ireland Social Security Agency, Overseas Branch, Belfast, as appropriate;
in Austria, the competent institution for sickness insurance;
in Finland, the 'Elaeketurvakeskus` (Central Pension Security Institute), Helsinki;
in Iceland, the 'Tryggingastofnun rikisins` (the State Social Security Institution), Reykjavik;
in Liechtenstein, the 'Amt fuer Volkswirtschaft` (Office of National Economy), Vaduz;
in Norway, 'Folketrygdkontoret for utenlandssaker` (the National Insurance Office for Social Insurance Abroad), Oslo;
in Sweden, the 'Riksfoersaekringsverket` (National Social Insurance Board), Stockholm.
To the authority of the European Communities empowered to conclude contracts of employment with auxiliary staff (b)When a person is engaged as a member of the auxiliary staff and he expresses the wish to use his right of option, the empowered authority of the European Communities must ensure that he completes part A of the form, with the exception of box 6 which must be completed by that authority.
(c)Two copies of the form should be sent to the institution designated by the competent authority of the Member State for whose legislation the person concerned has opted (see point (a) above).
NOTES *EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(1)Symbol of the country of employment of the person who completes the form: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = the Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(1a)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 as they appear on the identity card or passport.
(1b)In the case of Spanish nationals state the number appearing on the national identity card (D.N.I.), if it exists, even if the identity card is out of date. Failing this, indicate 'None`.
(1c)For workers subject to Belgian legislation please indicate the national registration number.
(2)Street, number, post code, town, country, telephone number.
(3)Complete 2.1, 2.2 and 2.3, according to the position of the worker completing the form, and put a cross in the corresponding box.
(4)State the occupation of the person concerned: chauffeur, cook, etc.
(5)State surname and forename of employer.
(6)Put a cross in the box preceding the appropriate subject. Please note that workers employed by diplomatic missions or consular posts and members of the private domestic staff of agents of such missions or posts may opt only for the social security legislation of the State of which they are a national.
(7)The right of option of workers employed by diplomatic missions or consular posts and members of the private domestic staff of agents of such missions or posts may be exercised at the end of each calendar year.
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Social Security Regulations EEA*on page 31CERTIFICATE CONCERNING THE AGGREGATION OF PERIODS OF INSURANCE, EMPLOYMENT OR RESIDENCE Sickness - Maternity - Death (grant) - Tuberculosis Reg. 1408/71: Art. 9.2; Art. 18.1; Art. 38.1; Art. 64 Reg. 574/72: Art. 6.2; Art. 16; Art. 39.1 and 2; Art. 79 The competent institution should complete part A of the form and send two copies to the institution of the Member State to whose legislation the person concerned was last subject. The latter institution should complete part B and return the form to the institution from which it received the form. If the form is drawn up at the request of the person concerned, the institution issuing the form should complete part B and give or send the form to the person concerned.
Part A 1Institution to which the form is addressed 1.1Name 1.2Address (2) 2Insured person 2.1Surname (2a) 2.2ForenamesPrevious names (2a)Date of birth 2.3Insurance No 2.4From the date stated at 3.1 the insured person has been pursuing an occupation as &square;an employed person&square;a self-employed person in (3):
2.5&square;Name of last employer &square;Last occupation as a self-employed person Address (2) 2.6Name of last employers or firms (4)&square;previous occupations as a self-employed person (Address) (2) 3With reference to a claim submitted by the insured person mentioned above, please indicate the periods of insurance, employment or residence completed by him 3.1from 3.2under the legislation of your country, for the following risk:
&square;sickness and maternity (5)&square;death (grant) &square;tuberculosis &square;invalidity (5b) 4Competent institution 4.1NameCode number (5a) 4.2Address (2) 4.3Stamp 4.4Date 4.5Signature ! Part B 5Insured person (6) 5.1Surname (2a) 5.2FornamesPrevious names (2a)Date of birth 5.3Insurance number 6The insured person mentioned&square;in box 2&square;in box 5 6.1.has been insured for the risk of sickness-maternity since the date stated, at 3.1&square;(8b) 6.2.completed&square;during the past three years (8)&square;during the past five years (8a) &square;since 7The following periods of insurance or employment for the following benefits (5) (7) 7.1fromto(9)for (10) the risk of&square;(11) 7.2fromto(9)for (10) the risk of&square;(11) 7.3fromto(9)for (10) the risk of&square;(11) 7.4fromto(9)for (10) the risk of&square;(11) 7.5fromto(9)for (10) the risk of&square;(11) 7.6fromto(9)for (10) the risk of&square;(11) 7.7fromto(9)for (10) the risk of&square;(11) 7.8fromto(9)for (10) the risk of&square;(11) 7.9fromto(9)for (10) the risk of&square;(11) 7.10fromto(9)for (10) the risk of&square;(11) 8The following periods of residence 8.1fromto(9)for (10) the risk of&square;(11) 8.2fromto(9)for (10) the risk of&square;(11) 8.3fromto(9)for (10) the risk of&square;(11) 8.4fromto(9)for (10) the risk of&square;(11) 8.5fromto(9)for (10) the risk of&square;(11) 8.6fromto(9)for (10) the risk of&square;(11) 8.7fromto(9)for (10) the risk of&square;(11) 8.8fromto(9)for (10) the risk of&square;(11) 8.9fromto(9)for (10) the risk of&square;(11) 8.10fromto(9)for (10) the risk of&square;(11) 9Institution completing part B 9.1Name 9.2Address (2):
9.3Stamp 9.4Date 9.5Signature " INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information.
NOTES *EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purpose of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(1)Symbol of the country to which the institution which first completes the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = the Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(2)Street, number, post code, town, country.
(2a)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 as they appear on the identity card or passport.
(3)Indicate the State.
(4)To be completed where possible.
(5)If the form is addressed to a Belgian, French, Greek or Liechtenstein institution, indicate the risk covered by using the following symbols: N = benefits in kind; F = benefits in cash.
(5a)To be completed where this exists.
(5b)For the purpose of French institutions.
(6)Complete only if the form is issued directly to the person concerned.
(7)If the certificate is addressed to an Italian institution in order to get cash benefits in the case of tuberculosis and the person concerned has not paid contributions for one full year, all the periods of insurance completed by him should be mentioned.
(8)Complete only if the competent institution is a United Kingdom institution.
(8a)Complete only if the competent institution is an Irish institution.
(8b)Complete only if the competent institution is a Belgian institution.
(9)If the certificate is intended for a Greek institution indicate whether the periods of activity were as an employed person or as a self-employed person by using the following symbols; D = employed person; I = self-employed person.
If the certificate is intended for a German or Luxembourg institution, indicate the insurance periods in section 7 using the following symbols: P = compulsory insurance, F = voluntary insurance.
(10)Indicate the risk covered by using the following symbols:
A = sickness and maternity; B = death (grant); C = tuberculosis; O = invalidity.
(11)If the competent institution is a German, Irish, United Kingdom or Austrian institution put a cross in this square if the period of insurance or the period of residence corresponds to a period of actual employment and indicate the type of employment or self-employment.
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E 105
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Social Security Regulations EEA *overleaf1CERTIFICATE CONCERNING THE MEMBERS OF THE FAMILY OF AN EMPLOYED PERSON OR SELF-EMPLOYED PERSON TO BE TAKEN INTO CONSIDERATION FOR THE CALCULATION OF CASH BENEFITS IN THE CASE OF INCAPACITY FOR WORK Reg. 1408/71: Art. 23.3; Art. 58.3 Reg. 574/72: Art. 25.1 and 2; Art. 70.1 This form should be completed by the sickness insurance institution or by a designated institution in the place of residence of the members of the family, and forwarded to the worker.
1&square;Employed person&square;Self-employed person 1.1Surname (1a) 1.2ForenamesPrevious names (1a)Date of birth 1.3Address in the country of residence, or the country of stay (2) 1.4Identification No 2Members of the family of the abovementioned worker 2.1Surname (1a)ForenamesPrevious namesDate of birthRelationship 2.2 &square;(3) 2.3 &square;(3) 2.4 &square;(3) 2.5 &square;(3) 2.6 &square;(3) 2.7 &square;(3) 2.8 &square;(3) 2.9 &square;(3) 3Institution of the place of residence of the members of the family 3.1Name 3.2Address (2) 3.3Stamp 3.4Date 3.5Signature ! E 105INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only.
Information for the insured person (a) If you are able to claim cash benefits in the case of incapacity for work in Belgium, the Federal Republic of Germany, Greece, France, Ireland, Portugal, the United Kingdom, Austria, Finland, countries whose legislation causes or can cause the amount of such benefits to vary according to the number of family members, you must forward this certificate to your insuring institution.
(b) This certificate is valid for a period of 12 months as from its date of issue (see point 3.4), on expiry of this period you may apply for renewal to the institution of the place of residence of the members of your family (see points 3.1 and 3.2).
(c) You are obliged to inform immediately the institution with which you are insured of any changes which have occurred in the information given in this certificate.
NOTES * EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purpose of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(1) Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = the Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(1a) 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.
(2) Street, number, post code, town, country.
(3) Please put a cross in the box if the family members are dependent upon the worker.
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Social Security Regulations EEA*on page 3 and 41CERTIFICATE 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 Reg. 1408/71: Art. 19.1.a; Art. 19.2; Art. 25.3.i Reg. 574/72: Art. 17.1 and 4; Art. 27 (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 1Institution of the place of residence (2) 1.1NameCode number (2a) 1.2Address (3) 1.3Reference: your E 107 form of 2&square;Employed person&square;Frontier worker (employed) &square;Self-employed person&square;Frontier worker (self-employed) &square;Unemployed person 2.1Surname (3a) 2.2ForenamesPrevious names (3a)Date of birth 2.3Address in the country of residence (3) 2.4Identification number (3b) 2.5The insured person&square;is&square;is not employed in a mine or similar place of employment 2.6&square;The insured person is covered by a scheme for self-employed persons as referred to in Annex 11 to Regulation 574/72 &square;
3Member of the family (4) 3.1Surname (3a) 3.2ForenamesPrevious namesDate of birth 3.3Address in the country of residence (3) 4&square;The abovementioned worker and the members of his family (5) residing with him 4.1&square;The members of the family (5) of the unemployed person mentioned above 5are entitled to sickness and maternity insurance benefits in kind as from 6The persons concerned will retain their entitlement 6.1&square;until this certificate is cancelled 6.2&square;for a period of one year from the date specified in point 5 (6) 6.3&square;untilinclusive (7) ! 7Competent institution for sickness and maternity insurance 7.1NameCode number (7a) 7.2Address (3) 7.3Stamp 7.4Date 7.5Signature 8Competent institution for non-occupational accidents (8) (8a) (10) 8.1NameCode number (7a) 8.2Address (3) 8.3Stamp 8.4Date 8.5Signature B. Notification of registration (9) 9 9.1&square;The worker named in box 2 and the members of his family 9.2&square;The members of the family of the unemployed person named in box 2 9.3&square;were registered with us on 9.4&square;could not be registered with us because 10Registered members of the family 10.1Surname (3a)ForenamesSexPrevious namesDate of birth FM 10.2&square;&square;
10.3&square;&square;
10.4&square;&square;
10.5&square;&square;
10.6&square;&square;
10.7&square;&square;
10.8&square;&square;
10.9&square;&square;
11Institution in the place of residence 11.1Name 11.2Address (3) 11.3Stamp 11.4Date 11.5Signature " 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 the 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)These 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 'Allgemeine Ortskrankenkasse` (AOK, local general sickness fund);
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 you 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 'Ministerio 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 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 Heroísmo;
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 Austria, the 'Gebietskrankenkasse` (Regional Fund for Sickness Insurance) competent for you place of residence;
in Finland, the local office of the 'Kansanelaekelaitos` (Social Insurance Institution);
in Iceland, the 'tryggingastofnun rikisins` (the State Social Security Institution), Reykjavik;
in Liechtenstein, the 'Amt fuer Volkswirtschaft` (the Office of National Economy), Vaduz;
in Norway, the 'lokale trygdekontor` (the local Insurance Office) at the place of residence;
in Sweden, the 'foersaekringskassan` (Social Insurance Office) at 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.
§ NOTES *EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purpose of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(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 = the Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(2) Complete only if the form is drawn up at the request of the institution of 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 number 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) If the form is issued by a French or Italian 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 benefits in kind relating to a non-occupational accident to the worker are borne by the accident insurance institution shown in box 8.
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Social Security Regulations EEA*on page 31APPLICATION FOR A CERTIFICATE OF ENTITLEMENT TO BENEFITS IN KIND Reg. 1408/71: Art. 19.1.a; Art. 19.2; Art. 22.1.a.i, b.i. and c.i; Art. 22.3; Art. 25.1.a and 3.i; Art. 26.1; Art. 28.1.a; Art. 29.1.a; Art. 31.a; Art. 52.a; Art. 55.1.a.i, b.i and c.i Reg. 574/72: Art. 17.1; Art. 20.2 and 3; Art. 21.1; Art. 22.1 and 3; Art. 23; Art. 27 (first sentence); Art. 28; Art. 29.2; Art. 30.1; Art. 31.1 and 3; Art. 60.1; Art. 62.3, 4 and 7; Art. 63.1 and 3 The institution of the place of residence or stay should complete part A and send two copies of the form to the competent institution, taking into account the provisions of the abovementioned Articles of Regulation 574/72. If that institution considers it is unable to send the requested form, it should complete part B and return one of the two copies to the institution from which it received them. If Belgium is the competent country, the form should be sent to the sickness insurance institution, except when it concerns an accident at work which has been verified or a disease recognized as an occupational disease.
