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This document is meant purely as a documentation tool and the institutions do not assume any liability for its contents
►B 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)
(OJ L 244, 19.9.1994, p. 22)
Amended by:
Official Journal
No page date
►M1Decision 98/441/EC No 166 of 2 October 1997 L 195 25 11.7.1998
►M2Decision 98/443/EC No 168 of 11 June 1998 L 195 37 11.7.1998
►M3Decision 2002/154/EC No 179 of 18 April 2000 L 54 1 25.2.2002
▼B
DECISION No 153
of 7 October 1993
on the model forms necessary for the application of Council Regu-
lation 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 COMMU-
NITIES 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 toemployed persons, to self-employed persons and to members of their
family moving within the Community, under which it isthe duty of
the Administrative Commission to deal with all administrative mattersarising from Regulation (EEC) No 1408/71 and subsequent Regula-tions,
Having regard to Article 2 (1) of Council Regulation (EEC) No 574/72
of 21 of March 1972, under which it isthe duty of the Adminis trativeCommission to draw up models of certificates, certifieds statements,declarations, applications and other documents necessary for the appli-
cation 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 amendmentswhich have been introduced intothe national legislation of Member States;
Whereasthe Agreement on the European Economic Area of 2 May
1992, asadjus ted by the Protocol of 17 March 1993, Annex VI, imple-mentsCouncil Regulations(EEC) No 1408/71 and (EEC) No 574/72within the European Economic Area;
Whereasby Decis ion 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;
Whereasthe language in which the formss hould be drawn up hasbeen
decided by recommendation No 15 of the Administrative Commission,
HAS DECIDED AS FOLLOWS:
1. The model formsE 001, E 103 to E 127 printed in Decis ion No 130
shall be replaced by the models appended hereto.
2. The competent authoritiesof the Member Statess hall make avail-
able 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 versionsare perfectly superposable, thereby making it possible for eachperson or body to which a form is addressed (rightful claimant,institution, employer, etc.) to receive the form printed in their ownlanguage.1994D0604 — EN — 01.03.2002 — 002.001 — 2
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4. This Decision shall be applicable from the first day of the month
following itspublication in the Official Journal of the European
Communities .
The Chairman of the Administrative
Commission
Gabrielle CLOTUCHE1994D0604 — EN — 01.03.2002 — 002.001 — 3
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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 optionE 104 — Certificate concerning the aggregation of periodsof ins urance,
employment or residence
E 105 — Certificate concerning the membersof 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 bene-
fits in kind for persons residing in a country other than the
competent country
E 107 — Application for a certificate of entitlement to benefitsin 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 benefitsin kind during a s tay in a
Member State
E 112 — Certificate concerning the retention of the right to sickness or mater-
nity benefitscurrently being provided
E 113 — Hospitalization: notification of entering and leaving hospital
E 114 — Granting of major benefitsin kindE 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 benefitsin kind for pens ion claimants
and membersof their family
E 121 — Certificate for the registration of pensioners and the updating of lists
E 122 — Certificate for the granting of benefitsin kind to membersof 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 expenditureE 126 — Ratesfor refund of benefitsin kind
E 127 — Individual record of monthly lump-sum payments1994D0604 — EN — 01.03.2002 — 002.001 — 4
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