# L_2004259EN.01000101.xml

| 5.8.2004 | EN | Official Journal of the European Union | L 259/1 |
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5.8.2004

EN

Official Journal of the European Union

L 259/1

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DECISION No 198

of 23 March 2004

concerning the replacement and discontinuance of the model forms necessary for the application of Regulations (EEC) No 1408/71 and (EEC) No 574/72 of the Council

(E 110, E 111, E 111 B, E 113, E 114, E 119, E 128 and E 128 B)

(Text with EEA relevance and the EU/Switzerland Agreement)

(2004/562/CE)

THE ADMINISTRATIVE COMMISSION 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 (1), under which it is the duty of the Administrative Commission to deal with all administrative matters arising from Regulation (EEC) No 1408/71 and subsequent regulations,

Having regard to Article 2(1) of Council Regulation (EEC) No 574/72 of 21 March 1972 (2), under which it is the duty of the Administrative Commission to draw up models of documents necessary for the application of the regulations,

Having regard to Decision No 153 of 7 October 1993 on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 001, E 103 to E 127) (3),

Having regard to Decision No 177 of 5 October 1999 on the forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 128 and E 128 B) (4),

Having regard to Decision No 179 of 18 April 2000 on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 111, E 111 B, E 113 to E 118 and E 125 to E 127) (5),

Having regard to Decision No 187 of 27 June 2002 on model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 111 and E 111B) (6),

Having regard to Decision No 191 of 18 June 2003 concerning the replacement of forms E 111 and E 111 B by the European health insurance card (7),

Whereas:

| (1) | There is a need to adapt forms necessary for the application of Regulations (EEC) No 1408/71 and (EEC) No 574/72 in connection with the entry into the European Union of the 10 new Member States on 1 May 2004. |
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(1)

There is a need to adapt forms necessary for the application of Regulations (EEC) No 1408/71 and (EEC) No 574/72 in connection with the entry into the European Union of the 10 new Member States on 1 May 2004.

| (2) | From 1 June 2004 the forms E 111 and E 111 B will be replaced by the European health insurance card in accordance with the procedures laid down in Decision No 191. However, the E 111 and E 111 B forms, delivered before 1 June 2004, will remain valid until 31 December 2004, unless an earlier expiry date is indicated on them. |
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(2)

From 1 June 2004 the forms E 111 and E 111 B will be replaced by the European health insurance card in accordance with the procedures laid down in Decision No 191. However, the E 111 and E 111 B forms, delivered before 1 June 2004, will remain valid until 31 December 2004, unless an earlier expiry date is indicated on them.

| (3) | Moreover, the Member States mentioned in the list annexed to Decision No 197 of 23 March 2004 are allowed a transitional period for the introduction of the European health insurance card. Hence the competent institutions of these Member States will continue to issue the E 111 forms on the basis of the model reproduced in the annex to this Decision until 31 December 2005. |
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(3)

Moreover, the Member States mentioned in the list annexed to Decision No 197 of 23 March 2004 are allowed a transitional period for the introduction of the European health insurance card. Hence the competent institutions of these Member States will continue to issue the E 111 forms on the basis of the model reproduced in the annex to this Decision until 31 December 2005.

| (4) | Regulation (EC) No 631/2004 has amended Regulation (EEC) No 1408/71 in such a way that as from 1 June 2004 all categories of insured persons are entitled to benefits in kind which are necessary for medical reasons during a stay in another Member State. Hence forms E 110, E 128 and E 128 B will become superfluous as from that date. Moreover, as from that date, form E 119 concerns only benefits in cash. |
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(4)

Regulation (EC) No 631/2004 has amended Regulation (EEC) No 1408/71 in such a way that as from 1 June 2004 all categories of insured persons are entitled to benefits in kind which are necessary for medical reasons during a stay in another Member State. Hence forms E 110, E 128 and E 128 B will become superfluous as from that date. Moreover, as from that date, form E 119 concerns only benefits in cash.

| (5) | Pursuant to the abovementioned EC regulation, paragraphs 6 and 7 of Article 17 of Regulation (EEC) No 574/72 will be abolished as from 1 June 2004. Hence it is necessary to discontinue forms E 113 and E 114. |
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(5)

Pursuant to the abovementioned EC regulation, paragraphs 6 and 7 of Article 17 of Regulation (EEC) No 574/72 will be abolished as from 1 June 2004. Hence it is necessary to discontinue forms E 113 and E 114.

| (6) | The Agreement on the European Economic Area (EEA Agreement) of 2 May 1992, supplemented by the Protocol of 17 March 1993, Annex VI, implements Regulations (EEC) No 1408/71 and (EEC) No 574/72 in the European Economic Area. |
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(6)

The Agreement on the European Economic Area (EEA Agreement) of 2 May 1992, supplemented by the Protocol of 17 March 1993, Annex VI, implements Regulations (EEC) No 1408/71 and (EEC) No 574/72 in the European Economic Area.