A. To be completed by the institution in the place of residence or stay 1Institution to which the form is addressed 1.1Name 1.2Address (2) 2&square;Employed person&square;Frontier worker (employed)&square;Pensioner (scheme for employed persons) &square;Self-employed person&square;Frontier worker (self-employed)&square;Pensioner (scheme for self-employed persons) &square;Unemployed person&square;Pension claimant 2.1Surname (2a) 2.2ForenamesPrevious names (2a)Date of birth 2.3Permanent address (2) 2.4Identification No (2b) 2.5&square;Person entitled to&square;Claimant of the pension in respect of &square;old age&square;invalidity&square;survival &square;accident at work&square;occupational disease No (3)category (3) 2.6Institution responsible for payment of pension 3&square;Last employer (4)&square;Last activity as a self-employed person(4) 3.1Name of employer or firm 3.2Address (2) 3.3Field of activity (5) 3.4Institution for insurance against accidents at work with which the employer is insured (5a) ! E 1074Members of the family (6) 4.1Surname (2a)ForenamesDate of birthIdentification No (2b) 4.2Address in the country of residence (2) (7) 5Onwe received a claim from the person mentioned &square;in box 2&square;in box 4 for:
5.1&square;the granting of benefits in kind 5.2&square;the retention of the right to benefits in kind 5.3&square;registration with us as a person entitled to benefits in kind 6The benefits in kind&square;have been awarded&square;have not been awarded6.1in accordance with Article&square;20.3 &square;29.2 &square;60.1&square;62.3 of Reg. 574/72 6.2The claimant&square;has not worked since the date indicated in item 5 above &square;has held the following occupation after that date 7Please send us the certificate of entitlement to benefits on formE valid fromto 8&square;Medical report attached (8) 9Institution in the place of residence or stay 9.1Name 9.2Address (2) 9.3Stamp 9.4Date 9.5Signature B. To be completed by the competent institution 10 10.1&square;Please find the aforementioned form attached and return to us a copy duly completed and signed (9) 10.2&square;We are unable to issue the certificate requested in part A, because 11Competent institution 11.1NameCode number (10) 11.2Address (2) 11.3Stamp 11.4Date 11.5Signature " INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information.
NOTES *EAA Agreement in the European Economic Area, Annex VI, Social Security; for the purpose of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(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 = the Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden..
(2) Street, number, post code, town, country.
(2a) 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.
(2b) In the case of Spanish nationals indicate the number appearing on the national identity card (D.N.I.), if it exists, even if the identity card is out of date. Failing this, state 'None`. For Italian nationals indicate, if possible, the insurance number and/or the 'codice fiscale`.
(3) Complete only if the institution responsible for the payment of the pension is an Italian institution.
(4) Complete only if the form concerns an employed person or self-employed person who is working or an unemployed person.
(5) Complete only if the form concerns an employed person assumed to have sustained an accident at work.
(5a) For Spain: 'Dirección Provincial del Instituto Nacional de la Seguridad Social`.
(6) Complete only for members of the family for whom a claim for benefits or a request for registration has been made. For registration, indicate one member of the family only.
(7) Complete only if the address of the members of the family is different from that of the head of household.
(8) To be attached only if necessary. In that case, put a cross in the corresponding square.
(9) For the purposes of Netherlands institutions and where the nature of the form to be returned permits.
(10) To be completed where this exists.
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Social Security Regulations EEA*overleaf1NOTIFICATION OF SUSPENSION OR WITHDRAWAL OF THE RIGHT TO SICKNESS AND MATERNITY INSURANCE BENEFITS IN KIND Persons residing in a country other than the competent country Reg. 1408/71: Art. 19.1.a and 2; Art. 25.3.i; Art. 26.1; Art. 28.1.a; Art. 29.1.a Reg. 574/72: Art. 17.2 and 3; Art 27; Art. 28; Art. 29.5; Art. 30; Art. 94.4; Art. 95.4 The competent institution should complete part A of the form and send two copies to the institution in the place of residence (where appropriate through the liaison body). The institution in the place of residence should complete part B and return one copy to the competent institution as soon as possible.
A. Notification 1Institution to which the form is addressed 1.1Name 1.2Address (2) 2&square;Employed person&square;Unemployed person &square;Self-employed person&square;Pension claimant &square;Frontier worker (employed)&square;Pensioner (scheme for employed persons) &square;Frontier worker (self-employed)&square;Pensioner (scheme for self-employed persons) 2.1Surname (2a) 2.2ForenamesPrevious names (2a)Date of birth 2.3Address in the country of residence (2) 2.4Identification No (2b) 3Member of the family (3) 3.1Surname (2a) 3.2ForenamesPrevious names (2a)Date of birth 3.3Address in the country of residence (2) 3.4Identification No (2b) 4Entitlement to benefits certified on our formof(date) has been suspended or withdrawn for the following reason:
4.1&square;The insurance of the abovementioned worker ended on 4.2&square;The pension of the abovementioned pensioner has been suspended or withdrawn since 4.3&square;All the persons registered with you have not resided in your country since 4.4&square;The person entitled to benefits died on 4.5&square;(4) ! E 1085Competent institution 5.1NameCode numer (5):
5.2Address (2) 5.3Stamp 5.4Date 5.5Signature B. Acknowledgement of receipt 6We received the above notification (part A) on 7&square;The person indicated in part A&square;The persons indicated in part A &square;has not received&square;have not received &square;will no longer receive&square;will no longer receive benefits since/as from (date).
8Institution in the place of residence 8.1Name 8.2Address (2) 8.3Stamp 8.4Date 8.5Signature INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only.
NOTES * EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purpose of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(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 = the Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(2) Street, number, post code, town, country.
(2a) 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 as they appear on the identity card or passport.
(2b) For Italian nationals indicate, if possible, the insurance number and/or the 'codice fiscale`.
(3) Complete only if the withdrawal or suspension of the right to benefits in kind notified by this form affects the members of the family only; in such case, indicate only one of them.
(4) Other reasons, if any, e.g. non-payment of contributions by self-employed persons.
(5) To be completed where this exists.
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Social Security Regulations EEA*page 31CERTIFICATE FOR THE REGISTRATION OF MEMBERS OF THE EMPLOYED OR SELF-EMPLOYED PERSON'S FAMILY AND THE UPDATING OF LISTS Reg. 1408/71: Art. 19.2 Reg. 574/72: Art. 17.1, 2, 3 and 4; Art. 94.4 The competent institution should complete part A of the form and issue 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 was 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 Benefits 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 1Institution in the place of residence (2) 1.1Name 1.2Address (3) 1.3Reference: your E 107 form of(date) 2&square;Employed person&square;Self-employed person&square;Seasonally employed person&square;Frontier worker 2.1Surname (3a) 2.2ForenamesPrevious names (3a)Date of birth 2.3Address (3) 2.4Identification No (3b) 2.5The insured person&square;is&square;is not employed in a mine or similar place of employment 2.6&square;The insured person is covered by a scheme for self-employed persons as referred to in Annex 11 to Regulation 574/72 3Member of the family (4) 3.1Surname (3a) 3.2ForenamesPrevious namesDate of birth 3.3Address (3) 4The members of the family of the abovementioned insured person are entitled to sickness and maternity insurance benefits in kind unless &square;they are already entitled to such benefits under the legislation of the country in which they reside (5) &square;they are pursuing a professional activity or trade (5) 5This entitlement begins on 6and continues 6.1&square;until this certificate is cancelled 6.2&square;for one year from the date specified in point 5 (6) 6.3&square;until the date on which the seasonal work ends, i.e.
6.4&square;until (7)inclusive ! E 1097Competent institution 7.1NameCode number (7a) 7.2Address (3) 7.3Stamp 7.4Date 7.5Signature B. Notification of registration (8) 8&square;(9) 8.1The members of the family of the insured person named in box 2 have not been registered because 8.2&square;no member of the family is entitled to benefits 8.3&square;all the members of the family are already entitled to benefits in kind under the legislation of our country 8.4&square;the spouse or the person caring for the children pursues a professional activity or trade in our country (10) 8.5&square;the required 'declaration of family status` has not been submitted 8.6&square;(11) 9&square;(9) 9.1The following members of the family of the insured person named in box 2 have been registered 9.2Surname (3a)ForenamesSexDate of birthIdentification No (3b) FM 9.3 9.4 9.5 9.6 9.7 9.8 9.9 9.10The cost of these benefits are payable by you;
the date from which the lump sum referred to in Article 94 of Regulation 574/72 should be calculated is 10Institution in the place of residence 10.1Name 10.2Address (3) 10.3Stamp 10.4Date 10.5Signature " E 109INSTRUCTIONS 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 worker (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 this 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 their choice;
in Denmark, the competent 'amtskommune` (local administration). In the commune of Copenhagen, the 'Magistrat` (municipal administration); in the commune of Frederiksberg, the 'kommunalbestyrelse` (municipal administration);
in Germany, the 'Allgemeine Ortskrankenkasse` (AOK, local general sickness fund);
in Greece, normally the regional or local branch of the Social Insurance Institute (IKA), which issues 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, 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 as regards the place of residence;
in Portugal, for metropolitan Portugal: the 'Centro Regional de Segurança Social` (Regional Social Security Centre) of the place of residence; 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 Heroísmo;
in Austria, the 'Gebietskrankenkasse` (Regional Fund for Sickness Insurance) competent for their place of residence;
in Finland, the local office of the 'kansanelaekelaitos` (Social Insurance Institution);
in Iceland, the 'Tryggingastofnu rikisins` (State Social Security Institute), Reykjavik;
in Liechtenstein, the 'Amt fuer Volkswirtschaft` (Office of National Economy), Vaduz;
in Norway, the 'lokale trygdekontor` (local Insurance Office) at the place of residence;
in Sweden, the 'foersaekringskassan` (Social Insurance Office) at the place of residence.
(c)This form is valid from the date stated in item 5 and for the period indicated in box 6 at 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 of residence or stay or of that of a member of your family.
§ NOTES *EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(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 = the Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(2)Complete only if the form is drawn up at the request of the institution of 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 number and/or the 'codice fiscale`.
(4)Mention one member of the family only. The members of the family of the beneficary will be specified in part B of the form as they are designated by the institution of 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 drawn up by a German, French or Italian institution.
(7)If the form is drawn up by a French institution for self-employed persons or Greek of United Kingdom institutions 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.
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Social Security Regulations EEA*on page 2 and 31CERTIFICATE CONCERNING EMPLOYED PERSONS IN INTERNATIONAL TRANSPORT Reg. 1408/71: Art. 14.2.a; Art. 22.1.a.i; Art. 22.3; Art. 55.1.a.i Reg. 574/72: Art. 20.1; Art. 62.1 The form should be completed and, if necessary, signed for extension by the employer, who should then give it to the employed person.
A. First certified statement 1Employed person 1.1Surname (1a) 1.2ForenamesPrevious names (1a) 1.3Date of birthNationalityD.N.I. (1b) 1.4Permanent address (2) 2Members of the family who accompany the head of household Surname (1a)ForenamesPrevious namesDate of birth 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 3Institution competent 3.1As regards insurance against accidents at work (name and address) (2) 3.2As regards insurance against occupational diseases (name and address) (2) (3) 4The undersigned certifies that the abovementioned employed person has been in his employment since ! 5Employer 5.1Name of employer or firm 5.2Nature of business 5.3Address (2) 5.4Stamp 5.5Date 5.6Signature of employer or his representative 6Institution competent as regards sickness and maternity insurance (4) (5) 6.1Name 6.2Address (2) 6.3Employed person`s insurance number 6.4Date 6.5Employed person`s signature6.6Signature of employer or his representative B. Extensions (6) 7The employer named in box 5 certifies that the abovementioned employed person is still in his employment on the date shown below 8Date8.1Signature of employer or his representative INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of 4 pages, none of which may be left out, even if it does not contain any relevant information.
Information for the employed person (a)This document is valid for the month during which it was issued and the two following calendar months (see items 5.5 and 8).
(b)During this term of validity it enables you and the members of your family listed in box 2 to receive benefits in kind in the territory of the Member State where you are staying whilst carrying out your work.
(c)When you need benefits in kind, you should submit this form as soon as possible to the insurance institution of the country in which you are staying i.e.:
-for benefits in case of sickness or maternity:
in Belgium, the 'mutualité` (local sickness insurance fund) of your choice;
in Denmark, the competent 'amtskommune` (local administration). In the commune of Copenhagen, the 'magistrat` (municipal administration); in the commune of Frederiksberg, the 'kommunalbestyrelse` (municipal administration). Assistance from a doctor, or dispensing chemist may be sought without first contacting the said institutions. The form must be submitted for each claim for benefits. Particulars about doctors and dentists available may be obtained from the local 'social- og sundhedsforvaltning` (social and health authority);
" in Germany, the accident insurance institution competent for the place of stay;
in Greece, normally the regional or local branch of the Social Insurance Institute (IKA), which issues the person concerned with a 'health book`, without which no benefits in kind can be provided;
in Spain, the medical and hospital services 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);
in Ireland, the Health Board in whose area the benefit is claimed;
in Italy, 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, the 'ANOZ Verzekeringen`, Utrecht. Assistance from a doctor, dentist or dispensing chemist may be sought without first contacting ANOZ Verzekeringen;
in Portugal, for metropolitan Portugal: the 'Administração Regional de Saúde` (Regional Health Administration) of the place of stay; for Madeira: the 'Direcção Regional de Saúde Pública` (Regional Public Health Directorate), Funchal; for the Azores: the 'Direcção Regional de Saúde` (Regional Health Directorate) in Angra do Heroísmo;
in the United Kingdom, the medical service (doctor, dentist, hospital, etc.) from which treatment is requested;.
in Austria, the 'Gebietskrankenkasse` (Regional Fund for Sickness Insurance) competent for the place of stay;
in Finland, the local office of the 'Kansanelaekelaitos` (Social Insurance Institution) if compensation is sought for medical expenses incurred in the private sector. Benefits in kind can be obtained from municipal health centres and public hospitals by presenting this certificate. Details from the local offices of the 'Kansanelaekelaitos`;
in Iceland, the 'Tryggingastofnun rikisins` (State Social Security Office), Reykajavik;
in Liechtenstein, the 'Amt fuer Volkswirtschaft` (Office of National Economy), Vaduz;
in Norway, the 'lokale trygdekontor` (Local Insurance Office). Assistance may be sought without first contacting the mentioned institution. The form must be presented when assistance is sought;
in Sweden, the 'foersaekringskassan` (Social Insurance Office). Assistance from the medical services (hospital, doctor, dentist, etc.) may be sought without first contacting the said institution.
