30.12.73 Official Journal oftheEuropean Communities NoL363/1
II
(Acts whose publication isnotobligatory )
COMMISSION
ADMINISTRATIVE COMMISSION
OF THE EUROPEAN COMMUNITIES
ON SOCIAL SECURITY FOR MIGRANT WORKERS
DECISION No 88
of12July 1973
adapting themodel forms necessary fortheapplication ofCouncil Regulation (EEC )
No1408/71andCouncil Regulation (EEC )No574/72foruseintheenlarged Community
(E101—127:E201—214;E301—303 ;E401—410 )
73/446/EEC )
THE ADMINISTRATIVE COMMISSION OFTHE EUROPEAN COMMUNITIES ON
SOCIAL SECURITY FOR MIGRANT WORKERS ,
Having regard toArticle 81(a )ofCouncil Regulation (EEC )No 1408/71of14June
1971 ontheapplication ofsocial security schemes toemployed persons andtheir families
moving within theCommunity ,under which itistheduty oftheAdministrative Com­
mission todeal with alladministrative questions arising from Regulation (EEC )No
1408/71andsubsequent regulations ;
Having regard toArticle 2(1)ofCouncil Regulation (EEC )No574/72of21March 1972
fixing theprocedure forimplementing Regulation (EEC )No1408/71,under which itis
theduty oftheAdministrative Commission todraw upmodels ofcertificates ,certified
statements ,declarations ,applications andother documents necessary fortheapplication
oftheregulations ;
Having regard toDecision No72of1October 1972 laying down themodel forms necess­
aryfortheapplication ofCouncil Regulation (EEC )No1408/71andCouncil Regulation
(EEC )No 574/72;
Whereas thesaid model forms should beadapted foruseintheenlarged Community ,

NoL363/2 Official Journal oftheEuropean Communities 30.12.73
HAS DECIDED ASFOLLOWS :
1.The model forms printed hereinafter shall beused forthepurposes ofapplying
Council Regulation (EEC )No1408/71and Council Regulation (EEC )No574/72,
which entered into force inthenine Member States on1April 1973 .
2.Each form will beavailable intheofficial languages oftheCommunity andlaidout
insuch amanner thatthedifferent versions areperfectly superposable ,thereby making
itpossible foreach person orbody towhich aform isaddressed (persons entitled to
claim ,institution ,employer ,etc.)toreceive theform printed intheir own language .
Theinstitution completing theform should filloutth:first copy and any additional
copies itneeds inthelanguage itnormally uses ;theother copies should bedrawn
upontheversions oftheform printed inthelanguage ofeach ofthepersons orbodies
towhom they aretobesent .
However ,benefits inkind claimed during astay inaMember State other than the
competent State (form E111)may notberefused iftheperson concerned submits a
form drawn upinalanguage other than that ofthecountry where thesaid benefits
are claimed .
The different forms consist ofseparate numbered sheets which should bestapled
together once theinformation required hasbeen filled in.
The Chairman oftheAdministrative Commission
A.TRIER

30.12.73 Official Journal oftheEuropean Communities NoL363/3
List ofForms
E101—Certificate ofposting
E102—Extension ofterm ofposting
E103—Exercise oftheright ofoption
E104 —Certificate concerning theaggregation ofperiods ofinsurance ,employment orresidence
E105—Certificate concerning themembers oftheworker 'sfamily tobetaken into consideration forthecalculation of
cash benefits incase ofincapacity forwork
E106—Certificate ofentitlement tosickness andmaternity insurance benefits inkind forpersons residing inacountry
other than thecompetent country
E107—Application foracertificate ofentitlement tobenefits inkind
E108—Notification ofsuspension orwithdrawal oftheright tosickness andmaternity insurance benefits inkind
E109—Certificate fortheregistration ofmembers oftheworker 'sfamily andthekeeping oflists
E110—Certificate concerning workers ininternational transport
E111—Certificate ofentitlement tobenefits inkind during astay inaMember State
E112—Certificate concerning theretention oftherights tosickness ormaternity benefits currently being provided
E113—Hospitalization :Notification ofentering andleaving hospital
E114—Grant ofprostheses ,major appliances ,etc.
E115 —Claim forcash benefits forincapacity forwork
E116—Medical report relating toincapacity forwork (sickness ,maternity ,accident atwork ,occupational disease )
E117—Granting ofcash benefits inthecase ofincapacity forwork
E118—Notification ofnon-recognition orofendofincapacity forwork
E119—Certificate concerning theentitlement ofunemployed persons andthemembers oftheir family tosickness andmater­
nity insurance benefits
E120—Certificate ofentitlement tobenefits inkind forpension claimants andmembers oftheir family
E121—Certificate fortheregistration ofpensioners andthekeeping oflists
E122—Certificate forthegrant ofbenefits inkind tomembers ofthefamily ofpensioners
E123—Certificate ofentitlement tobenefits inkind under insurance against accidents atwork andoccupational diseases
E124 —Claim ofdeath grant
E125—Individual record ofactual expenditure
E126 —Rates forrefund ofbenefits inkind
E127—Individual record ofmonthly lump-sum payments
E201 —Certificate concerning theaggregation ofperiods ofinsurance orperiods ofresidence
E202—Investigation ofaclaim foranold-age pension
E203 —Investigation ofaclaim forasurvivor 'spension
E204 —Investigation ofaclaim foraninvalidity pension
E205 —Certificate concerning insurance record inBelgium
—Certificate concerning periods ofinsurance andperiods ofresidence inDenmark
—Certificate concerning insurance record inGermany
—Certificate concerning insurance record inFrance
—Certificate concerning insurance record inIreland
—Certificate concerning insurance record inItaly
—Certificate concerning insurance record inLuxembourg
—Certificate concerning insurance record intheNetherlands
—Certificate concerning insurance record intheUnited Kingdom