| (7) | The European Community and its Members, and the Swiss Confederation have signed an agreement on the free movement of persons (Switzerland Agreement), which entered into force on 1 June 2002. Annex II to this Agreement implements Regulations (EEC) No 1408/71 and (EEC) No 574/72 in the relations between the European Community and its Members, and the Swiss Confederation. |
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(7)

The European Community and its Members, and the Swiss Confederation have signed an agreement on the free movement of persons (Switzerland Agreement), which entered into force on 1 June 2002. Annex II to this Agreement implements Regulations (EEC) No 1408/71 and (EEC) No 574/72 in the relations between the European Community and its Members, and the Swiss Confederation.

| (8) | For practical reasons, identical forms should be used within the Community, within the European Economic Area and in relations between the Community and the Swiss Confederation, |
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(8)

For practical reasons, identical forms should be used within the Community, within the European Economic Area and in relations between the Community and the Swiss Confederation,

HAS DECIDED AS FOLLOWS:

| 1. | The model form E 119 reproduced in Decision No 153 shall be replaced by the model reproduced in the annex to this Decision. |
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1.

| 2. | From 1 June 2004 until 31 December 2005, the model form E 111 reproduced in Decision No 187 shall be replaced by the model reproduced in the annex to this Decision. In principle, all norms applicable, according to Decision No 190 to the optical-reader data included in the European Card and related to the description, values, length and remarks of the data fields are applicable to the model form E 111. |
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2.

| 3. | The model forms E 113 and E 114 reproduced in Decision No 179 shall be discontinued as from 1 June 2004. |
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3.

| 4. | Model form E 110 reproduced in Decision No 153, and model forms E 128 and E 128B reproduced in Decision No 177, shall be discontinued as from 1 June 2004. |
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4.

| 5. | The competent authorities of the Member States shall make available to the parties concerned (rightful claimants, institutions, etc.) the forms corresponding to the models reproduced in the annex to this Decision. |
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5.

| 6. | Each form shall be available in the official languages of the Community. The models shall be laid out in such a manner that the different language versions are perfectly superposable. |
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6.

| 7. | This Decision shall be published in the Official Journal of the European Union. It shall enter into force on 1 June 2004. |
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7.

The Chairman of the Administrative Commission

Tim QUIRKE

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(1)  
  OJ L 149, 5.7.1971, p. 2, Regulation last amended by Regulation (EC) No 631/2004 of the European Parliament and of the Council (OJ L 100, 6.4.2004, p. 1).

1

(2)  
  OJ L 74, 27.3.1972, p. 1. Regulation as last amended by Regulation (EC) No 631/2004.

2

(3)  
  OJ L 244, 19.9.1994, p. 22.

3

(4)  
  OJ L 302, 1.12.2000, p. 65.

4

(5)  
  OJ L 54, 25.2.2002, p. 1.

5

(6)  
  OJ L 93, 10.4.2003, p. 40.

6

(7)  
  OJ L 276, 27.10.2003, p. 19.

7

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ANNEX

Image 1

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INSTRUCTIONS
  Please complete this form in blocnk letters


  (a) This form is personal and non-transferable.

  (b) This document allows any insured person and the members of his/her family to receive any benefits in kind that may become necessary for medical reasons during a stay in another Member State, taking account of the nature of the services and the duration of the stay.
  (c) When a person has to seek benefits, including hospitalisation, this document must be presented to the health care provider.
  NOTES
  (1) Symbol of the country in which the institution completing the form is situated: IT = Italy, NL = Netherlands, AT = Austria, PT = Portugal, UK = United Kingdom, IS = Iceland, LI = Liechtenstein, CY = Cyprus, LV = Latvia, LT = Lithuania, HU = Hungary, MT = Malta, PL = Poland, SK = Slovakia, CH = Switzerland.
  (2) If the family member does not have a personal identification number, indicate the identification number of the person from whom the rights of the family member are derived.

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ADMINISTRATIVE COMMISSION
  ON SOCIAL SECURITY FOR MIGRANT WORKERS
  E 119(1)
  CERTIFICATE CONCERNING THE ENTITLEMENT OF UNEMPLOYED PERSONS AND THE MEMBERS OF THEIR FAMILY TO CASH BENEFITS
  (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 has been drawn up at the latter's request.)
  Information on the beneficiary
  1. Surname(s):
  2. Forename(s):
  3. Date of birth:
  4. Personal identification number (2):
  5. Address in the country in which employment is being sought:

  Information on the institution in the place of residence or stay (3)
  6. Name of the institution:
  7. Identification number of the institution:
  8. Address:
  9. Your form h E 107 of h E 115 of
  10. The person referred to above is entitled to cash benefit
  10.1. h for himself/herself
  10.2. h for members of his/her family
  11. In the case of incapacity for work, cash benefits may be provided
  11.1. h for a period not exceeding that fixed for entitlement to unemployment benefits
  11.2. h for cases of sickness occurring up to inclusive,
  lasting for days weeks