-for benefits in case of accident at work or occupational disease:
in Belgium, the 'mutualité` (local sickness insurance fund) of your choice;
in Denmark, see above under 'for benefits in case of sickness or maternity`;
in Germany, the accident insurance institution competent for the place of stay;
in Greece, normally the regional or local branch of the Social Insurance Institute (IKA), which issues the person concerned with a 'health book`, without which no benefits in kind can be provided;
in Spain, the medical and hospital services 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);
in Ireland, the Health Board in whose area the benefit is claimed;
in Italy,
(a)for benefits in kind, the 'Unità sanitaria locale` (USL) (local health administration unit) responsible for the area concerned;
(b)for prostheses, major appliances, legal medical benefits and relevant examinations and certificates, the provincial office of the 'Istituto nazionale per l`assicurazione contro gli infortuni` (INAIL, National Institute for Insurance against Accidents at Work);
in Luxembourg, the 'Association d`assurance contre les accidents` (Accident Insurance Association);
in the Netherlands, 'ANOZ Verzekeringen`, Utrecht. Assistance from a doctor, dentist or dispensing chemist may be sought without first contacting ANOZ;
in Portugal, the 'Caixa Nacional de Seguros de Doenças Profissionais` (National Insurance Fund for Occupational Diseases), Lisbon;
in the United Kingdom, the medical service (doctor, dentist, hospital, etc.) from which treatment is requested;
in Austria, the 'Gebietskrankenkasse` (Regional Fund for Sickness Insurance) competent for the place of stay or the 'Allgemeine Unfallversicherungsanstalt` (General Accident Insurance Institution), Vienna;
in Finland, the 'Tapaturmavakuutuslaitosten liitto` (Federation of Accident Insurance Institutions);
in Iceland, the 'Tryggingastofnun rikisins` (State Social Security Office), Reykjavik;
in Liechtenstein, the 'Amt fuer Volkswirtschaft` (Office of National Economy), Vaduz;
in Norway, the 'lokale trygdekontoret` (Local Insurance Office). Assistance may be sought without first contacting the mentioned institution. The form must be presented when assistance is sought;
in Sweden, the 'foersaekringskassan` (Social Insurance Office). Assistance from the medical services (hospital, doctor, dentist, etc.) may be sought without first contacting the said institution.
(d)If your employer has not done so, please complete box 6 of the form.
(e)In order to receive benefits in kind, you may submit an E 111 form instead of this form.
§ NOTES *EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(1)Symbol of the country where the undertaking has its registered office: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = the Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(1a)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.
(1b)In the case of Spanish nationals state the number appearing on the national identity card (D.N.I.), if it exists, even if the card is out of date. Failing this, state 'None`.
(2)Street, number, post code, town, country.
(3)Complete only if different from the institution mentioned in item 3.1.
(4)If the employer, under the legislation of the competent country, is not obliged to know which institution is competent as regards sickness and maternity insurance, this box should be completed by the worker.
(5)For the Netherlands, indicate the sickness fund ('ziekenfonds`).
(6)This part may be completed only if no change has taken place in the information given in part A.
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Social Security Regulations EEA*on page 2 and 31CERTIFICATE OF ENTITLEMENT TO BENEFITS IN KIND DURING A STAY IN A MEMBER STATE Reg. 1408/71: Art. 22.1.a.i; Art. 22.3; Art. 31.a Reg. 574/72: Art. 20.4; Art. 21.1; Art. 23; Art. 31.1 and 3 1&square;Employed person&square;Pensioner (scheme for employed persons)&square;Other &square;Self-employed person&square;Pensioner (scheme for self-employed persons) &square;(Surname (1a), Previous names (1a), D.N.I. (2a), address (2)) 1.1Identification No (2b)Date of birth 1.2&square;The person named above is covered by a scheme for self-employed persons as referred to in Annex 11 to Regulation 574/72 2Members of the family (3) 2.1Surname (1a)ForenamesPrevious namesDate of birthIdentification No (2b) 2.2Permanent address (2) (4) 3The above-named persons are entitled to benefits in kind under sickness and maternity insurance.
These benefits may be provided 3.1(5) &square;fromtoinclusive 3.2(5) &square;from ! E 1114Competent institution 4.1NameCode number (6) 4.2Address (2) 4.3Stamp 4.4Date 4.5Signature 4.6Valid fromto 4.7Stamp4.8Date 4.9Signature 4.10Valid fromto 4.11Stamp4.12Date 4.13Signature 5Competent French institution for non-occupational accidents sustained by self-employed farmers 5.1NameCode number (6) 5.2Address (2) 5.3Stamp 5.4Date 5.5Signature INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information.
The competent institution or, where appropriate, the institution in the place of residence of the pensioner, or the member of the family of the worker should complete this form and send it to the person concerned, or send it to the institution in the place of stay if the form has been drawn up at the latter's request. This form is not required if the person concerned is staying in the United Kingdom.
Information for the insured person and the members of his family (a) The document enables:
- in the case of immediate need the employed or self-employed person and the members of his family named in box 2 who are staying temporarily in a Member State other than the competent State, and - the pensioner and the members of his family named in box 2 who are staying temporarily in a Member State other than that in which they habitually reside,
to obtain benefits in kind from insurance bodies in the country of stay, in the case of sickness or maternity and, provisionally, in the case of an accident at work or occupational disease. However this document does not provide entitlement to benefits in kind if the aim of the journey is to receive medical treatment abroad.
(b) When one of the persons concerned has to seek benefits, including hospitalization, he should submit this form to the insurance body in the country in which he is staying, i.e.:
in Belgium, the 'mutualité` (local sickness insurance fund) of his choice;
in Denmark, the competent 'amtskommune` (local administration). In the commune of Copenhagen, the 'magistrat` (municipal administration); in the commune of Frederiksberg, the 'kommunalbestyrelse` (municipal administration). Assistance from a doctor, dentist or dispensing chemist may be sought without first contacting the said institution. This form must be submitted for each claim for benefits. Particulars about doctors and dentists available may be obtained from the local 'social- og sundhedsforvaltning` (social and health authority);
in Germany, the 'Allgemeine Ortskrankenkasse` (AOK, local general sickness fund);
in Greece, normally the regional or local branch of the Social Insurance Institute (IKA), which issues the person concerned with a 'health book`, without which no benefits in kind can be provided;
" E 111in Spain, the medical and hospital services of the Spanish Social Security health system. The form must be submitted, together with a photocopy;
in France, the 'Caisse primaire d'assurance-maladie` (local sickness insurance fund);
in Ireland, the Health Board in whose area the benefit is claimed;
in Italy, 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 marrittima o aerea` (Ministry of Health, the navy or aviation health office responsible for the area in question);
in Luxembourg, the 'Caisse de maladie des ouvriers` (Sickness Fund for Manual Workers);
in the Netherlands, the ANOZ Verzekeringen, Utrecht. Assistance from a doctor, dentist or dispensing chemist may be sought without first contacting ANOZ Verzekeringen;
in Portugal, for metropolitan Portugal: the 'Administração Regional de Saúde` (Regional Health Administration) of the place of stay; for Madeira: the 'Direcção Regional de Saúde Pública` (Regional Public Health Directorate) in Funchal; for the Azores: the 'Direcção Regional de Saúde` (Regional Health Directorate) in Angra do Heroísmo.
in Austria, The 'Gebietskrankenkasse` (Regional Fund for Sickness Insurance);
in Finland, the local office of the 'kansanelaekelaitos` (Social Insurance Institution), if compensation is sought for medical expenses incurred in the private sector. Benefits in kind can be obtained from municipal health centres and public hospitals by presenting the certificate;
in Iceland, the 'Tryggingastofnun rikisins` (State Social Security Institute), Reykjavik;
in Liechtenstein, the 'Amt fuer Volkswirtschaft` (Office of National Economy), Vaduz;
in Norway, the 'lokale trygdekontor` (local Insurance Office). Assistance from the medical service may be sought without first contacting the institution mentioned. This form should be presented when assistance is sought;
in Sweden, the 'foersaekringskassan` (Social Insurance Office). Assistance from the medical service (hospital, doctor, dentist, etc.) may be sought without first contacting the said institution.
(c) In order to receive cash benefits the person concerned shall, within three days of commencement of the incapacity for work, apply to the institution of the place of stay by submitting a notification of having ceased work or, if the legislation administered by the competent institution or by the institution of the place of stay so provides, a certificate of incapacity for work issued by the doctor providing treatment for the person concerned.
NOTES * EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(1) Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = the Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(1a) 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.
(2) Street, number, post code, town, country.
(2a) In the case of Spanish nationals state the number appearing on the national identy card (D.N.I.), if it exists, even if the card is out of date. Failing this, state 'None`.
(2b) For Italian nationals indicate, if possible, the insurance number and/or the 'codice fiscale`.
(3) Include only those members of the family who are temporarily going to another Member State.
(4) Complete only if the address of the members of the family differs from that of the worker or pensioner.
(5) These two items are mutually exclusive. Give only that which is applicable and put a cross in the corresponding box.
(6) To be completed where this exists.
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()XTB:763EU01700 EUROPEAN COMMUNITIESSee 'Instructions` Social Security Regulations EEA*overleafBSCHEME FOR SELF-EMPLOYED PERSONS 1CERTIFICATE OF ENTITLEMENT TO BENEFITS IN KIND DURING A STAY IN A MEMBER STATE Reg. 1408/71; Art. 22.1.a.i; Art. 22.3; Art. 31.a Reg. 574/72: Art. 20.4; Art. 21.1; Art. 23; Art. 31.1 and 3 1&square;Self-employed person&square;Pensioner(Surname (1a), Previous names (1a), forenames, address (2)) 1.1Identification No (1b)Date of birth 2Members of the family (3) 2.1Surname (1a)ForenamesPrevious namesDate of birthIdentification No (1b) 2.2Permanent address (2) (4) 3The above-named persons are entitled to benefits in kind in the case of hospitalization only.
These benefits may be provided 3.1fromtoinclusive 4Competent institution 4.1NameCode number (5) 4.2Address (2) 4.3Stamp 4.4Date 4.5Signature 4.6Valid fromto 4.7Stamp4.8Date 4.9Signature 4.10Valid fromto 4.11Stamp4.12Date 4.13Signature ! BSCHEME FOR SELF-EMPLOYED PERSONS 4.14Valid fromto 4.15Stamp4.16Date 4.17Signature 4.18Valid fromto 4.19Stamp4.20Date 4.21Signature INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only.
The competent institution or, where appropriate, the institution in the place of residence of the pensioner, should complete this form and send it to the person concerned, or send it to the institution in the place of stay if the form has been drawn up at the latter's request. This form is not required if the person concerned is staying in the United Kingdom.
Information for the insured person and the members of his family (a)This document enables:
-the self-employed person and the members of his family named in box 2, who are staying temporarily in a Member State other than the competent State, and -the pensioner covered by the scheme for the self-employed and the members of his family named in box 2, who are staying temporarily in a Member State other than that in which they habitually reside,
to obtain benefits in kind from insurance bodies in the country of stay only in the case of hospitalization.
(b)When one of the persons concerned has to enter hospital, he should submit this form to the insurance body in the country in which he is staying, i.e.:
in Denmark, the competent 'amtskommune` (local administration). In the commune of Copenhagen, the 'magistrat` (municipal administration); in the commune of Frederiksberg, the 'kommunalbestyrelse` (municipal administration). This form must be submitted for each claim for benefits;
in Germany, the 'Allgemeine Ortskrankenkasse` (AOK, local general sickness fund);
in Greece, the regional or local branch of the Social Insurance Institute (IKA) which issues the person concerned with a 'health book` without which no benefits can be provided;
in Spain, the hospital services provided under the social security scheme. The form must be submitted, together with a photocopy;
in France, the 'Caisse primaire d'assurance-maladie` (local sickness insurance fund);
in Ireland, the Health Board in whose area the benefit is claimed;
in Italy, the 'Unitá 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, the 'ANOZ-Verzekeringen`, Utrecht;
in Portugal, for metropolitan Portugal: the 'Administração Regional de Saúde` (Regional Health Administration of the place of stay); for Madeira: the 'Direcção Regional de Saúde Pública` (Regional Public Health Directorate) in Funchal; for the Azores: the 'Direcção Regional de Saúde` (Regional Health Directorate) in Angra do Heroísmo;
in Austria, the 'Gebietskrankenkasse` (Regional Fund for Sickness Insurance) competent for your place of stay;
in Finland, the local office of the 'Kansanelaekelaitos` (social insurance Institution) and the hospital providing treatment. This form must be submitted with each claim for benefits;
in Iceland, the 'Tryggingastofnun rikisins` (the State Social Security Institution), Reykjavik;
in Liechtenstein, the 'Amt fuer Volkswirtschaft` (the Office of National Economy), Vaduz;
in Norway, the 'lokale trygdekontor` (the local Insurance Office) at the place of stay;
in Sweden, the 'foersaekringskassan` (Social Insurance Office) at the place of stay.
()NOTES *EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
1Symbol of the country to which the institution completing the form belongs: B = Belgium.
1aIn 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.
1bFor Italian nationals indicate, if possible, the insurance number and/or the 'codice fiscale`.
2Street, number, post code, town, country.
3Include only those members of the family who are temporarily going to another Member State.
4Complete only if the address of the members of the family differs from that of the insured person or pensioner.
5To be completed where this exists.
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Social Security Regulations EEA*on page 31 CERTIFICATE CONCERNING THE RETENTION OF THE RIGHT TO SICKNESS OR MATERNITY BENEFITS CURRENTLY BEING PROVIDED Reg. 1408/71: Art. 22.1.b.i; Art. 22.1.c.i; Art. 22.3; Art. 31 Reg. 574/72: Art. 22.1; and 3; Art. 23 The competent institutions or the institution of the place of residence of the pensioner or the member of the family should issue this form to the insured person or the pensioner or the member of the pensioner's family. If the insured person or the pensioner is going to the United Kingdom, one copy of the form should also be sent to the Department of Social Security, Benefits Agency, Overseas Benefits Directorate, Newcastle upon Tyne.
1&square;Employed person&square;Pensioner (scheme for employed persons) &square;Self-employed person&square;Pensioner (scheme for self-employed persons) &square;Other 1.1Surname (1a) 1.2ForenamesPrevious names (1a)Date of birth 1.3Address in the competent country (2) 1.4Address in the country to which the insured person or the pensioner is going (2) (3) 1.5Identification No (3a) 1.6&square;The insured person or pensioner is covered by a scheme for self-employed persons as referred to in Annex 11 to Regulation 574/72 2Member of the family going to another Member State 2.1Surname (1a) 2.2ForenamesPrevious namesDate of birth 2.3Address in the competent country (2) (4) 2.4Address in the country to which the person concerned is going (2) 2.5Identification No (3a) 3The person mentioned&square;in box 1&square;in box 2 retains the right to receive benefits in kind &square;from sickness and maternity insurance&square;from non-occupational accident insurance (5) in(country), where he/she is going 3.1&square;to take up his/her residence 3.2&square;to receive treatment there at/from &square;(6) &square;(6) &square;or at any other establishment of a similar nature in case of a transfer which is medically necessary in respect of this treatment 3.3&square;to send biological samples to have tests carried out 4These benefits may be provided on production of this certificate 4.1fromtoinclusive 4.2fromtoinclusive only in the event of hospitalization (7) ! 5The report from our examining doctor 5.1&square;is attached to this form in a sealed envelope 5.2&square;was sent onto (8) &square;
5.3&square;will be sent by us on request 5.4&square;has not been drawn up 6Competent institution 6.1NameCode number (9) 6.2Address (2) 6.3Stamp 6.4Date 6.5Signature " INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information.