NoL363/4 Official Journal oftheEuropean Communities 30.12.73
E206 —Certificate concerning periods ofemployment inmines and similar undertakings
E207 —Information concerning theworker 'sinsurance history
E208 —Determination ofrights topensions
E209 —Determination ofpension amounts
E210 —Notification ofdecision concerning aclaim forpension
E211 —Summary ofdecisions
E212 —Legal remedies andperiods allowed forappeals
E213 —Detailed medical report
E214 —Medical report concerning assessment offunctional abilities andlimitations
E301 —Certificate concerning theperiods tobetaken into account forthegrant ofunemployment benefits
E302 —Certificate relating tomembers ofthefamily ofanunemployed person who must betaken into account forthe
calculation ofbenefits
E303 —Certificate concerning theretention oftheright tounemployment benefits
—Information fortheunemployed person who intends togotoanother Member State toseek employment
E401 —Certificate concerning thecomposition ofthefamily forthepurpose ofthegranting offamily benefits
E402 —Certificate ofcontinuation ofstudies forthepurpose ofthegranting offamily benefits
E403 —Certificate ofapprenticeship forthepurpose ofthegranting offamily benefits
E404 —Medical certificate forthepurpose ofthegranting offamily benefits
E405 —Payment offamily benefits orfamily allowances inthecase ofsuccessive employment inseveral Member States
between thedates onwhich payment isdueaccording tothelegislation ofthese states
E406 —Claim forfamily allowances tobesubmitted byaworker who issubject toFrench legislation and whose family
resides inaMember State other than France
E407—Certificate ofperiods ofemployment inFrance ,orperiods ofunemployment inFrance forwhich benefits were paid ,
forthepurpose ofgranting family allowances tomembers ofthefamily ofaworker orunemployed person who
reside inaMember State other than France
E408 —Request forinformation
E409 —Verification ofthedeclaration ofabsence ofentitlement tofamily allowances byvirtue ofaprofessional ortrade
activity inthecountry ofresidence ofthefamily
E410 —Notification ofcancellation ofentitlement tofamily allowances

EUROPEAN COMMUNITIES See'Instructions 'onpage 3
Social -Security Regulations
E101 C)
CERTIFICATE OF POSTING
Reg .1408 /71:Art .14.1.a.i ;Art .14.2.a ;Art .22.1 .a.i;Art .22.3 ;Art .55.1 .a.i
Reg .574172 :Art .11.1;Art .20.1 ;Art .62.1
Thedesignated institution ofthecountry inwhich theundertaking hasitsregistered office should complete points
1.1—7.5and ,ifpossible ,also boxes 8and 9.Theform should beissued totheworker ortotheemployer .Ifthe
worker isposted inBelgium acopy oftheform should also besent tothe'Office national desécurité sociale ',Brussels .
1 Worker
1.1 Surname Forenames Maiden name
1? Date ofbirth : Nationality :
1.3 Permanent address (2):
1.4 Insurance number :
2 Members ofthefamily who accompany theworker
2.1 Surname Forenames Maiden name Date ofbirth
3 Employer
3.1 Name ofemployer orfirm :
3.2 Address (2):
4 The abovementioned worker isposted foraperiod probably lasting
from to
4.1 (3)[~|totheundertaking mentioned below : \ontheship mentioned below :
5 Name ofemployer orfirm :
5.1 Address (2):
©

E101
6 During this period theworker remains subject tothelegislation ofthecountry inwhich theundertaking has
itsregistered office ,inaccordance with Article
6.1 (3)Q14.1 .a.i □14.2 .aofRegulation No1408/71.
7IDesignated institution ofthecountry inwhich theundertaking hasitsregistered office
7.1 Name :
7.2 Address (2):
7.3 Stamp
7.4 Date :
7.5 Signature
8ITobecompleted bythedesignated institution ortheworker
8.1 Institution competent forsickness and maternity insurance (name and address )(2)(4):
8.2 Stamp
8.3 Date :
8.4 Signature oftheinstitution 'srepresentative 8.5 Signature oftheworker
9|Tobecompleted bythedesignated institution ortheemployer
9.1 Institution competent forinsurance against accidents atwork (name and address )(2):
9.2 Institution competent forinsurance against occupational diseases (name andaddress )(2)(5):
9.3 Stamp
Date : 9.4
9.6 9.5 Signature oftheinstitution 'srepresentative Signature oftheemployer