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12. These cash benefits will be paid
  12.1. h by us
  12.2. h by you on our behalf
  13. Benefit should be paid
  13.1. h for the same days of the week as those laid down for unemployment insurance
  13.2. h for every day of the week except h Monday h Tuesday h Wednesday
  h Thursday h Friday h Saturday
  h Sunday
  14. The daily net amount of this benefit (4)
  14.1. h is the same as that laid down for unemployment insurance
  14.2. h is if the insured person is not in hospital
  or if he/she is in hospital
  Information on the competent institution
  15. Name of the institution:
  16. Identification number of the institution:
  17. Address:
  18. Stamp: 19. Date:
  20. Signature:

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INSTRUCTIONS
  Please complete the form in block capitals
  Information for the unemployed person:
  In order to obtain cash benefits for yourself in the event of incapacity for work or if you are in hospital, you must (unless you are in the Netherlands) submit the form referred to above and a certificate of incapacity for work issued by your doctor to the following institution:
  in Belgium, the mutualité (local sickness insurance fund) of your choice,
  in Denmark, the local kommunekantoret på opholdsstedet(municipal administration of the place of stay),
  in Germany, the sickness fund of your choice,
  in Greece, normally the regional or 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) at the place of stay or residence,
  in France, the Caisse primaire d'assurance-maladie (local sickness insurance fund),
  in Ireland, the Department of Social and Family Affairs,
  in Italy, the Azienda sanitaria locale(ASL) responsible for the area concerned,
  in Luxembourg, the Caisse de maladie des ouvriers(sickness fund for manual workers),
  in the Netherlands you must declare your incapacity for work to het Uitvoering werknemersverzekeringen (UWV),
  in Portugal: for metropolitan Portugal, the Instituto de Solidaridade e Segurança Social — Centro Distrital de Solidaridade et Segurança Social (regional social security centre); for Madeira, the Centro de Segurança Social da Madeira (regional social security directorate), Funchal; for the Azores, the Centro de Prestações Pecunarias (regional social security directorate), Angra do Heroísmo,
  in the United Kingdom: the Department for Work and Pensions, the Pension Service, International Pension Centre, Tyneview Park, Newcastle-upon-Tyne, or for Northern Ireland, the Department for Social Development, Overseas Benefits Unit, Block 2, Castle Buildings, Belfast,
  in Austria, the Gebietskrankenkasse (regional sickness insurance fund) competent for your place of residence or stay,
  in Finland, the local office of the Kansanzlaekelaitos' (social insurance institution,
  in Iceland, the Tryggingastofrun riskins (state social security institute), Reykjavik,
  in Liechtenstein, the Amt für Volkswirtschaft(office of national economy), Vaduz,
  in Norway, the lokale Trygdekontor(local insurance office) at the place of residence or stay,
  in Sweden, the försäkringskassan(social insurance office) at the place of residence or stay,
  in Switzerland, the Institution commune LAMal — Istituzione comune LAMal — Gemeinsame Einrichtung KVG (common institution under the Federal Sickness Insurance Act), Solothurn,
  in the Czech Republic, územní organiza?ní jednotky ?eské správy,
  in Latvia, the Valsts soci?l?s apdrošin?šanas a?ent?ra (state social insurance agency),
  in Lithuania, the Valstybinio socialinio draudimo fondo valdybos teritorinial skyriai (territorial branch of the state social insurance fund board),
  in Slovakia, the Sociálna pois?ov?a (social insurance Officey), Bratislava,
  in Estonia, the Eesti Haigekassa(Estonian health insurance fund),
  In Malta, the department of Social Security, Valetta,
  in Poland, Wojewódzkiego Urz?du Pracy(WUP),
  in Hungary, the locally competent Megyei Egészségbiztosítási Pénztár(county health insurance office),
  in Slovenia, the competent regional unit of the Zavod za zdravstveno zavarovanje Slovenije (ZZZS) (health Insurance Institute of Slovenia) in the place of residence or stay,
  In Cyprus, the Ministry of Health.

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NOTES.
  (1) Symbol of the country to which the institution completing the form belongs: BE = Belgium; DK = Denmark; DE = Germany; GR = Greece; ES = Spain; FR = France; IE = Ireland; LU = Luxembourg; FI = Finland; SE = Sweden; IT = Italy; NL = the Netherlands; AT = Austria; PT = Portugal; UK = United Kingdom; NO = Norway; IS = Iceland; LI = Liechtenstein, CZ = Czech Republic; CY = Cyprus; EE = Estonia, LV = Latvia, LT = Lithuania, HU = Hungary, MT = Malta, PL = Poland, SI = Slovenia, SK = Slovakia, CH = Switzerland.
  (2) If the family member does not have a personal identification number, state the number of the person from whom the rights of the person concerned derive.
  (3) To be completed only where the form is issued at the request of the institution in the place of residence or stay.
  (4) To be completed only where the cash benefits are to be paid by the institution in the place of residence or stay.

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