Information for the insured person You should submit this form as soon as possible to the sickness and maternity insurance institution of the place to which you are going, i.e.:
in Belgium, the 'mutualité` (local sickness insurance fund) of your choice;
in Denmark, the competent 'amtskommune` (local administration). In the commune of Copenhagen, the 'magistrat` (municipal administration); in the commune of Frederiksberg, the 'kommunalbestyrelse` (municipal administration). The form should be submitted to the institution providing treatment;
in Germany, the 'Allgemeine Ortskrankenkasse` (AOK, local general sickness fund);
in Greece, normally the regional or local branch of the Social Insurance Institute (IKA), which issues the person concerned with a 'health book`, without which no benefits in kind can be provided;
in Spain, the medical an hospital services 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);
in Ireland, the Health Board in whose area the benefit is claimed;
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, or in case of temporary stay, the 'AOZ Verzekeringen` Utrecht;
in Portugal, for metropolitan Portugal: the 'Administração Regional de Saúde` (Regional Health Administration) of the place of residence or stay; for Madeira: the 'Direcção Regional de Saúde Pública` (Regional Public Health Directorate) in Funchal; for the Azores: the 'Direcção Regional de Saúde (Regional Health Directorate) in Angra do Heroísmo;
in the United Kingdom, the medical service (doctor, dentist, hospital, etc.) from which treatment is requested;
in Austria, the 'Gebietskrankenkasse` (regional fund for sickness insurance) competent for the place of residence or place of stay;
in Finland, the local office of the 'kansanelaekelaitos` (social insurance institution). This form must be presented to the municipal health centre or public hospital providing treatment;
in Iceland, the 'Tryggingastofnun rikisins' (the State social Security institute) Reykjavik;
in Liechtenstein, the 'Amt fuer Volkswirtschaft` (the office of National Economy), Vaduz;
in Norway, the 'lokale trygdekontor` (the local Insurance Office);
in Sweden, the 'foersaekringskassan` (Social Insurance Office).
The form should be submitted to the institution providing treatment.
NOTES *EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(1)Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = the Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(1a)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.
(2)Street, number, post code, town, country.
(3)Indicate only if the form concerns the insured person or the pensioner himself.
(3a)For Italian nationals indicate, if possible, the insurance number and/or the 'codice fiscale`.
(4)Indicate only if the address of the member of the family is different from that of the insured person or the pensioner.
(5)To be completed by French institutions for self-employed agricultural workers.
(6)As precise as possible.
(7)To be completed by Belgian institutions for self-employed persons.
(8)Name and address of the institution to which the medical report has been sent.
(9)To be completed where this exists.
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Social Security Regulations EEA*on page 21HOSPITALIZATION: NOTIFICATION OF ENTERING AND LEAVING HOSPITAL Reg. 1408/71: Art. 19; Art. 22; Art. 25.1 and 3.i; Art. 26; Art. 31.a; Art. 52.a; Art. 55.1 Reg. 574/72: Art. 17.6; Art. 20.5; Art. 21.2; Art. 22.2 and 3; Art. 23; Art. 26.3;
Art. 27; Art. 28; Art. 31.2 and 3; Art. 60.5; Art. 62.7; Art. 63.2 This form should be drawn up in the event of a refund of benefits in kind on the basis of actual expenditure. It should be completed by the institution in the place of residence or stay: part A to notify entry into hospital, part B to notify discharge from hospital. It should be sent to the competent institution. If the competent institution is an institution in Denmark or the United Kingdom, this form is not required.
1Competent institution 1.1Name 1.2Address (2) 2&square;Employed person&square;Pensioner (scheme for employed persons) &square;Self-employed person&square;Pensioner (scheme for self-employed persons) &square;Unemployed person&square;Pension claimant 2.1Surname (2a) 2.2ForenamesPrevious names (2a)Date of birth 2.3Address in the country of residence or stay (2) 2.4Identification No (2b) 3Member of the family who is in hospital 3.1Surname (2a) 3.2ForenamesPrevious namesDate of birth 3.3Address in the country of residence or stay (2) (3) 3.4Identification No (2b) 4Reference:
4.1&square;your formof(4) 4.2&square;our E 107 form of A. Notification of entry into hospital 5The person mentioned&square;in box 2&square;in box 3 5.1entered hospital on(date) 5.2namely (5) 5.3because of&square;sickness&square;maternity&square;an accident at work (6) &square;an occupational disease (7)&square;an accident in private life (8) 5.4He/she will probably stay in hospital until 5.5&square;(9) Supporting documents or medical report attached B. Notification of discharge from hospital 6The hospitalization notified &square;by our E 113 form dated &square;in part A above ended on ! 7Institution in the place of residence or stay 7.1Name 7.2Address (2) 7.3Stamp 7.4Date 7.5Signature INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only.
NOTES *EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purpose of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(1)Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein, N = Norway; S = Sweden.
(2)Street, number, post code, town, country.
(2a)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.
(2b)In the case of Spanish nationals state the number appearing on the national identity card (D.N.I.), if it exists, even if the identity card is out of date. Failing this, state 'None`. For Italian nationals indicate, if possible, the insurance and/or the 'code fiscale'. For persons insured in Sweden enter national personal identification number.
(3)To be indicated if the address of the member of the family is different from that mentioned in box 2.
(4)Number and date of issue of the form certifying the insured person's entitlement to benefits.
(5)Name of hospital.
(6)If the patient is insured in Belgium or Liechtenstein, indicate in the box below the name and address of the employer.
Name of employer or firm Address (2) (7)Indicate if possible.
(8)To be completed for French institutions for self-employed agricultural workers and for Portuguese institutions.
(9)Where appropriate, put a cross in this square.
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Social Security Regulations EEA*on page 21GRANTING OF MAJOR BENEFITS IN KIND Reg. 1408/71: Art. 19; Art. 22; Art. 24; Art. 25.1 and 3.i; Art. 26; Art. 31.a; Art. 52.a; Art. 55.1 Reg. 574/72: Art. 17.7; Art. 20.5; Art. 21.2; Art. 22.2 and 3; Art. 23; Art. 26.3;
Art. 27; Art. 28; Art. 31.2 and 3; Art. 60.6; Art. 62.7; Art. 63.2 and 3 This form should be drawn up in the event of a refund of benefits in kind on the basis of actual expenditure. The institution in the place of residence or stay should complete part A, and send to the competent institution one or two copies of the form, depending on whether this notification concerns the case provided for in item 7.1 or 7.2. If the competent institution decides that it must oppose the granting of benefits, it should complete part B and return a copy of the form to the institution in the place of residence or stay. If the competent institution is an institution of the United Kingdom, this form is not required.
A. Notification 1Competent institution 1.1Name 1.2Address (2) 2(3) &square;Employed person&square;Pensioner (scheme for employed persons) (3) &square;Self-employed person&square;Pensioner (scheme for self-employed persons) (3) &square;Unemployed person&square;Pension claimant 2.1Surname (3a) 2.2ForenamesPrevious names (3a)Date of birth 2.3Address in the country of residence or stay (2) 2.4Identification No (3b) 3Member of the family concerned 3.1Surname (3a) 3.2ForenamesPrevious namesDate of birth 3.3Address in the country of residence or stay (2) (4) 3.4Identification No (3b) 4Reference 4.1&square;your formof(5) 4.2&square;our E 107 form of(date) 5Our medical service has recognized, for the person mentioned &square;in box 2&square;in box 3 5.1&square;the necessity&square;the extreme urgency 5.2of the following benefits 5.3the&square;probable&square;actual costs of which are within the meaning of our legislation (6) 6&square;Please find attached the report from our examining doctor (7) 7The benefits mentioned in item 5.2 (8) 7.1&square;have already been provided in view of the urgent nature of the case, on 7.2&square;will be provided unless we receive any reasons for objection on your part within 15 days of the date of dispatch of this &square;notification ! 8Institution in the place of residence or stay 8.1Name 8.2Address (2) 8.3Stamp 8.4Date 8.5Signature B. Reasons for objection on the part of the competent institution, if any 9With reference to item 7.2 above, we hereby inform you that the benefits indicated in item 5.2 cannot be granted Reason 10Competent institution 10.1NameCode number (9) 10.2Address (2) 10.3Stamp 10.4Date 10.5Signature INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only.
NOTES * EEA Agreement on the European Economic Area, Annex VI, social security for the purpose of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(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; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(2) Street, number, post code, town, country.
(3) If the patient is insured in Belgium or Liechtenstein, give name and address of employer in the box below:
Name of employer or firm Address (2) (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 number and/or the 'codice fiscale`.
(4) Indicate only if the address of the member of the family is different from that mentioned in box 2.
(5) Number and date of issue of the form certifying that the person concerned is entitled to benefits.
(6) The cost should be indicated in the currency of the country of stay or residence.
(7) If the medical report is attached to the form, put a cross in the square provided.
(8) Where the person concerned is a self-employed Belgian take into account only benefits in kind in the event of hospitalization.
(9) To be completed where this exists.
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E 115
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Social Security Regulations EEA*on page 31CLAIM FOR CASH BENEFITS FOR INCAPACITY FOR WORK Reg. 1408/71: Art. 19.1.b; Art. 22.1.a.ii; Art. 25.1.b.; Art. 52.b; Art. 55.1.a.ii Reg. 574/72: Art. 18.2 and 3; Art. 24; Art. 26.5 and 7; Art. 61.2 and 3; Art. 64 If the form is drawn up for an insured person in active employment, one copy only should be completed and sent to the institution competent as regards sickness and maternity insurance or as regards an insurance against accidents at work and occupational diseases. However, if it concerns an unemployed person, two additional copies should be drawn up, one of which should be sent to the institution competent in unemployment insurance, the other to the corresponding institution in the country to which the unemployed person has gone to seek employment (see also notes 7 and 9).
1Competent institution 1.1Name 1.2Address (2) 2&square;Employed person&square;Self-employed person&square;Unemployed person 2.1Surname (2a) 2.2ForenamesPrevious names (2a)Date of birth 2.3Address in the competent country (2) 2.4Address in the country of residence or stay (2) 2.5Identification No (2b) 2.6holds an E 119 form issued on(3) and an E 303 form issued on(3) 3Employer (4) 3.1Name of employer or firm 3.2Address (2) 3.3Nature of business A. &square;(5) Claim for benefits 4The person mentioned in box 2 applied on(date) for cash benefits for incapacity for work due to 4.1&square;sickness (6)&square;maternity (expected date of confinement) &square;accident at work&square;accident sustained on(date) &square;occupational disease&square;adoption&square;reduced compensation in case of maternity and &square;adoption (6) 5The certificate of the doctor treating him/her &square;is attached&square;could not be supplied ! 6In the opinion of our examining doctor&square;whose report is attached &square;whose report will be sent to you as soon as &square;possible 6.1&square;the incapacity for work began on &square;and will probably continue until 6.2&square;there is no incapacity for work (7) 7&square;The person concerned is deemed not to have complied with the provisions of our legislation for the following reasons:
8&square;The incapacity for work was presumably caused by an accident for which a third party was responsible.
8.1&square;A report on this accident with the address of the third party involved is attached to this form.
&square;
9&square;We are willing to provide cash benefits to the person concerned on your behalf. Will you please let us know if you agree to this &square;procedure and, if so, give us all information necessary for the payment of the benefits (8).
&square;
10&square;We are not willing to provide cash benefits to the person concerned on your behalf.
B. &square;(5) Extension of the incapacity for work 11With reference to 11.1&square;our E 115 form of(date) 11.2&square;your E 117 form of(date) 11.3we wish to inform you that, in the opinion of our examining doctor &square;whose report is attached &square;whose report will be sent to you as soon as possible the person mentioned in box 2 will probably remain incapable of work until inclusive 12Institution in the place of residence or stay 12.1Name 12.2Address (2) 12.3Stamp 12.4Date 12.5Signature " INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information.
NOTES * EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purpose or this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(1) Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(2) Street, number, post code, town, country.
(2a) 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 they appear on the identity card or passport.
(2b) For Italian nationals indicate if possible, the insurance number and/or the 'codice fiscale`.
(3) Complete only if the form concerns an unemployed person.
(4) For unemployed persons, indicate the last employer.
(5) Complete either part A or part B and put a cross in the square corresponding to the part completed. For the Netherlands box 4 must be filled in.
(6) When applying from Norway.
(7) Please attach a copy of an E 118 form sent to the person concerned.
(8) If the form is being sent to a German or an Italian institution, this box need not be ticked, only box 10.
(9) In Italy you should submit this form - in case of sickness or maternity to the local office of the 'Instituto nazionale della previdenza sociale` (INPS, National Social Welfare Institute) - in case of an accident at work or occupational disease to the 'Instituto nazionale assicurazione contro gli infortuni sul lavoro` (INAIL). For the Netherlands if the competent sickness insurance institution is not known send the form to the G.A.X., Postbus 8300 Amsterdam.
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E 116
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Social Security Regulations EEA*on page 31MEDICAL REPORT RELATING TO INCAPACITY FOR WORK (SICKNESS, MATERNITY, ACCIDENT AT WORK, OCCUPATIONAL DISEASE) Reg. 1408/71: Art. 19.1.b; Art. 22.1.a.ii; 1.b.ii; 1.c.ii; Art. 25.1.b; Art. 52.b; Art. 55.1.a.ii; 1.b.ii and 1.c.ii Reg. 574/72: Art. 18.2 and 3; Art. 24; Art. 26.5 and 7; Art. 61.2 and 3; Art. 64; Art. 65.2 and 4 To be completed by the doctor of the institution which draws up an E 115 form to be attached to that form and sent under sealed cover in the case of sickness or maternity. For Belgium, this form should always be sent first to the Belgian institution competent as regards sickness insurance (9). In Liechtenstein, Norway and Sweden the form is filled in by the doctor the person concerned is visiting and verified by the insurance institution.