E101
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .Itconsists ofthree pages ,
none ofwhich may beleft out even ifitdoes notcontain any relevant information .
Information for the worker
a)This form enables theworker and themembers ofhisfamily mentioned inbox 2toobtain from theinsurance institutions oftheplace
where heisposted benefits inkind incase ofsickness ,maternity ,accident atwork oroccupational disease .
b)When oneofthepersons concerned hastoseek benefits ,including hospitalization ,theform should besubmitted totheinsurance institution
oftheplace ofposting ,i.e.
—forbenefits incase ofsickness ormaternity :
inBelgium ,the'mutualité '(local sickness insurance fund )ofhischoice ;
inDenmark ,thecompetent 'amtskommune '(local administration ).Inthecommune ofCopenhagen ,the'magistrat (municipal
administration );inthecommune ofFrederiksberg ,the'kommunalbestyrelse '(municipal administration ).Assistance from adoctor ,
dentist ordispensing chemist may besought without first contacting thesaid institutions .Particulars about doctors and dentists
available may beobtained from thelocal 'social -ogsundhedsforvaltning '(social and health authority );
inGermany ,the'Allgemeine Ortskrankenkasse '(AOK ,local general sickness fund);
inFrance ,the'Caisse primaire d'assurance-maladie '(local sickness insurance fund);
inIreland ,theHealth Board inwhose area thebenefit issought ;
inItaly ,theprovincial office ofthe'Istituto nazionale perl'assicurazione contro lemalattie '(INAM,national sickness insurance
institute );
inLuxembourg ,the'Caisse nationale d'assurance-maladie desouvriers '(national sickness insurance fund formanual workers );
intheNetherlands ,the'Algemeen Nederlands Onderling Ziekenfonds '(ANOZ ,general sickness fund oftheNetherlands ),Utrecht .
Assistance from adoctor ,dentist ordispensing chemist may besought without first contacting ANOZ ;
intheUnited Kingdom ,themedical service (doctor ,dentist ,hospital ,etc.)from which treatment isrequested .
—forbenefits incase ofaccident atwork oroccupational disease :
inBelgium ,the'mutualité '(local sickness insurance fund )ofhischoice ;
inDenmark ,the'Sikringsstyrelse '(national office forsocial security ),Copenhagen ;
inGermany ,the'Allgemeine Ortskrankenkasse '(AOK ,local general sickness fund);
inFrance ,the'Caisse primaire d'assurance-maladie '(local sickness insurance fund);
inIreland ,theHealth Board inwhose area thebenefit issought ;
inItaly ,theprovincial office ofthe'Istituto nazionale perl'assicurazione contro gliinfortuni sullavoro '(INAIL ,national institute
forinsurance against accidents atwork);
inLuxembourg ,the'Association d'assurance contre lesaccidents '(accident insurance association );
intheNetherlands ,the'Algemeen Nederlands Onderling Ziekenfonds '(ANOZ ,general sickness fund oftheNetherlands ),Utrecht .
Assistance from adoctor ,dentist ordispensing chemist may besought without first contacting ANOZ ;
intheUnited Kingdom ,themedical service (doctor ,dentist ,hospital ,etc.)from which treatment isrequested .
c)Ifboxes 2,8and 9have notbeen completed bytheinstitution ,boxes 2and 8should becompleted bytheworker andbox 9byhis
employer before theworker leaves forthecountry towhich heisposted .
d)Inorder toreceive benefits inkind theworker may present form E111instead ofthisform .
NOTES
(1)Symbol ofthecountry inwhich theundertaking has itsregistered office :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Postal code ,town ,street ,number ,country .
(3)Putacross inthesquare preceding theappropriate subject .
(4)FortheNetherlands indicate thesickness fund ('ziekenfonds ').
(5)Complete only ifdifferent from theinstitution mentioned atpoint 9.1.

See'Instructions onpage 4 EUROPEAN COMMUNITIES
Social Security Regulations
E102 n
EXTENSION OF TERM OF POSTING
Reg .1408/71:Art.14.1.a.ii ;Art.14.2.a ;Art.22.1 .a.i;Art.22.3;Art.55.1 .a.i
Reg .574/72:Art .11.2;Art.20.1;Art.62.1
A.Tobecompleted bythe employer
1 Institution towhich theform isaddressed (2)
1.1 Name :
1.2 Address (3):
2 Worker
2.1 Surname Forenames Maiden name
?? Date ofbirth : Nationality :
2.3 Permanent address (3):
2.4 Insurance number :
3 Competent institution
3.1 forinsurance against accidents atwork (name andaddress )(3):
3.2 forinsurance against occupational diseases (name andaddress )(3)(4):
4 Theabovementioned worker hasbeen posted ,inaccordance with Article
4.1 (5)□14.1 .a.i□14.2 .a ofRegulation 1408/71,
4.2 forthe period from to
4.3 (5) totheundertaking mentioned below :[ ontheship mentioned below :
5 Name ofemployer orfirm :
5.1 Address (3):

E102
6 This worker held aCertificate ofPosting (form E101 )
6.1 issued bythefollowing institution (name andaddress )(3)
6.2 on and expiring on
7 Werequest that this worker may continue tobesubject tothelegislation of
1the country
7.1 fortheperiod from to (6).
8 Employer
8.1 Name ofemployer orfirm :
8.2 Address (3):
8.3 Stamp
8.4 Date :
8.5 Signature
B.Tobecompleted bythecompetent authority orthedesignated body ofthecountry ofemployment (7)
9 We declare that
9.1 (5)Qitisagreed Qitisnotagreed
thattheworker mentioned inbox 2shall continue tobesubject tothesocial security legislation of
the country : n
9.2 forthe period from to
10 Competent authority ordesignated body ofthecountry ofemployment
10.1 Name :
10.2 Address (3):
10.3 Stamp
10.4 Date :
10.5 Signature

E102
C.Tobecompleted bythe worker
11 Institution competent forsickness and maternity insurance (8)
11.1 Name :
11.2 Address (3):
12 Members ofthefamily who accompany theworker
12.1 Surname Forenames Maiden name Date ofbirth
13 Date :
14 Signature
(D

