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II Acts whose publication is not obligatory

Commission

Administrative Commission of the European Communities on Social Security for Migrant Workers

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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:

HAS DECIDED AS FOLLOWS:

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).

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

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

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

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

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

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

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ANNEX
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ADMINISTRATIVE COMMISSIONON SOCIAL SECURITYFOR MIGRANT WORKERSE 111 (1)CERTIFICATE OF ENTITLEMENT TO BENEFITS IN KIND DURING A STAY IN ANOTHER MEMBER STATE(This form can only be used by certain States and is of a transitional nature. Form E 111 may not be issued or utilised after 31 December 2005,the date on which the European health insurance card will be distributed by all the Member States)Note!This document establishes no entitlement if the purpose of the journey is to receive medical treatmentInformation concerning the beneficiary1. Name(s):2. First name(s):3 Date of birth4. Personal identification number (2)Information concerning the institution5. Name of institution:6. Identification number of the institution:Period of validity of the formDate of issue of the form(a) From:(b) To: Signature and seal of the institutio(c)(d)
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INSTRUCTIONSPlease 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 COMMISSIONON SOCIAL SECURITY FOR MIGRANT WORKERSE 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 beneficiary1. 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 of10. The person referred to above is entitled to cash benefit10.1. h for himself/herself10.2. h for members of his/her family11. In the case of incapacity for work, cash benefits may be provided11.1. h for a period not exceeding that fixed for entitlement to unemployment benefits11.2. h for cases of sickness occurring up to inclusive,lasting for days weeks
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12. These cash benefits will be paid12.1. h by us12.2. h by you on our behalf13. Benefit should be paid13.1. h for the same days of the week as those laid down for unemployment insurance13.2. h for every day of the week except h Monday h Tuesday h Wednesdayh Thursday h Friday h Saturdayh Sunday14. The daily net amount of this benefit (4)14.1. h is the same as that laid down for unemployment insurance14.2. h is if the insured person is not in hospitalor if he/she is in hospitalInformation on the competent institution15. Name of the institution:16. Identification number of the institution:17. Address:18. Stamp: 19. Date:20. Signature:
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INSTRUCTIONSPlease complete the form in block capitalsInformation 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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