1Competent institution to which the form is addressed 1.1Name 1.2Address (2) 1.3Reference: our E 116 form of(date) 2Attached to an E 115 form of(date) 3&square;Employed person&square;Self-employed person&square;Unemployed person 3.1Surname (2a) 3.2ForenamesPrevious names (2a)Date of birth 3.3Address in the country of residence or stay (2) 3.4Identification No (3) 4I, the undersigned,, doctor of medicine, having examined the person mentioned above on 4.1consider that it is &square;a case of sickness&square;a case of maternity (expected date of confinement) 4.2that it is probably &square;an accident at work&square;an occupational disease&square;an accident 4.3&square;a relapse or aggravation ! A. General report 5To be completed in every case, particularly in the case of an accident at work 5.1Medical history and present symptoms 5.2Clinical examination 5.3General conditionWeightHeight(4) 5.4Other observations 5.5Special examinations (5) 5.6Diagnosis 5.7Conclusions 5.8&square;The person concerned has not been found to be unfit for work 5.9&square;The person concerned has been found to be unfit for work &square;fromto 5.10&square;The person concerned has been found partly unfit for work to a degree of &square;%fromto(5a) 5.11&square;The person concerned will be given a further medical examination on 5.12&square;The person concerned should be fit for work on B. Reports in the case of an accident at work 6First medical report 6.1This accident has resulted in the following injuries (6) 6.2These injuries&square;have had&square;will have the following effects (7) 6.3Incapacity for work began on 6.4The injured person is being treated &square;at home&square;at the doctor's surgery &square;in hospital&square;elsewhere Address (2) (8) " 7Final medical report 7.1The treatment ended on 7.2The injuries were consolidated on 7.3&square;without after-effects 7.4&square;and will probably have the following consequences 7.5Detailed description of the injured person's condition after recovery or at the end of the medical treatment 8Institution in the place of residence or stay 8.1Name 8.2Address (2) 8.3Stamp 8.4Date 8.5Doctor's signature INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information.
NOTES *EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(1)Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(2)Street, number, post code, town, country.
(2a)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.
(3)For Italian nationals indicate, if possible, the insurance number and/or the 'codice fiscale`.
(4)Information to be given only where necessary.
(5)Indicate the type of examination and the date.
(5a)For the purpose of Norwegian institutions.
(6)Indicate the type and nature of the injuries and the part of the body injured: fracture of arm, bruising of head, fingers, internal injuries, asphyxia, etc.
(7)Indicate the certain or probable consequences of the injuries verified: death, permanent or temporary incapacity, total or partial; in the case of temporary incapacity, indicate the probable duration.
(8)If the injured person receives treatment in hospital, please give name of hospital.
(9)Form E 116 is not required for claims for maternity benefits payable by Belgium.
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E 117
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Social Security Regulations EEA*on page 21GRANTING OF CASH BENEFITS IN THE CASE OF MATERNITY AND INCAPACITY FOR WORK Reg. 1408/71: Art. 19.1.b; Art. 22.1.a.ii; Art. 25.1.b; Art. 52.b; Art. 55.1.a.ii Reg. 574/72: Art. 18.6 and 8; Art. 24; Art. 26.7; Art. 61.6 and 8; Art. 64 The competent institution should complete this form and send it to the institution in the place of residence or stay. The competent institution should also inform the worker if cash benefits are paid by the institution in the place of residence (Regulation 574/72: Article 61.8).
1Institution of the place of residence or stay 1.1Name 1.2Address (2) 2Reference: your E 115 form of(date) 3&square;Employed person&square;Self-employed person&square;Unemployed person 3.1Surname (2a) 3.2ForenamesPrevious names (2a)Date of birth 3.3Address in the country of residence or stay (2) 3.4Identification No (2b) 4&square;is provisionally entitled to receive cash benefits fromto,with possibility of extension 4.1&square;is not entitled to cash benefits Reason: see the E 118 form attached 4.2&square;is no longer entitled to cash benefits from(date) Reason: see the E 118 form attached 5These benefits will be provided (3a) 5.1&square;by us 5.2&square;by you on our behalf (3b) 5.3&square;by the employer (4) fromto (5) 6(3) (6) 6.1The allowance should be paid 6.2for every day of the week, except&square;Monday&square;Tuesday&square;Wednesday &square;Thursday&square;Friday&square;Saturday&square;Sunday 6.3The daily net amount of this allowance is (7) if the insured person is not in hospital (7) if the insured person is in hospital 6.4&square;(8) If the allowance is paid monthly, the amount provided is for 30 days, regardless &square;(8) of the number of days in the month 7Please inform us as soon as possible of the result of 7.1&square;examination (9) (9) 7.2&square;administrative checks 7.3&square;a further medical examination, to be carried out about(date) ! 8Competent institution 8.1NameCode number (10) 8.2Address (2) 8.3Stamp 8.4Date 8.5Signature INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only.
NOTES * EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(1) Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = Netherlands; P = Portugal; GB = United Kingdom, A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(2) Street, number, post code, town, country.
(2a) 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.
(2b) For Italian nationals indicate, if possible, the insurance number and/or the 'codice fiscale`.
(3) Need not be completed for unemployed persons for whom a form E 119 has been issued.
(3a) The competent institution may indicate here the method of payment.
(3b) When this form is adressed to a French or an Italien institution, this box need not be ticked.
(4) To be completed, where appropriate, by Danish, German or Luxembourg institutions.
(5) To be completed by German, Spanish and Luxembourg institutions.
(6) Complete only in the case indicated at point 5.2.
(7) Indicate the amount in the currency of the competent country.
(8) Put a cross in this square if appropriate.
(9) Indicate the type of medical examination requested (radiography, analysis of ........., etc.).
(10) To be completed where this exists.
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E 118
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Social Security Regulations EEA*overleaf1NOTIFICATION OF NON-RECOGNITION OR OF END OF INCAPACITY FOR WORK Reg. 1408/71: Art. 19.1.b; Art. 22.1.a.ii, b.ii and c.ii; Art. 25.1.b; Art. 52.b; Art. 55.1.a.ii, b.ii and c.ii Reg. 574/72: Art. 18.4 and 6; Art. 24; Art. 26.5 and 7; Art. 61.4 and 6; Art. 64 If this form relates to an insured person in active employment, the institution in the place of residence or stay (or the competent institution) should draw up two copies of the form, one of which should be sent to the insured person himself and the other to the sickness and maternity insurance institution or to the institution for insurance against accidents at work and occupational diseases of the competent country (in the place of residence or stay). If it relates to an unemployed person, it is necessary to draw up, in addition to the copies mentioned (one of which is addressed to the unemployed person himself), two extra copies, one of which should be sent to the institution competent in unemployment insurance and the other to the institution of the country to which the unemployed person has gone to seek employment.
1&square;Employed person&square;Self-employed person&square;Unemployed person 1.1Surname (1a) 1.2ForenamesPrevious names (1a)Date of birth 1.3Address in the country of residence or stay (2) 1.4Identification No (2a) 2&square;Competent institution&square;Institution in the place of residence or stay 2.1Name 2.2Address (2) 3&square;The facts which have been brought to our notice &square;The examination carried out by our doctor on(date) &square;shows 3.1&square;&square;that your incapacity for work is only partial 3.2&square;&square;that you are entitled to partial cash benefits amounting to (3) &square;&square;from (date) 3.3&square;&square;that you are fit for work 3.4&square;&square;that your incapacity for work ended on(4) 3.5&square;the last day for which you will receive cash benefits is 3.6&square;the competent institution shall determine the last day for which you receive cash benefits 3.7&square;You are not entitled to benefits because 4&square;Institution in the place of residence or stay&square;Competent institution 4.1NameCode number (5) 4.2Address (2) 4.3Stamp 4.4Date 4.5Signature ! INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of two pages, including the Annex, none of which may be left out even if it does not contain any relevant information.
Information for the employed person, the self-employed person or the unemployed person.
If you disagree with the decision which is notified to you by this document, you may appeal against it. For details of the legal remedies and periods allowed for appeals, please see the Annex. For procedures and time limits you should follow the instructions indicated for the competent State.
NOTES *EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(1)Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = the Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(1a)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.
(2)Street, number, post code, town,
(2a)For Italian nationals indicate, if possible, the insurance number and/or the 'codice fiscale`.
(3)This information is to be provided only if the competent institution is completing the form. Indicate whether benefits are provided daily, weekly or monthly.
(4)Indicate the last day of incapacity for work.
(5)To be completed where this exists.
" Annex LEGAL REMEDIES AND PERIODS ALLOWED FOR APPEALS Reg. 574/72: Art. 18.4; Art. 61.4 1.Belgium If you do not agree with the decision attached, you have the right to lodge an appeal in writing, dated and signed, to be submitted or sent by registered letter to the office of the clerk of the competent labour court within a period of one month of the date on which you received notification of the decision.
Competent labour courts are:
(a)if you are domiciled in Belgium, the labour court of the district where you are domiciled;
(b)if you are not or no longer domiciled in Belgium, the labour court of the district where you were last domiciled or resident in Belgium;
(c)if you have not been domiciled or resident in Belgium, the labour court of the district where you were last employed in Belgium.
2.Denmark If you wish to contest the decision attached, you may, within four weeks of the date on which you received notification of the decision lodge an appeal with 'Den Sociale Ankestyrelse Dagpengeudvalget, Amaliegade 25, PO. Box 3061, 1021 Copenhagen K (The Social Appeals Board, Daily Cash Benefits Committee).
3.Germany This official act becomes binding if within three months of notification you have not submitted an appeal. Appeals should be lodged in writing within three months with the following German institution:
Name Address 4.Greece If you do not agree with the attached decision you may submit an appeal, within a period of 30 days of the date on which you received the attached decision to:
Name Address 5.Spain You may, within a period of 30 working days of the date on which you received notification of the attached decision, submit an appeal against the decision to the following institution:
Name Address either directly or via the institution of your place of stay or residence.
6.France If you wish to contest the decision attached, you may, within a period of two months of the date on which you received notification of the decision, lodge an appeal with the chief physician of the sickness insurance fund indicated in the box below Name Address § Annex 7.Ireland If you do not agree with the decision attached, you may submit a request to the Social Welfare Appeals Office, D'Olier House, D'Olier Street, Dublin 2. Such a request should be made within 21 days of the date on which you received this decision.
8.Italy Decisions of INPS (Sickness and Maternity).
An insured person may contest a decision of the INPS by lodging an administrative appeal with the competent Provincial Commission within 90 days of receiving notice of the relevant decision.
Moreover, the person concerned may initiate legal proceedings within a period of one year of the date on which the Commission's decision was notified or after 90 days have elapsed since lodging his appeal if the Commission has taken no decision.
Decisions of INAIL (accidents at work and occupational diseases) An insured person wishing to contest a decision of INAIL may, within 60 days of the receipt of the notification sent to him, inform INAIL, by registered letter with advice of delivery or notice of receipt, of the reasons why he considers that the decision is unjustified; in the case of permanent incapacity for work, he should indicate the amount of the allowance to which he feels entitled; in all cases, a medical certificate in support of his claim should be sent with the letter of appeal.
If the person concerned has not received a reply within a period of 60 days of the date of the advice of delivery or the notice of receipt referred to above, or if he is not satisfied with the reply, he may take INAIL to court over the matter.
The letter setting out the reasons why the insured person does not agree with a decision of INAIL may be sent to INAIL either directly or through the institution of the place of residence or stay.
9.Luxembourg If you do not agree with the decision attached, you have the right to lodge an appeal in principle with the 'Conseil arbitral des assurances sociales', within a period of 40 days of the date on which you received notification of the decision.
10.Netherlands If you do not agree with the communication attached, you may request the competent Netherlands institution mentioned in box 2 or 4 of the E 118 form to take an appealable decision within a reasonable period of time. The method of appealing and the time limit within which to appeal will be specified in the decision.
11.Portugal If you do not agree with this decision, you may,
-If incapacity for work has not been recognized, lodge an appeal with the Regional Administrative Health Board (Commissão Instaladora da Administraçao Regional de Saude) within eight days of receiving notice of the decision,
or -if a claim of cash benefits has been rejected on administrative grounds, lodge an appeal with the locally competent Adminstrative Tribunal (Tribunal Administrative de Circulo) within two months of receiving notice of the decision. If you have been residing outside of Portugal, four months, of receiving notice of the decision.
12.United Kingdom If you do not agree with the decision attached, you may, within 28 days of the date of receipt of the decision, lodge an appeal with 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.
13.Austria If you do not agree with the attached information (form E 118), you can request a decision from the competent Austrian Institution mentioned in box 2 or 4 of the form referred to before, from which you can take the instruction about the admissable legal remedy.
$ Annex 14.Finland If you wish to contest the decision attached, you may submit an appeal within 30 days of the date on which you received notification of the attached decision to either the Finnish insurance institution indicated in box 2 or 4 of the E 118 form, or the insurance institution nearest to your place of residence, which is also indicated in one of the abovementioned boxes.
15.Iceland If you wish to contest the decision attached, you may lodge an appeal with the State Social Security Board, Reykjavik.
16.Liechtenstein (a)concerning sickness insurance: if you do not agree with a decision of a sickness insurance fund, you might ask for a formal decree that must contain the reasons and the information concerning the course of law.
Within 60 days after having received this formal decree the persons concerned can file a legal suit with the respective court.
(b)concerning accident insurance: if you do not agree with a decree of an accident insurer, you can within two months after having received this decree ask the respective accident insurer to reconsider its decree.
If you do not agree with a decree of an accident insurer, you can also, within two months after having received this decree file a legal suit with the respective court. This also applies to the decision of the accident insurers concerning the abovementioned application for reconsideration.
17.Norway An appeal against a Norwegian decision must be sent to the institution indicated in box 2 or 4 in form E 118 within six weeks after receiving notice of the decision.
18.Sweden You may within a period of two months from the actual taking part of the decision lodge an appeal to the competent Swedish institution indicated in boxes 2 or 4 of the E 118 form. In your appeal you should state why you consider that the decision is unjustified.
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E 119
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Social Security Regulations EEA*pages 3 and 4E 1191CERTIFICATE CONCERNING THE ENTITLEMENT OF UNEMPLOYED PERSONS AND THE MEMBERS OF THEIR FAMILY TO SICKNESS AND MATERNITY INSURANCE BENEFITS Reg. 1408/71: Art. 25.1 and 3.i Reg. 574/72: Art. 26.1 The competent institution should issue the form to the unemployed person or send it to the institution in the place of residence or stay if it was drawn up at the latter institution's request.