E102
INSTRUCTIONS
Please complete four copies ofthisform inblock letters ,writing onthedotted lines only .Itconsists
offour pages ,none ofwhich may beleftout even ifitdoes notcontain any relevant information .
Information forthe employer
a)Theemployer should complete partAoffour copies oftheform ,which heshould send tothecompetent authority ortothedesignated
body ofthecountry towhich theworker hasbeen posted ,i.e.
inBelgium ,the'Ministère delaprévoyance sociale '(ministry ofsocial welfare ),Brussels ,orthe'Office national desecurity sociale '
(national office forsocial security ),Brussels ;
inDenmark ,the'Sikringsstyrelse '(national office forsocial security ),Copenhagen ;
inGermany ,the'Bundesministerium furArbeit und Sozialordnung '(federal ministry oflabour and social affairs ),Bonn ;
inFrance ,the'Direction regionale delasécurité sociale '(regional directorate forsocial security );
inIreland ,theDepartment ofSocial Welfare ,Dublin ;
inItaly ,the'Ministero dellavoro edelta previdenza sociale '(ministry oflabour andsocial welfare ),Rome ;
inLuxembourg ,the'Ministère dutravail etdelasécurité sociale '(ministry oflabour andsocial security ),Luxembourg ;
inthe Netherlands ,the'Ministerie vansociale zaken '(ministry ofsocial affairs ).TheHague ;
intheUnited Kingdom ,theDepartment ofHealth and Social Security ,Overseas Group ,Newcastle-upon-Tyne ,ortheMinistry
ofHealth and Social Services ,Overseas Branch ,Belfast ,asappropriate .
b)Two copies oftheform ,with part Bcompleted ,willbesent totheemployer ,who should give oneofthem totheworker .
Information for the worker
a)This form enables theworker and themembers ofhisfamily mentioned inbox 12toobtain from theinsurance bodies oftheplace
where heisposted benefits inkind incase ofsickness ,maternity ,accident atwork oroccupational disease .
b)When oneofthepersons concerned hastoseek benefits ,including hospitalization ,theform should besubmitted totheinsurance
institution oftheplace ofposting ,i.e.
—forbenefits incase ofsickness ormaternity :
inBelgium ,the'mutualité '(local sickness insurance fund)ofhischoice ;
inDenmark ,thecompetent 'amtskommune '(local administration ).Inthecommune ofCopenhagen ,the'magistrat '(municipal
administration );inthecommune ofFrederiksberg ,the'kommunalbestyrelse '(municipal administration ).Assistance from adoctor ,
dentist ordispensing chemist may besought without first contacting thesaid institutions .Particulars about doctors and dentists
available may beobtained from thelocal 'social -ogsundhedsforvaltning '(social and health authority );
inGermany ,the'Allgemeine Ortskrankenkasse '(AOK ,local general sickness fund);
inFrance ,the'Caisse primaire d'assurance-maladie 'floral sickness insurance fund);
inIreland ,theHealth Board inWhose area thebenefit issought ;
inItaly ,theprovincial office ofthe 'Istituto nazionale perl'assicurazione contro lemalattie '(INAM ,national sickness insurance
institute );
inLuxembourg the'Caisse nationale d'assurance-maladie desouvriers '(national sickness insurance fund formanual workers );
intheNetherlands ,the'Algemeen Nederlands Onderling Ziekenfonds '(ANOZ ,general sickness fund oftheNetherlands ),Utrecht .
Assistance from adoctor ,dentist ordispensing chemist may besought without first contacting ANOZ ;
intheUnited Kingdom ,themedical service (doctor ,dentist ,hospital ,etc.)from which treatment isrequested .
—forbenefits incase ofaccident atwork oroccupational disease :
inBelgium ,the'mutualité 'local sickness insurance fund)ofhischoice ;
inDenmark ,the'Sikringsstyrelse '(national office forsocial security ),Copenhagen ;
inGermany ,the'Allgemeine Ortskrankenkasse '(AOK ,local general sickness fund);
inFrance ,the'Caisse primaire d'assurance-maladie '(local sickness insurance fund);
inIreland ,theHealth Board inwhose area thebenefit issought ;
inItaly ,theprovincial office ofthe'Istituto nazionale perl'assicurazione contro gliinfortuni sullavoro '(INAL ,national institute
forinsurance against accidents atwork);
inLuxembourg ,the'Association d'assurance contre lesaccidents '(accident insurance association );
intheNetherlands ,the'Algemeen Nederlands Onderling Ziekenfonds '(ANOZ ,general sickness fund oftheNetherlands ),
Utrecht .Assistance from adoctor ,dentist ordispensing chemist may besought without firstcontacting ANOZ ;
intheUnited Kingdom ,themedical service (doctor ,hospital ,etc.)from which tretament isrequested .
c)Theworker should complete part Coftheform ,taking particular care toindicate inbox 12themembers ofhisfamily who areentitled
tosickness ormaternity insurance benefits .
d)Inorder toreceive benefits inkind theworker may present form E111instead ofthisform .
NOTES
(1)Symbol ofthecountry inwhich theundertaking hasitsregistered office :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Seetheinformation given atpoint a)of'Information fortheemployer '.
(3)Postal code ,town ,street ,number ,country .
(4)Complete only ifdifferent from theinstitution mentioned atpoint 3.1 .
(5)Put across inthesquare preceding theappropriate subject .
(6)This period must notbemore than 24month from thedate ofthecommencement ofposting .
(7)Two copies should bereturned totheclaimant andonecopy senttothedesignated institution ofthecountry inwhich theundertaking
has itsregistered office .
(8)FortheNetherlands indicate thesickness fund ('ziekenfonds ').
©

©See 'Instructions overleaf EUROPEAN COMMUNITIES
Social Security Regulations
E103 V)
EXERCISE OF THE RIGHT OF OPTION
Reg .1408/71:Art 16.2 and 3
Reg .574/72:Art .13.2 and 3;Art.14.1and 2
After having completed partAoftheform inaccordance withpoints (a)and(b)oftheinstructions ,theworker should
hand itover ordispatch itinaccordance withpoints (a)and(c)oftheinstructions .Theinstitution receiving theform
should complete part Bandreturn onecopy totheworker .
A.Option
m The undersigned
1.1 Surname Forenames Maiden name
1.2 Date ofbirth : Nationality :
1.3 Address (2):
1.4 Insurance number :
2 employed since
2.1 (3)Qas bythediplomatic mission orconsular post
named hereafter
2.2 (3)□asn
intheprivate staff ofthefollowing employer (5)
agent ofthediplomatic mission orconsular post named hereafter :
2.3 (3)[Jasamember oftheauxiliary staffoftheEuropean Communities ,
3 hereby opts tobesubject tothesocial security legislation
3-1 (6)QoftheMember State ofwhich heisanational :
3.2 (6)rioftheMember State towhose legislation hewas lastsubject ,viz.thelegislation of
(6)[_JBelgium
(6)□Italy[IDenmark
IILuxembourg||France [JIreland
IIUnited Kingdom .I[Germany
[|Netherlands
4 Place and date :
5 Signature
6Authority oftheEuropean Communities which hasconcluded thecontract with themember ofthe
auxiliary staff
6.1 Name :
6.2 Address (2):
6.3 Stamp
6.4 Date :
6.5 Signature