1Institution of the place of residence or stay (2) 1.1Name 1.2Address (3) 1.3Reference: your&square;E 107 form of&square;E 115 form of 2Unemployed person 2.1Surname (3a) 2.2ForenamesPrevious names (3a)Date of birth 2.3Address in the country where the person concerned is seeking employment (3) 2.4Identification No 3Last employer, if any 3.1Name of employer or firm 3.2Address (3) 4The person concerned mentioned above is entitled to sickness and maternity benefits &square;in kind for himself &square;in cash for himself &square;in kind for the members of his family provided that the unemployment insurance institution in the country where he has gone to seek employment has sent to the sickness and maternity insurance institution of that country an E 303/3 form containing the certified statement provided for in the first subparagraph of Article 26 (2) of Reg. 574/72 5Benefits in kind may be provided 5.1&square;for a period not exceeding that fixed for entitlement to unemployment benefits 5.2&square;for cases of sickness that have occurred untilinclusive, and &square;fordaysweeks 6In the case of incapacity for work, cash benefits may be provided 6.1&square;for a period not exceeding that fixed for entitlement to unemployment benefits 6.2&square;for cases of sickness that have occurred untilinclusive, and &square;fordaysweeks 7These cash benefits will be paid 7.1&square;by us 7.2&square;by you on our behalf (3b) ! 8 8.1The benefit should be paid 8.2&square;for the same days of the week as those laid down for unemployment insurance 8.3&square;for every day of the week, except&square;Monday&square;Tuesday &square;Wednesday&square;Thursday&square;Friday&square;Saturday&square;Sunday 9(4) 9.1The daily net amount of this benefit 9.2&square;is the same as that laid down for unemployment insurance 9.3&square;is(5) if the insured person is not in hospital &square;(5) if he is in hospital 10Competent institution (6) 10.1NameCode number (7) 10.2Address (3) 10.3Stamp 10.4Date 10.5Signature " 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 unemployed person (a)In addition to this E 119 form you should have a copy of an E 303/3 form on which item 7 will have been completed by the unemployment insurance institution in the country where you are seeking employment.
In order to obtain sickness insurance benefits in kind for yourself and for members of your family, you should apply to one of the following institutions:
in Belgium, the 'mutualité` (local sickness insurance fund) of your choice;
in Denmark, the competent 'amtskommune` (local administration). In the commune of Copenhagen, the 'magistrat` (municipal administration); in the commune of Frederiksberg, the 'kommunalbestyrelse` (municipal administration). Assistance from a doctor, dentist or dispensing chemist may be sought without first contacting the said institutions. The form should be presented every time you apply for benefits. Particulars about doctors and dentists available may be obtained from the local 'social- og sundhedsforvaltning` (social and health authority);
in Germany, the 'Allgemeine Ortskrankenkasse` (AOK, local general sickness fund);
in Greece, normally the regional or local branch of the Social Insurance Institute (IKA) which issues 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 stay or residence; if you require benefits you may apply to the medical and hospital services 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);
in Ireland, the Health Board in whose area the benefit is claimed;
in Italy, 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 or stay;
in Portugal for metropolitan Portugal: the 'Administração Regional de Saúde` (Regional Health Administration) of the place of stay or residence; for Madeira: the 'Direcção Regional de Saúde Pública` (Regional Public Health Directorate) in Funchal; for the Azores: the 'Direcção Regional de Saúde` (Regional Health Directorate) in Angra do Heroísmo;
in the United Kingdom, the medical service (doctor, dentist, hospital, etc.) from which treatment is requested.
in Austria, the 'Gebietskrankenkasse` (Regional Fund for Sickness Insurance) competent for you place of residence or place of stay;
in Finland, the local office of the 'Kansanzlaekelaitos` (Social Insurance Institution), if compensation is sought for medical expenses incurred in the private sector. Benefits in kind can be obtained from municipal health centres and public hospitals by presenting this certificate;
in Iceland, the 'Tryggingastofrun riskins` (the State Social Security Institute, Reykjavik;
in Liechtenstein, the 'Amt fuer Volkswirtschaft` (the Office of National Economy), Vaduz;
in Norway, the 'lokale Trygdekontor` (the local Insurance Office) at the place of residence or stay. The medical service may be sought without first contacting the mentioned institution. The form must be presented when assistance is sought;
in Sweden, the 'foersaekringskassan` (Social Insurance Office) at the place of residence or stay. Assistance from the medical service (hospital, doctor, dentist, etc.) may be sought without first contacting the said institution..
(b)In order to obtain cash benefits for yourself in case of incapacity for work or hospitalization, you should submit - except if you are in the Netherlands - the forms mentioned in item (a) above and a certificate of incapacity for work issued by the doctor treating you to the following institution:
- in Belgium, Germany, Spain, France, Italy, Luxembourg, Austria, Finland, Iceland, Liechtenstein, Norway and Sweden, to the insurance institution indicated in item (a) above,
- in Denmark, to the local 'social- og sundhedsforvaltning` (social and health authority) and, in the communes of Copenhagen, Odense, AAlborg and AArhus, to the 'magistrat` (municipal administration);
- in Ireland, to the Department of Social Welfare, EC Record Section, Dublin 2,
- in the Netherlands you must declare your incapacity for work to the local office of the 'Gemeenschappelijk Administratiekantoor` (G.A.K.) (Joint Administrative Office), which will provide you with unemployment benefits,
- in Portugal, for metropolitan Portugal: to the 'Centro Regional de Segurança Social` (Regional Social Security Centre) of the place of stay or residence; 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 Heroísmo;
- in the United Kingdom, to the Department of Social Security, Benefits Agency, Overseas Benefits Directorate, Newcastle upon Tyne, or to the Northern Ireland Social Security Agency, Overseas Branch, Belfast, as appropriate.
§ NOTES * EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purpose of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(1) Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = the Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein, N = Norway; S = Sweden.
(2) Complete only if the form is issued at the request of the institution of the place of residence or stay.
(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) If this form is being sent to an Italian institution, this box need not be ticked, only box 7.1.
(4) Complete this box only if the cash benefits have to be paid by the institution of the place of residence or stay.
(5) Show the amount in the currency of the competent country.
(6) If this is issued by an institution in the Netherlands, the benefits in kind are payable by the 'ziekenfondsraad` (Sickness Fund Council), Amstelveen; the cash benefits are payable by the institution issuing the form.
(7) To be completed where this exists.
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Social Security Regulations EEA*on page 41CERTIFICATE OF ENTITLEMENT TO BENEFITS IN KIND FOR PENSION CLAIMANTS AND MEMBERS OF THEIR FAMILY Reg. 1408/71: Art. 26.1 Reg. 574/72: Art. 28 The competent institution should complete part A of the form and issue two copies to the person concerned, who should submit them to the institution in his place of residence. If the pension claimant resides in the United Kingdom, both copies of the form should be sent direct to the Department of Social Security, Benefits Agency, Overseas Benefits Directorate, Newcastle-upon-Tyne. On receipt of the copies in question, the institution in the place of residence should complete part B and send one of the copies to the other institution mentioned in box 6. If necessary, the two copies should first be sent to the institution that has to complete boxes 5 and 6.
A. Notification of entitlement 1Institution of the place of residence (2) 1.1Name 1.2Address (3) 1.3Reference: your E 107 form of(date) 2Pension claimant 2.1Surname (3a) 2.2ForenamesPrevious names (3a)Date of birth 2.3Address in the country of residence (3) 2.4Identification No (3b) 3To be completed by the institution to which the claim for a pension has been submitted 3.1The claimant indicated above submitted on a claim for a pension for (4) &square;old age&square;invalidity&square;survival (4) &square;accident at work&square;occupational disease 3.2(4) &square;The investigation of this claim has shown that the person concerned is entitled to receive a pension from us 4Institution which completed box 3 4.1Name 4.2Address (3) 4.3Stamp 4.4Date 4.5Signature ! 5To be completed by the institution to which the claim for a pension was submitted or by the sickness and maternity insurance institution in the country in which this claim was submitted (6) 5.1Code number of the investigating institution (4a) 5.2The claimant indicated in box 2 and the members of his family are entitled to sickness and maternity insurance benefits in kind 5.3&square;from (date), until this certificate is cancelled 5.4&square;for one year starting on6Institution which completed box 5 (6) 6.1Name 6.2Address (3) 6.3Stamp 6.4Date 6.5Signature B. Notification of registration or non-registration 7(5) &square;
7.1The claimant indicated in box 2 and the members of his family could not be registered because 8(5) &square;
8.1Code number of the institution of the place of residence (4a) 8.2The claimant indicated in box 2 and the members of his family indicated below were registered on (date) 9Registered members of the family Surname (3a)ForenamesSexPrevious namesDate of birth FM 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 " 10Institution of the place of residence 10.1Name 10.2Address (3) 10.3Stamp 10.4Date 10.5Signature § 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 certificate gives you and the members of your family the right to receive benefits in kind in case of sickness or maternity in your country of residence.
(b)You should, as soon as possible, submit the two copies of this certificate in your possession to one of the following insurance institutions:
in Belgium, the 'mutualité` (local sickness insurance fund) of your choice;
in Denmark, the competent 'amtskommune` (local administration). In the commune of Copenhagen, the 'magistrat` (municipal administration); in the commune of Frederiksberg, the 'kommunalbestyrelse` (municipal administration);
in Germany, the 'Allgemeine Ortskrankenkasse` (AOK, local general sickness fund);
in Greece, normally the regional or local branch of the Social Insurance Institute (IKA), which issues 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 you require benefits you may apply to the medical and hospital services 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);
in Ireland, the Health Board in whose area the benefit is claimed;
in Italy, 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 Portugal, for metropolitan Portugal: the 'Centro Regional de Segurança Social` (Regional Social Security Centre) of the place of residence; for Madeira: the 'Direcção Regional de Segurança Social` (Regional Social Security Directorate) in Funchal; for the Azores: the 'Direcção Règional de Saude' (Regional Health Directorate) in Angra do Heroismo;
in Austria, the 'Gebietskrankenkasse` (Regional Fund for Sickness Insurance) competent for your place of residence;
in Finland, the local office of the 'kansanelaekelaitos` (Social Insurance Institution);
in Iceland, the 'Tryggingastofnun rikisins` (State Social Security Institute), Reykjavik;
in Liechtenstein, the 'Amt fuer Volkswirtschaft` (Office of National Economy), Vaduz;
in Norway, the 'lokale trygedekontor` (local Insurance Office) at the place of residence;
in Sweden, the 'foersaekringskassan` (Social Insurance Office) at the place of residence. Assistance from the medical service (hospital, doctor, dentist, etc.) may be sought without first contacting the said institution.
(c)You must inform the insurance institution to which you submit the form of any change of circumstances which might affect the right to benefits in kind, such as the grant of pension claimed or a change of your place of residence or stay or of that of a member of your family.
NOTES *EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Austria, Iceland, Liechtenstein, Norway and Sweden.
(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 = the Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway, S = Sweden.
(2) Complete only if the form is issued at the request of the institution of 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 number and/or the 'codice fiscale`.
(4) Where appropriate, put a cross in this square.
(4a) To be completed where this exists.
(5) Complete box 7 or 8, where appropriate, and put a cross in the corresponding square.
(6) In Italy, box 5 and 6 should be completed exclusively by USL or the Ministry of Health.
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Social Security Regulations EEA*on page 41CERTIFICATE FOR THE REGISTRATION OF PENSIONERS AND THE UPDATING OF LISTS Reg. 1408/71; Art. 28.1.a Reg. 574/72: Art. 29.1.2 and 3; Art. 95.4 The institution which has to draw up this certificate in accordance with Article 29.2 of Regulation 574/72 should complete part A of the form and issue two copies to the pensioner or send them to the institution in the place of residence if the form was requested by the latter institution. If the pensioner resides in the United Kingdom, the two copies of the form should be sent direct to the Department of Social Security Benefits Agency, Overseas Benefits Directorate, Newcastle upon Tyne. Where appropriate, the two copies shall first be sent to the institution which has to complete boxes 5 and 6. The institution in the place of residence should, on receiving the two copies, complete part B and send one copy to the institution shown in box 6.
A. Notification of entitlement 1Institution of the place of residence (2) 1.1Name 1.2Address (3) 1.3Reference: your E 107 form of(date) 2&square;Pensioner (scheme for employed persons) &square;Pensioner (scheme for self-employed persons) 2.1Surname (3a) 2.2ForenamesPrevious names (3a)Date of birth 2.3Address in the country of residence (3) 2.4Date of transfer of residence, if applicable 2.5Identification No (3b) 2.6&square;The pensioner is covered by a scheme for self-employed persons as referred to in Annex 11 to Regulation No 574/72 3To be completed by the institution responsible for payment of the pension 3.1The person concerned indicated above has been entitled to a pension for &square;old age&square;invalidity&square;survival &square;accident at work&square;occupational disease 3.2since 3.3Pension No ! E 1214Institution which completed box 3 (4) 4.1Name 4.2Address (3) 4.3Stamp 4.4Date 4.5Signature 5To be completed by the institution responsible for payment of the pension or by the sickness and maternity insurance institution in the country responsible for payment of the pension (7) 5.1Code number of the investigating institution (4a) 5.2The person concerned indicated in box 2 and the members of his family are entitled to sickness and maternity insurance benefits in kind from (date) 5.3The cost of the benefits to be provided in their country of residence - unless they reside in the competent country - will be borne by us 5.4From (date)until this certificate is cancelled 5.5&square;The issue of this certificate renders the E 120 form of (date) &square;null and void 6Institution which completed box 5 (7) 6.1Name 6.2Address (3) 6.3Stamp 6.4Date 6.5Signature B. Notification of registration or non-registration 7(5) &square;
7.1The person concerned mentioned in box 2 and members of his family could not be registered 7.2&square;because the person concerned is already entitled to benefits in kind under the legislation of our country 7.3&square;other reasons " E 1218(5) &square;
8.1The person concerned mentioned in box 2 and the members of his family have been registered 8.2Registered members of the family (6) 8.3Surname (3a)ForenamesSexPrevious namesDate of birth FM 8.4 8.5 8.6 8.7 8.8 8.9 8.10 8.11 8.12The cost of these benefits should be borne by you; the date from which the lump sum provided for in Article 95 of Regulation 574/72 should be calculated is 8.13Code number of the institution of the place of residence (4a) 9Institution of the place of residence 9.1Name 9.2Address (3) 9.3Stamp 9.4Date 9.5Signature § E 121INSTRUCTIONS 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 pensioner (a) You should, as soon as possible, send the two copies of this form to one of the following insurance institutions:
in Belgium, the 'mutualité` (local sickness insurance fund) of your choice;
in Denmark, the competent 'amtskommune` (local administration). In the commune of Copenhagen, the 'magistrat` (municipal administration) in the commune of Frederiksberg, the 'kommunalbestyrelse` (municipal administration);
in Germany, the 'Allgemeine Ortskrankenkasse` (AOK, local general sickness fund);
in Greece, normally the regional or local branch of the Social Insurance Institute (IKA), which issues 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;
in France, the 'Caisse primaire d'assurance-maladie` (local sickness insurance fund);
in Ireland, the Health Board in whose area the benefit is claimed;
in Italy, 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 Portugal, for metropolitan Portugal: to the 'Centro Regional de Segurança Social` (Regional Social Security Centre) of the place of residence; 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 Heroísmo.
in Austria, the 'Gebietskrankenkasse` (Regional Fund for Sickness Insurance) competent for your place of residence;
in Finland, the local office of the 'kansanelaekelaitos` (Social Insurance Institution);
in Iceland, the 'Tryggingastofnun rikisins` (the State Social Security Institute), Reykjavik;
in Liechtenstein, the 'Amt fuer Volkswirtschaft` (the Office of National Economy), Vaduz;
in Norway, the 'lokale trygdekontor` (the local Insurance Office) at the place of residence;
in Sweden, the 'foersaekringskassan` (Social Insurance Office) at the place of residence.
(b) You must inform the insurance institution to which you submit the form of any change of circumstances which might affect the right to benefits in kind, such as suspension or withdrawal of pension, or change of your place of residence or of that of a member of your family.
NOTES * EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(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 = Nederlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(2) Complete only if the form is drawn up at the request of the institution of 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 number and/or the 'codice fiscale`.
(4) In France, for self-employed persons, the box must be filled in by the institution for sickness and maternity insurance.
(4a) To be completed where this exists.
(5) Complete box 7 or 8, where appropriate, and put a cross in the corresponding square.
(6) To be completed by Netherlands institutions only.
(7) In Italy box 5 and 6 should be completed exclusively by USL or the Ministry of Health.
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Social Security Regulations EEA*on page 31CERTIFICATE FOR THE GRANTING OF BENEFITS IN KIND TO MEMBERS OF THE FAMILY OF PENSIONERS Member of the family residing in a Member State other than that in which the pensioner is resident Reg. 1408/71: Art. 29.1.a Reg. 574/72: Art. 30.1 The competent sickness institution in the place of residence of the pensioner should complete part A of the form and issue two copies to the pensioner, or send them to the institution in the place of residence of the members of the family if the form is drawn up at the request of the latter institution. If the members of the family reside in the United Kingdom, the two copies of the form should be sent direct to the Department of Social Secrutiy, Benefits Agency, Overseas Benefits Directorate, Newcastle upon Tyne. The institution in the place of residence should, on receiving the two copies in question, complete part B and send one copy to the sickness insurance institution of the place of residence of the pensioner. If the members of the family reside in several different countries, a separate certificate should be drawn up for each of these countries.
A. Notification of entitlement 1(2) Institution to which the form is addressed 1.1Name 1.2Address (3) 1.3Reference: your E 107 form of (date) 2&square;Pensioner (scheme for employed persons) &square;Pensioner (scheme for self-employed persons) 2.1Surname (3a) 2.2ForenamesPrevious names (3a)Date of birth 2.3Address (3) 2.4Identification No (4) 3Member of the family (4b) 3.1Surname (3a) 3.2ForenamesMaiden nameDate of birth 3.3Address (3) 3.4Identification No (4) 4The person concerned is entitled to receive sickness and maternity insurance benefits in kind for himself and for the members of his family.
5For the granting of these benefits to the members of the family, this certificate is valid &square;fromuntil receipt of notification of its cancellation &square;for one year starting on(5) &square;until (6)inclusive ! 6Competent institution 6.1NameCode number (8) 6.2Address (3) 6.3Stamp 6.4Date 6.5Signature B. Notification of registration 7(7) &square;The members of the family of the pensioner mentioned in box 2 have not been registered (7) &square;Reason:
(7) &square;
(7) &square;
8(7) &square;The following members of the family of the pensioner mentioned in box 2 have been registered.
9Registered members of the family Surname (3a)ForenamesSexDate of birthIdentification No (4) FM 9.1 9.2 9.3 9.4 9.5 9.6 9.7 9.8 10Institution in the place of residence of the members of the family 10.1NameCode number (8) 10.2Address (3) 10.3Stamp 10.4Date 10.5Signature " INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information.
Information for the pensioner (a)This form gives the members of your family the right to receive sickness and maternity insurance benefits in kind in their country of residence 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 this form, you should send them to the members of your family who should submit them immediately to a sickness and maternity insurance institution of their place of residence, i.e.:
in Belgium, the 'mutualité` (local sickness insurance fund) of their choice;
in Denmark, the competent 'amtskommune` (local administration). In the commune of Copenhagen, the 'magistrat` (municipal administration); in the commune of Frederiksberg, the 'kommunalbestyrelse` (municipal administration);
in Germany, the 'Allgemeine Ortskrankenkasse` (AOK, local general sickness fund);
in Greece, normally the regional or local branch of the Social Insurance Institute (IKA), which 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), if you require benefits you may apply to the medical and hospital services 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);
in Ireland, the Health Board in whose area the benefit is claimed;
in Italy, 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 Portugal: for metropolitan Portugal: the 'Centro Regional de Segurança Social` (Regional Social Security Centre) of the place of residence; 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 Heroísmo.
in Austria, the 'Gebietskrankenkasse` (the Regional Fund for sickness Insurance) in Finland, the local office of the 'Kansanelaekelaitos` (Social Insurance Institution);
in Iceland, the 'Tryggingastofnun rikisins' (the State Social Security Institute) Reykijavik;
in Liechtenstein, the 'Amt fuer Volkswirtschaft` (the office of National Economy), Vaduz;
in Norway, the 'lokale trygdekontor` (the local Insurance Office);
in Sweden, the 'foersaekringskassan` (Social Insurance Office).
(c)This form is valid from the date and for the period indicated in item 5.
(d)The members of your family must inform the insurance institution to which they have submitted the form of any change of circumstances which might affect the right to benefits in kind, in particular a change of their place of residence.
NOTES *EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(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 = the Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(2)Complete only if the form is drawn up at the request of the institution in the place of residence of the members of the family.
(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.
(4)For Italian nationals indicate, if possible, the insurance number and/or 'codice fiscale`.
(4b)Mention one Member of the family only. The members of the family of the beneficary will be specified in part B of the form as they are designated by the institution of the place of residence.
(5)If the form is issued by a French institution.
(6)Where the form has been drawn up by a French institution for self-employed persons.
(7)Complete item 7 or 8, where appropriate, and put a cross in the corresponding square.
(8)To be completed where this exists.
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Social Security Regulations EEA*on page 31CERTIFICATE OF ENTITLEMENT TO BENEFITS IN KIND UNDER INSURANCE AGAINST ACCIDENTS AT WORK AND OCCUPATIONAL DISEASES Reg. 1408/71: Art. 52.a; Art. 55.1.a.i, b.i and c.i Reg. 574/72: Art. 60.1; Art. 62.4 and 6; Art. 63.1 and 3 If the form has been requested by the institution in the place of residence or stay of the person concerned by means of form E 107, it should be sent to the said institution, otherwise it should be issued to the insured person. If the insured person goes to the United Kingdom, a copy of the form should also be sent to the Department Social Security, Benefits Agency, Overseas Benefits Directorate, Newcastle upon Tyne.
1Institution in the place of residence or stay (2) 1.1Name 1.2Address (3) 1.3Reference: your E 107 form of (date) 2&square;Employed person&square;Self-employed person 2.1Surname (3a) 2.2ForenamesPrevious names (3a)Date of birth 2.3Address in the competent country (3) 2.4Address in the country where the person concerned is going (3) 2.5Identification No (3b) 3On the grounds of 3.1&square;the information supplied on your E 107 form of (date) 3.2&square;the accident at work sustained on(date),
&square;which had the following consequences &square;
&square;
&square;
3.3&square;the occupational disease diagnosed on(date),
&square;which had the following consequences &square;
&square;
3.4&square;the authorization which we have granted to the person concerned to retain the right to benefits in kind &square;in(country) where he is going &square;to take up residence&square;to receive medical treatment ! E 1234The abovementioned insured person may receive benefits in kind &square;for accident at work&square;for occupational disease 4.1&square;for a period laid down in the provisions of the legislation of his country of residence 4.2&square;until 4.3&square;for a maximum of three months 4.4&square;for an unlimited period 5The report of our examining doctor 5.1&square;is attached in a sealed envelope 5.2&square;was sent onto (4) &square;
5.3&square;may be obtained from us on request 6.4&square;has not been drawn up 6Competent institution 6.1NameCode number (5) 6.2Address (3) 6.3Stamp 6.4Date 6.5Signature " E 123INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information.
Information for the insured person You should submit this certificate as soon as possible to the insurance institution of the country to which you have gone, i.e.:
in Belgium, the 'mutualité` (local sickness insurance fund) of your choice;
in Denmark, the competent 'amtskommune` (local administration) In the commune of Copenhagen, the 'magistrat` (municipal administration); in the commune of Frederiksberg, the 'kommunalbestyrelse` (municipal admistration). In the case of temporary stay, assistance from a doctor, dentist or dispensing chemist may be sought without first contacting the said institution. The form should be presented every time you apply for benefits. Particulars on the doctors and dentists available may be obtained from the local 'social- og sundhedsforvaltning` (social and health authority). If you are being treated in Denmark, you should present the form to the institution treating you;
in Germany, the accident insurance institution competent for the place of residence or stay;
in Greece, normally the regional branch of the Social Insurance Institute (IKA), which issues the person concerned with a 'health book`, without which no benefits in kind can be provided;
in Spain, the medical and hospital services 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);
in Ireland, the Health Board in whose area the benefit is claimed;
in Italy,
(a) 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 marrittima o aerea` (Ministry of Health, the navy or aviation health office responsible for the area in question);
(b) for prostheses, major appliances, legal medical benefits and relevant examinations and certificates, the provincial office of the 'Istituto nazionale per l'assicurazione contro gli infortuni (INAIL, the National Institute for Insurance against Accidents at Work);
in Luxembourg, the 'Association d'assurance contre les accidents` (Accident insurance Association);
in the Netherlands, any sickness fund competent for the place of residence or, in the case of temporary residence, 'ANOZ Verzekeringen`, Utrecht. Assistance from a doctor, dentist or dispensing chemist may be sought without first contacting 'ANOZ Verzekeringen`;
in Portugal, the 'Caixa Nacional de Seguros de Doenças Profissionais` (National Insurance Fund for Occupational Diseases), Lisbon;
in the United Kingdom, the medical service (doctor, dentist, hospital, etc.) from which treatment is requested.
in Austria, the 'Gebietskrankenkasse` (Regional Fund for Sickness Insurance) competent for the place of residence or place of stay or the 'Allgemeine Unfallversicherungsanstalt` (General Accidence Insurance institution), Vienna;
in Finland, the 'Tapaturmavakuutuslaitosten liitto` (Federation of Accident Insurance Institutions);
in Iceland, the 'Tryggingastofun rikisins` (the State Social Security Institute), Reykjavik;
in Liechtenstein, the 'Amt fuer Volkswirtschaft` (the Office of National Economy), Vaduz;
in Norway, the 'lokale trygdekontor` (the local Insurance Office). Assistance may be sought without first contacting the institution mentioned;
in Sweden, the 'foersaekringskassan` (Social Insurance Office). Assistance from the medical service (hospital, doctor, dentist, etc.) may be sought without first contacting the said institutions.
NOTES * EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(1) Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = the Nederlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(2) Complete only if the form is drawn up at the request of the institution of the place of residence or stay of the person concerned.
(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 number and/or the 'codice fiscale`.
(4) Name and address of the institution to which the medical report has been sent.
(5) To be completed where this exists.
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Social Security Regulations EEA*on pages 2 and 3E 1241CLAIM FOR DEATH GRANT Reg. 1408/71: Art. 65 Reg. 574/72: Art. 78 1I, the undersigned 1.1Surname (1a) 1.2ForenamesPrevious names (1a)Date of birth 1.3Identification No (2) (2b) 1.4Institution with which I am insured (2) (3) 1.5Family relationship with the deceased 1.6Address (4) 2hereby claim a grant by reason of the death of the undermentioned (5) 3&square;employed person&square;pensioner &square;self-employed person&square;pension claimant &square;member of my family 3.1Surname (1a) 3.2ForenamesPrevious names (1a)Date of birth 3.3Identification No (2) (2a) 3.4Date of death 3.5Cause of death (6) &square;illness&square;accident&square;accident at work &square;occupational disease &square;other causes 3.6Institution with which the deceased was insured (2) (3) 4I, the undersigned&square;was&square;was not a dependant of the deceased 5The deceased person&square;was&square;was not a dependant of mine 6The deceased person&square;was&square;was not accommodated in return for payment &square;by the claimant &square;in an establishment of which the claimant is the manager, by a member of the staff or an inmate (7) 7The claimant&square;is&square;is not a funeral undertaker or an agent or representative of such an undertaker (7) (8) 8The cost of the funeral was (9); it has been paid by 9You will find attached the following documents 10Please pay the sum due to my account No with the at (10) 11Date 11.1Signature ! INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information.