E103
B.Declaration
7 Wenote that theworker mentioned inbox 1above issubject tothelegislation of
(6)QBelgium [JDenmark QGermany QFrance QIreland
(6)QItaly QLuxembourg QNetherlands QUnited Kingdom
7.1 asfrom
7.2 fortheperiod during which heisengaged intheemployment indicated inpart Aofthisform (7)
8 Institution designated bythecompetent authority
8.1 Name :
8.2 Address (2):
8.3 Stamp
8.4 Date :
8.5 Signature
INSTRUCTIONS
Please complete three copies ofthis form inblock letters ,writing onthedotted lines only .
Tothestaff ofdiplomatic missions orconsular posts and their private domestic staff
a)After having completed part Aoftheform ,excluding box6,youshould give onecopy oftheform toyour employer andsend twocopies totheinstitution designated
bythecompetent authority oftheMember State forwhose legislation youhave opted ,i.e.
inBelgium ,the'Office national desicurite sociaie '(national office forsocial security ),Brussels ;
inDenmark ,the'Sikringsstyrelse '(national office forsocial security ),Copenhagen ;
inGermany ,the'Allgemeine Ortskrankenkasse Bonn '(AOK ,local general sickness fund ),Bonn ;
inFrance ,the'Caisse primaire centrale d'assurance maladie delaregion parisienne '(central sickness insurance fund oftheParis region );
inIreland ,theDepartment ofSocial Welfare ,Dublin ;
inItaly ,theprovincial office ofthe'Istituto nazionale peri'assicurazione contro lemalattie '(INAM ,national sickness insurance institute );
inLuxembourg ,the'Ministhre dutravail etdelasecurity sociaie '(ministry oflabour andsocial security ).Luxembourg ;
intheNetherlands ,the'Sociaie verzekeringsraad '(social insurance council ).TheHague ;
intheUnited Kingdom ,theDepartment ofHealth and Social Security ,Overseas Group ,Newcastle-upon-Tyne ,ortheMinistry ofHealth andSocial Services
Overseas Branch ,Belfast ,asappropriate .
Totheauthority oftheEuropean Communities empowered toconclude contracts ofemployment with auxiliary staff
b)When aperson isengaged asamember oftheauxiliary staff andheexpresses thewish tousehisright ofoption ,theempowered authority oftheEuropean Commu­
nities must ensure that hecompletes part Aoftheform ,with theexception ofbox 6which must becompleted bythat authority .
c)Two copies oftheform should besent totheinstitution designated bythecompetent authority oftheMember State forwhose legislation theperson concerned has
opted (seepoint a)above ).
NOTES
(') Symbol ofthecountry ofemployment oftheperson who completes theform :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;Irl=Ireland ;I=Italy
L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Postal code ,town ,street ,number ,country .
(3)Give information at2.1,2.2or2,3,according totheposition oftheworker completing theform ,and putacross inthecorresponding square .
(4)State theoccupation oftheperson concerned :chauffeur ,cook ,etc.
(5)State surname and forenames ofemployer .
(6)Putacross inthesquare preceding theappropriate subject .Please note that workers employed bydiplomatic missions orconsular posts and members oftheprivate
domestic staff ofagents ofsuch missions orposts may optonly forthesocial security legislation oftheMember State ofwhich they areanational .
(7)The right ofoption ofworkers employed bydiplomatic missions orconsular posts and members oftheprivate domestic staff ofagents ofsuch missions orposts may
beexercised attheend ofeach calendar year .
©

See 'Instructions onpage 3 EUROPEAN COMMUNITIES
Social Security Regulations
E1041
CERTIFICATE CONCERNING THE AGGREGATION OFPERIODS OFINSURANCE ,EMPLOYMENT
OR RESIDENCE
Sickness —Maternity —Death (grant )—Tuberculosis
Reg .1408/71:Art .9.2;Art .18.1;Art .64
Reg .574/72:Art .6.2;Art .16;Art.79
Thecompetent institution should complete partAoftheform andsend two copies totheinstitution oftheMember
State towhose legislation theperson concerned was lastsubject .Thelatter institution should complete part Band
return theform totheinstitution from which itreceived theform .Iftheform isdrawn upattherequest oftheperson
concerned ,theinstitution thathastoissue itshould complete part Bandgive orsend theform totheperson concerned .
Part A
1|Institution towhich theform isaddressed
1.1 Name :
1.2 Address (2):
2 Insured person
2.1 Surname Forenames Maiden name Date ofbirth
2.2 Insurance number :
2.3 Last employer inthecountry towhose legislation theworker was lastsubject :
2.4 Name ofemployer orfirm :
2.5 Address (2):
3 Inorder todeal with aclaim submitted bytheinsured person mentioned above ,werequest youtoindicate
theperiods ofinsurance ,employment orresidence completed byhim
3.1 from
3.2 under thelegislation ofyour country ,forthefollowing risk :
(3)Qsickness andmaternity Q]death (grant ) tuberculosis
©

E104
4 Competent institution
4.1 Name :
4.2 Address (2):
4.3 Stamp
4.4 Date :
4.5 Signature
Part B
5 Competent institution (4)
5.1 Name :
5.2 Address (2):
6m Insured person (5)
6.1 Surname Forenames Maiden name Date ofbirth
6.2 Insurance number :
inbox 6 7 Theinsured person mentioned (3)[_Jinbox2
completed (3)Qduring thepasttwoyears (6)
(3)Qduring thepastthree years (7)
(3)Qsince
8Ithefollowing periods ofinsurance :
8.1 from to
8.2 from to
8.3 from to
8.4 from to
8.5 from to
8.6 from to
8.7 from to
8.8 from to
8.9 from to
8.10 from tofor (8)the risk of □(9>
for /8)the risk of □ <9>
for (8)the risk of □(9)
for (8)the risk of □(9>
for (8)the risk of □ <a>
for (8)the risk of □(9)
for (8)the risk of □n
for (8)the risk of □(9>
for (8)the risk of □(9>
for (8)the risk of □ <9>
©