Information for the claimant (a) In order to receive a death grant you should, by means of this form, submit a claim:
- either to the competent insurance institution,
- or to the insurance institution of the place where you are, i.e.:
in Belgium, a 'mutualité` (local sickness insurance fund) of your choice;
in Denmark, the 'Sundhedsministeriet` (Ministry of Health), Copenhagen;
in Germany, the 'Allgemeine Ortskrankenkasse` (AOK, local general sickness fund);
in Greece, the local branch of the Social Insurance Institute (IKA);
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;
in France, the institution that awards or would award the benefits in kind of the sickness insurance;
in Ireland, the Department of Social Welfare, Dublin;
in Italy, the provincial office of the INAIL;
in Luxembourg, the 'Union des caisses de maladie` (Union of Sickness Funds);
in Portugal, for metropolitan Portugal: the 'Centro Regional de Segurança Social` (Regional Social Security Centre) of the place of residence; 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 Heroísmo;
in Austria, the 'Gebietskrankenkasse` (Regional Fund for Sickness Insurance) competent for your place of residence;
in Finland, the 'kansanselaekelaitos` (Social Insurance Institution), Helsinki local office, PO Box 00601 Helsinki;
in Iceland, Tryggingastofnun riksins` /State Social Security Institute), Reykjavuk;
in Liechtenstein, the 'Amt fuer Volkswirtschaft` (Office of national Economy), Vaduz;
in Norway, 'lokale trygdekontor` (local Insurance Office) at the place of residence or stay;
in Sweden, the 'foersaekringskassan` (Social Insurance Officie), at the place of residence or stay.
(b) Together with your claim you should send the following documents:
for Belgium, an extract of the death certificate, issued by the municipal administration;
the receipted bills relating to funeral expenses; all documents proving the family relationship or relationship through marriage with the deceased or, where appropriate, cohabitation with him;
for Denmark, the death certificate;
please read carefully the 'vejledning om ansoegning for begravelseshjaelp` (Instructions for claiming a Death Grant) which you will subsequently receive;
for Germany, the death certificate;
for Greece, the death certificate, the health book, the insurance card; where necessary, the receipted bills relating to funeral expenses;
for Spain, - the death certificate, and - the certificate attesting a family relationship or the receipted bills relating to funeral expenses if the claimant has no family relationship with the deceased person;
for France, - in every case the 'bulletin de décès` (death certificate) of the insured person;
- in addition, as appropriate:
- if the insured person was your husband or wife, the 'fiche familiale d'état civil` (family card of the registry of births, deaths and marriages);
- if you are his/her descendant (son, daughter, grandson, etc.), the 'fiche familiale d'état civil` (family card of the registry of births, deaths and marriages), showing your family relationship to the deceased;
- if you are his/her ascendant (father, mother, grandfather, etc.), his/her 'fiche individuelle d'état civil` (individual card of the registry of births, deaths and marriages);
- if you were his/her dependant in any other way, a statutory declaration testifying that you were factually, wholly and constantly supported by the deceased;
for Ireland, the death certificate;
the marriage certificate, if appropriate;
the undertaker's account or estimate or the receipt for funeral expenses if paid by you;
for Italy, the death certificate;
the document of insurance registration;
if appropriate, a declaration of family status;
" for Luxembourg, the death certificate; the receipted bills relating to funeral expenses;
if appropriate, a declaration from the municipal administration testifying cohabitation as husband and wife;
for Portugal, in all cases, the death certificate and the receipted bills relating to funeral expenses;
also, where appropriate - if you were the spouse of the deceased or a relative in the descending line, your complete certificate of birth,
- if you were a relative of the deceased in the ascending line and supported by him/her, your certificate of earnings;
for Austria, the death certificate:
the receipted bills on funeral expenses;
for Finland, the death certificate:
documents proving the realtionship with the deceased;
if the claiment is a funeral undertaker, a letter of attorney of the person entitled to the benefit;
for Liechtenstein, the death certificate:
the certificate attesting the cause of death;
the receipted bills concerning funeral expenses,
for Norway, the death certificate;
for Sweden, the death certificate;
the certificate attesting the cause of death.
NOTES * EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(1) Symbol of the country of residence of the claimant of the grant: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = the Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(1a) 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.
(2) Indicate only if it concerns a worker, pensioner, or pension claimant.
(2a) In the case of a pension recipient or claimant of Spanish nationality, state the number appearing on the national identity card (D.N.I.), if it exists, even if the card is out of date. Failing this, state 'None`.
(2b) For the benefit of the Finnish institution, please quote the population register (identy) number, if the claiment is a natural person.
(3) Give name and address.
(4) Street, number, post code, town, country.
(5) For the purposes of Portuguese institutions, complete the additional page.
(6) When applying for a death grant according to Liechtenstein and Swedish legislation, the cause of death must have been either 'accident at work` or 'occupational disease`.
(7) To be completed where the grant is claimed under Belgian legislation if the claimant is not the deceased person's spouse, relative or relative through marriage to the third degree.
(8) If the claimant is a funeral undertaken a letter of attorney of the person entitled to the benefit should be sent when the grant is claiment under Finnish legislation.
(9) Indicate the amount in the currency of the country of residence of the claimant.
(10) Does not apply to Irish institutions.
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ADDITIONAL INFORMATION FOR THE PURPOSES OF PORTUGUESE INSTITUTIONS 1Spouse 1.1Civil status &square;Widow/widower&square;Remarried&square;Divorced 1.2At the time of the deceased`s death was he/she living under the same roof as, and being supported by, the deceased? &square;Yes&square;No 2Children entitled to family allowances SurnameForenamesRelationshipDate of birthLevel of educationHandi- capped child 2.1 2.2 2.3 2.4 2.5 2.6 2.7 ! END OF GRAPHIC
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Social Security Regulations EEA*on page 31INDIVIDUAL RECORD OF ACTUAL EXPENDITURE Reg. 1408/71: Art. 36.1 and 2; Art. 63.1; Art. 87.1 Reg. 574/72: Art. 93.1, 2, 4 and 5; Art. 105.1 A separate form should be completed for each recipient.
1Invoice No(2)&square;1st half year&square;2nd half year of the financial year19 2Competent institution to which the form is addressed 2.1NameCode number (2a) 2.2Address (3):
3&square;Employed person&square;Pensioner (scheme for employed)&square;other (4) &square;Self-employed person&square;Pensioner (scheme for self-employed) 3.1Surname (4a) 3.2ForenamesPrevious names (4a)Date of birth 3.3Address (3) 3.4Address (3) in the competent country 3.5Identification No (4b) 4Member of the family (5) 4.1Surname (4a) 4.2ForenamesPrevious namesDate of birth 5The person mentioned&square;in box 3&square;in box 4has received benefits under the following Article of Regulation 1408/71:
5.1&square;19.1 and 2&square;22.1.a and 3&square;22.1.b and 3&square;22.1.c and 3 &square;25.1, 3 and 4&square;26&square;29.1&square;31 &square;52 (5a)&square;55.1 (5a) on the basis of the following forms which were sent to us 5.2&square;an Eform of&square;an E 117 form of &square;valid fromto 5.3The person mentioned&square;in box 3&square;in box 4 underwent the medical examination requested on ! 6Expenditure incurred6.1 Amount (6) 6.2For benefits in kind providedfromto 6.3Medical treatment 6.4Dental treatment 6.5Medicaments 6.6Hospitalizationfromto fromto 6.7Other benefits (7) 6.8Total benefits in kind 6.9Medical examinations (8) 6.10For cash benefits providedfromto 6.11Total expenditure 7Creditor institution 7.1NameCode number (9) 7.2Address (3) 7.3Stamp 7.4Date 7.5Signature 8Reserved for the institution in the competent country " INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of three pages none of which may be left out even if it does not contain any relevant information.
NOTES * EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of the Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(1) Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = the Nederlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(2) To be indicated if the creditor institution needs this information.
(2a) To be completed if it is known.
(3) Street, number, post code, town, country.
(4) Indicate here if it concerns a frontier worker, an unemployed person, a seasonal worker, a pension claimant or any other.
(4a) 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.
(4b) In the case of Spanish nationals who are pension recipients or claimants, state the number appearing on the national identity card (D.N.I.), if it exists, even if the identity card is out of date. Failing this, state 'None`. For Italian nationals indicate, if possible, the insurance number and/or the 'codice fiscale`.
(5) Complete only when the account refers to a member of the family of the insured person.
(5a)For the purpose of Danish institutions please state if possible the name and address of the employer when benefits are received under Article 52 or 55 (1).
Name of employer:
Address:
(6) Indicate the amount in national currency.
(7) Indicate the kind of benefits: confinement, dentures, orthopaedic prostheses, spa treatment, ambulance, additional diagnostic means, etc.
(8) Indicate the kind of medical checks and examinations carried out.
(9) To be completed where this exists.
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Social Security Regulations EEA*on page 31RATES FOR REFUND OF BENEFITS IN KIND Reg. 1408/71: Art. 22.1.a.i; Art. 22.3; Art. 31.a Reg. 574/72: Art. 34 The competent institution should complete part A of the form and send, either directly or through the liaison body, two copies to the institution which would have had to provide the benefits to the person concerned in the country of stay. The institution in the place of stay, after completing part B of the form, should return one copy to the competent institution.
A. Request 1Institution to which the form is addressed (2) 1.1Name 1.2Address (3):
2&square;Employed person&square;Pensioner (scheme for employed persons) &square;Self-employed person&square;Pensioner (scheme for self-employed persons) 2.1Surname (3a) 2.2ForenamesPrevious names (3a)Date of birth 2.3&square;This person is covered by a scheme for self-employed persons as referred to in Annex 11 to Regulation No 574/72 2.4Identification No 3Member(s) of the family who received treatment 3.1Surname (3a)ForenamesPrevious namesDate of birth 3.2 3.3 3.4 ! E 1264The abovementioned person 4.1during a stay in(country) 4.2at(town) 4.3himself paid for the benefits which he required 4.4The person concerned is&square;a widower/widow&square;an invalid (4) 4.5and earns an income of(4) 5Please indicate on the receipts attached, for each benefit separately, the amount to be refunded to the person concerned according to the rates administered by the institution of the place of stay. Only in the case of Luxembourg, indicate the amount he/she has to contribute to the cost of treatment.
6Attachedreceipts 7Competent institution 7.1NameCode number (4a) 7.2Address (3) 7.3Stamp 7.4Date 7.5Signature B. Reply 8Attachedreceipts indicating the requested rates 9&square;Amount to be reimbursed (5)&square;No reimbursement 10Remarks 11Institution of the place of stay 11.1Name 11.2Address (3) 11.3Stamp 11.4Date 11.5Signature " E 126INSTRUCTIONS Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out even if it does not contain any relevant information.
NOTES * EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this Agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(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 = the Nederlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway; S = Sweden.
(2) If the institution which would have to provide the benefits in kind is not known, the form may be sent to the liaison body in the country of stay, i.e.:
- in Belgium, the 'Institut national d'assurance maladie-invalidité (INAMI)` (National Sickness and Invalidity Insurance Institute), Brussels;
- in Denmark, the 'Sundhedsministeriet` (Ministry of Health), Copenhagen;
- in Germany, the 'AOK-Bundesverband` (National Federation of Local Sickness Funds), Bonn;
- in Greece, the regional or local branch of the Social Insurance Institute (IKA); for mariners, the Seamen's Pension Fund (NAT);
- in Spain, the 'Instituto Nacional de la Seguridad Social` (National Social Security Institute), Madrid;
- in France, the 'Centre de sécurité sociale des travailleurs migrants` (Centre for the Social Security of Migrant Workers), Paris;
- in Ireland, the Department of Health, Dublin;
- in Italy, the 'Ministero della Sanità` (Ministry of Health), Rome;
- in Luxembourg, the 'L'Union des Caisses de Maladie`, Luxembourg;
- in the Netherlands, the 'ANOZ Verzekeringen`, Utrecht;
- in Portugal, the 'Departamento de Relações Internacionais e Convenções de Segurança Social` (Department of International Relations and Social Security Conventions), Lisbon;
- in Austria, the 'Hauptverband der oesterreichische Socialversicherungstraeger` (Main Association of Austrian Social Insurance Institutions), Vienna;
- in Finland, the 'Kansanelaekelaitos` (Social Insurance Institution), Helsinki;
- in Iceland, the 'Tryggingastofnun rikisins` (State Social Security Institute), Reykjavik;
- in Liechtenstein, the 'Amt fuer Volkswirtschaft` (Office of National Economy), Vaduz;
- in Norway, the 'Rikstrygdeverket` (National Insurance Administration), Oslo;
- in Sweden, the 'Riksfoersaekringsverket` (National Social Insurance Board), Stockholm.
(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.
(4) Complete only if the request is sent to a Belgian institution.
(4a) To be completed where this exists.
(5) Indicate the total amount.
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Social Security Regulations *EEAoverleaf1INDIVIDUAL RECORD OF MONTHLY LUMP-SUM PAYMENTS Reg. 1408/71: Art. 36.1 and 2 Reg. 574/72: Art. 94; Art. 95 1 Record Noof year19(2) 2Competent institution 2.1NameCode number (3a) 2.2Address (3) 3The right to benefits in kind has been acquired for the &square;employed person&square;pensioner (scheme for employed persons) &square;self-employed person&square;pensioner (scheme for self-employed persons) 3.1Surname (4) 3.2ForenamesPrevious names (4)Date of birth 3.3Identification number allocated by the competent institution (4b) 4Address of the worker's family or address of the pensioner and his family (3) 5The right to benefits in kind is held by the members of the family of the worker named above or by the pensioner named above and the members of his family, as certified by your form Eform of(date) 6For the period during which this existed (fromto) 6.1the number of monthly lump-sum payments &square;per family or per pensioner and family&square;per family member&square;per individual &square;is 7Creditor institution 7.1NameCode number (5) 7.2Address (3) 7.3Stamp 7.4Date 7.5Signature ! 8To be completed by the competent institution INSTRUCTIONS Please complete three copies of this form in block letters, writing on the dotted lines only.
The institution in the place of residence should draw up the form for one calendar year and send it to the competent institution through the body designated for the implementation of Article 102.2 of Regulation 574/72.
NOTES *EEA Agreement on the European Economic Area, Annex VI, Social Security: for the purposes of this agreement the present form shall also apply to Austria, Finland, Iceland, Liechtenstein, Norway and Sweden.
(1)Symbol of the country to which the institution completing the form belongs: B = Belgium; DK = Denmark; D = Germany; GR = Greece; E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = the Netherlands; P = Portugal; GB = United Kingdom; A = Austria; FIN = Finland; IS = Iceland; FL = Liechtenstein; N = Norway, S = Sweden.
(2)The year to be indicated here is that in which the benefits were provided.
(3)Street, number, post code, town, country.
(3a)To be completed if it is known.
(4)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.
(4b)For Italian nationals indicate, if possible, the insurance number and/or the 'codice fiscale`.
(5)To be completed where this exists.
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