E104
9 thefollowing periods ofresidence :
9.1 from to
9.2 from to
9.3 from to
9.4 from to
9.5 from to
9.6 from to
9.7 from to
9.8 from to
9.9 from to
9.10 from tofor (8\the risk of □(9)
for (8)the risk of □<»>
for (8)the risk of □(9)
for (8)the risk of □C)
for(8)the risk of □O
for (βλthe risk of □(9>
for (8)the risk of □ <9>
for(8)the risk of □<9>
for (8)the risk of □<a>
for (8)the risk of □(9)
10 Institution completing part B
10.1 Name :
10.2 Address (2):
10.3 Stamp
10.4 Date :
10.5 Signature
INSTRUCTIONS
Please complete ofthis form inblock letters ,writing onthedotted lines only .Itconsists ofthree
pages ,none ofwhich may beleftout even ifitdoes notcontain any relevant information .
NOTES
(1)Symbol ofthecountry towhich theinstitution which firstcompletes theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;
F=France ;Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Postal code ,town ,street ,number ,country .
(3)Put across inthesquare preceding theappropriate subject .
(4)Complete only iftheform isissued attherequest ofthecompetent institution .
(5)Complete only ittheform isissued directly totheperson concerned .
(6)Ifthecertificate isaddressed toanItalian institution and relates tobenefits inthecase oftuberculosis ,andtheperson concerned has
notpaid contributions foronefullyear during thelasttwo years ,theperiods ofinsurance completed byhimduring thelastfiveyears
should beindicated .
(7)Complete only ifthecompetent institution isanIrish orUnited Kingdom institution .
(8)Indicate theriskcovered byusing thefollowing symbols :
A=sickness and maternity
B=death (grant )
C=tuberculosis .
(9)Where thecompetent institution isanIrish orUnited Kingdom institution ,put across inthis square iftheperiod ofinsurance orthe
period ofresidence corresponds toaperiod ofactual employment .

See Instructions 'overleaf EUROPEAN COMMUNITIES
Social Security Regulations
E1051)
CERTIFICATE CONCERNING THE MEMBERS OF THE WORKER 'SFAMILY TO BETAKEN INTO
CONSIDERATION FOR THE CALCULATION OF CASH BENEFITS INCASE OFINCAPACITY 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 becompleted bythesickness insurance institution orbyadesignated institution oftheplace of
residence ofthemembers ofthefamily ,andforwarded totheworker .
1 Worker
1.1 Surname Forenames Maiden name Date ofbirth
1.2 Address (2)inthecountry ofresidence orthecountry ofstay :
1.3 Insurance number :
2 Thefollowing persons aredependants oftheabovementioned worker :
3IMembers ofthefamily
3.1 Surname Forenames Maiden name Date ofbirth Relationship
4 Institution oftheplace ofresidence ofthemembers ofthefamily
4.1 Name :
4.2 Address (2):
4.3 Stamp
4.4 Date :
4.5 Signature
©

E105
INSTRUCTIONS
Please complete thisform inblock letters ,writing onthedotted lines only .
Information for the worker
a)Ifyouareentitled tocash benefits forincapacity forwork inGermany ,Belgium ,France ,Ireland ortheUnited Kingdom ,under whose
legislation theamount ofthese benefits varies with thenumber ofmembers ofthefamily ,youshould present thiscertificate tothein­
stitution with which you areinsured .
b)This certificate isvalid foraperiod oftwelve months asfrom itsdate ofissue (seepoint 4.4);onexpiry ofthisperiod youmay apply for
renewal totheinstitution oftheplace ofresidence ofthemembers ofyour family (seepoints 4.1and4.2).
c)You areobliged toinform immediately theinstitution with which you areinsured ofany changes which have occurred inthe
information shown onthis certificate .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Postal code ,town ,street ,number ,country .

Sea'Instructions onpage 3 EUROPEAN COMMUNITIES
Social Security Regulations
E106 (1
CERTIFICATE OF ENTITLEMENT TO SICKNESS AND MATERNITY INSURANCE BENEFITS IN
KIND FOR PERSONS RESIDING INACOUNTRY OTHER THAN THE COMPETENT COUNTRY
Workers andmembers oftheir family residing with them ;members ofthefamily ofunemployed persons
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 )
Thecompetent institution should complete part Aoftheform andsend two copies totheinsured person ,orsend
them —where necessary through theliaison body —totheinstitution oftheplace ofresidence iftheform isdrawn
upatthatinstitution 'srequest .Assoon asithasreceived thetwo copies ,thelatter institution should complete part B
andreturn onecopy tothecompetent institution .
A.Notification ofentitlement
1|Institution oftheplace ofresidence (2)
1.1 Name :
1.2 Address (3):
1.3 Reference :your form E107 of
2 (4)nWorker fjFrontier worker MUnemployed person
2.1 Surname Forenames Maiden name Date ofbirth
2.2 Address inthecountry ofresidence (3):
2.3 Insurance number :
3 Member ofthefamily (5)
3.1 Surname Forenames Maiden name Date ofbirth
3.2 Address inthecountry ofresidence (3):
4 (4)[_jTheabovementioned worker andthemembers ofhisfamily (6)residing with him
4-1 (4)Q]Themembers ofthefamily (6)oftheunemployed person mentioned above
5 areentitled tosickness and maternity insurance benefits inkind (7)
asfrom
6jThepersons concerned willretain theirentitlement
6-1 (4)d]unt|lthiscertificate iscancelled
6.2 (4)nforaperiod ofthree months from thedate ofissue ofthiscertificate (8)
©

E106
7 Competent institution (7)
7.1 Name :
7.2 Address (3):
7.3 Stamp
7.4 Date :
7.5 Signature
B.Notification ofregistration (9)
|8jCompetent institution
8.1 Name :
8.2 Address (3):
9
9-1 (4)LJTheworker named inbox2andthemembers ofhisfamily
9.2 (4)QThemembers ofthefamily oftheunemployed person named inbox2
(4)EUwere registered with uson
9-4 (4)□cou'dnotberegistered with usbecause :
10 Registered members ofthefamily
10.1 Surname Forenames Maiden name Date ofbirth
10.2
10.3
10.4
10.5
10.6
10.7
10.8
10.9

E106
111 Institution oftheplace ofresidence
11.1 Name :
11.2 Address (3):
11.3Stamp
11.4 Date :
11.5 Signature
INSTRUCTIONS
Please complete thisform inblock letters ,writing onthedotted lines only .Itconsists ofthree pages ,
none ofwhich may beleftout even ifitdoes notcontain any relevant information .
Information forthe insured person
a)This form entitles youtoreceive sickness andmaternity insurance benefits inkind
—foryourself andthemembers ofyour family ,ifyou areemployed ;
—forthemembers ofyour family who reside inaMember State other than theonewhere youareinsured ,ifyou areunemployed .
b)Thetwocopies oftheform which areinyour possession must besubmitted assoon aspossible
—byyourself ,tothesickness andmaternity insurance institution ofyour place ofresidence ,ifyouareemployed ;
—bythemembers ofyour family ,tothesickness andmaternity insurance institution oftheir place ofresidence ,ifyouareunemployed .
c)These sickness andmaternity insurance institutions are:
inBelgium ,the'mutuality (local sickness insurance fund)ofyour choice ;
inDenmark ,thecompetent 'amtskommune (local administration ).Inthecommune ofCopenhagen ,the 'magistrat '(municipal administration );inthecommune of
Frederiksberg ,the'kommunalbestyrelse '(municipal administration ).Assistance from adoctor ,dentist ordispensing chemist may besought without firstcontacting
thesaid institutions .Particulars about doctors anddentists available may beobtained from thelocal 'social -ogsundhedsforvaltning '(social andhealth authority );
inGermany ,the'Allgemeine Ortskrankenkasse '(AOK ,local general sickness fund);
inFrance ,the'Caisse primaire d'assurance-maladie '(local sickness insurance fund);
inIreland ,theHealth Board inwhose area thebenefit issought ;
inItaly ,theprovincial office ofthe'Istituto nazionaie peri'assicurazione contro lemalattie '(INAM ,national sickness insurance institute );
inLuxembourg ,the'Caisse nationale d'assurance-maladie desouvriers '(national sickness insurance fund formanual workers );
intheNetherlands ,anysickness fund competent fortheplace ofresidence ;
intheUnited Kingdom ,theDepartment ofHealth andSocial Security ,Overseas Group ,Newcastle-upon-Tyne ,ortheMinistry ofHealth andSocial Services ,Over­
seas Branch ,Belfast ,asappropriate .
d)Thisform isvalid from thedate indicated atpoint 5andfortheperiod indicated inbox6bythesquare marked with across .
e)You orthemembers ofyour family must inform theinsurance institution towhich theform hasbeen sent ofanychange ofcircumstances which might affect the
right tobenefits inkind ,such astermination orchange ofemployment ,change ofyour place ofresidence orstay orofthatofamember ofyour family .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing partAoftheform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;Irl=Ireland ;1=Italy
L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Complete only iftheform isdrawn upattherequest oftheinstitution oftheplace ofresidence .
(3)Postal code ,town ,street ,number ,country .
(4)Put across inthesquare preceding theappropriate subject .
(5)Complete only iftheform relates tomembers ofthefamily ofanunemployed person ;inthat case give theinformation foronemember ofthefamily only .
(6)Thelegislation ofthecountry ofresidence determines which members ofthefamily areentitled tobenefit .
(7)Forpersons insured inItaly ,benefits fortuberculosis canbeprovided only onproduction ofacertificate issued bythe'Istituto nazionaie della previdenza~ sociale '
(INPS ,national social welfare institute ).
(a)Iftheform isissued byaFrench institution .
(9)Ifthisform isissued inrenewal ofacertificate previously provided ,part Bneed notbecompleted .
©

©See 'Instructions 'onpage 3 EUROPEAN COMMUNITIES
Social Security Regulations
E1071
APPLICATION FOR ACERTIFICATE OF ENTITLEMENT TO BENEFITS IN KIND
Reg .1408 /71:Art .19.1 .a;Art.19.2;Art .22.1 .a.i,b.iand c.i;Art .22.3 ;Art .25.1 .aand 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.iand c.i
Reg .574/72:Art .17.1;Art .20.3 and4;Art .21.1 ;Art .22.1and3;Art .23;Art .27(firstsentence );Art .28;Art .29.2;
Art .30.1 ;Art .31.1 and 3;Art .60.1 ;Art .62.3 ,4and 7;Art .63.1 and 3
Theinstitution oftheplace ofresidence orstay should complete part Aand send two copies oftheform tothecom­
petent institution ,taking into account theprovisions oftheabovementioned articles ofRegulation 574/72.Ifthat
institution considers itisunable tosend therequested form ,itshould complete part Band return one ofthetwo
copies totheinstitution from which itreceived them .IfBelgium isthecompetent country ,theform should besent
tothesickness insurance institution ,except when itconcerns anaccident atwork which hasbeen verified oradisease
recognized asanoccupational disease .
A.Tobecompleted bytheinstitution oftheplace ofresidence orstay
Pi fInstitution towhich theform isaddressed
1.1 Name :
1.2 Address (2):
(3)[jWorker [HPensioner
o
(3)Q]Unemployed person [HPension claimant
2.1 Surname Forenames Maiden name Date ofbirth
2.2 Permanent address (2):
2.3 Insurance number :
2-4 (3)QPerson entitled to QClaimant of
the pension inrespect of
(3)Qoldage Qinvalidity Qsurvival
(3)Qaccident atwork Q]occupational disease
No. (4) category : (4)
2.5 Institution responsible forpayment ofthepension :

E107
3JLastemployer (5)
3.1 Name ofemployer orfirm :
3.2 Address (2):
3.3 Branch ofactivity (6):
3.4 Institution forinsurance against accidents atwork with which theemployer isinsured :
41Members ofthe family (7)
4.1 Surname Forenames Maiden name Date ofbirth
4.2 Address inthecountry ofresidence (2)(8):
5 On wereceived aclaim from theperson shown
(3)Qinbox2 EH 'nbox4
for :
5-1 (3)[E]thegranting ofbenefits inkind
5-2 (3)Otheretention oftheright tobenefits inkind
5.3 (3)Qregistration with usasaperson entitled tobenefits inkind .
6 The benefits inkind (3)Qhave been awarded Qhave notbeen awarded
6.1 inaccordance with Article (3)Q20.3 Q29.2 Q60.1 Q62.3 ofReg .574/72.
6.2 The claimant (3)Qhasnotworked since thedate indicated atpoint 5above
||has held thefollowing occupation after that date :
7 Please send usthecertificate ofentitlement tobenefits onform : E
orinform usifyou areunable toissue it.
8 [~]Medical report attached .(9)
m Institution oftheplace ofresidence orstay
9.1 Name :
9.2 Address (2):
9.3 Stamp
9.4 Date :
9.5 Signature

E107
B.Tobecompleted bythecompetent institution
I101Institution oftheplace ofresidence orstay (10)
10.1 Name :
10.2 Address (2):
11 Weareunable toissue thecertificate asked inpartA,because
1? Competent institution
12.1 Name :
12.2 Address (2):
12.3 Stamp
12.4 Date :
12.5 Signature
INSTRUCTIONS
Please complete thisform inblock letters ,writing onthedotted lines only .Itconsists ofthree pages ,
none ofwhich may beleftout even ifitdoes notcontain any relevant information .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing partAoftheform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;
F=France ;Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Postal code ,town ,street ,number ,country .
(3)Put across inthesquare preceding theappropriate subject .
(4)Complete only iftheinstitution responsible forthepayment ofthepension isanItalian institution .
(5)Complete only iftheform concerns anemployed orunemployed person .
(6)Complete only iftheform concerns aworker assumed tohave sustained anaccident atwork .
(7)Complete only formembers ofthefamily forwhom aclaim forbenefits orarequest forregistration hasbeen made .Forregistration ,
indicate one member ofthefamily only .
(8)Complete only iftheaddress ofthemembers ofthefamily isdifferent from thatofthehead ofhousehold .
(9)Tobeattached only ifnecessary .Inthat case ,putacross inthecorresponding square .
(10)Institution mentioned inbox 9.

See 'Instructions overleaf EUROPEAN COMMUNITIES
Social Security Regulations
E108 (1
NOTIFICATION OF SUSPENSION ORWITHDRAWAL OF THE RIGHT TO SICKNESS AND
MATERNITY INSURANCE BENEFITS INKIND
Persons residing inacountry other than thecompetent country
Reg .1408/71:Art .19.1 .aand 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
Thecompetent institution should complete part Aoftheform andsend two copies totheinstitution oftheplace of
residence (where appropriate through theliaison body ).Theinstitution oftheplace ofresidence should complete
part Bandreturn onecopy tothecompetent institution assoon aspossible .
A.Notification
pi IInstitution towhich theform isaddressed
1.1 Name :
1.2 Address (2):
2(3)I IWorker ||Frontier worker
(3)QUnemployed person Q]Pension claimant[jPensioner
2.1 Surname Forenames Maiden name Date ofbirth
2.2 Address inthecountry ofresidence (2):
2.3 Insurance number :
3 Member ofthefamily (4)
3.1 Surname Forenames Maiden name Date ofbirth
3.2 Address inthecountry ofresidence (2):
4 Entitlement tobenefits certified onour
form of
hasbeen suspended orwithdrawn forthefollowing reason (3)(date )
4.1 (3)||Theabovementioned worker hasnotbeen insured with ussince
4.2 (3)Q]Thepension oftheabovementioned pensioner hasbeen suspended orwithdrawn since
4.3 (3)nA"thepersons registered with you have notresided inyour country since
4-4 (3)LJThe person entitled tobenefits died on
4.5 (■')n <■■)
©

E108
5 Competent institution
5.1 Name :
5.2 Address (2):
5.3 Stamp
5.4 Date :
5.5 Signature
B.Acknowledgement ofreceipt
6ICompetent institution
6.1 Name :
6.2 Address (2):
7 Wereceived theabove notification (part A)on
8 (3)Q]Theperson indicated inpartA [JThepersons indicated inpartA
(3)Qhasnotreceived Qhave notreceived
(3)Qwillnolonger receive Qwillnolonger receive
benefits since /asfrom :
(date).
m Institution oftheplace ofresidence
9.1 Name :
9.2 Address (2):
9.3 Stamp
9.4 Date :
9.5 Signature
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only
NOTES
(1)Symbol ofthecountry towhich theinstitution completing partAoftheform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;
F=France ;Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Postal code ,town ,street ,number ,country .
(3)Putacross inthesquare preceding theappropriate subject .
(4)Complete only ifthewithdrawal orsuspension oftheright tobenefits inkind notified bythisform affects themembers ofthefamily
only ;insuch case ,indicate only oneofthem .
(5)Other reasons ,ifany .
@

See Instructions onpage 3 EUROPEAN COMMUNITIES
Social Security Regulations
E109 (1)
CERTIFICATE FOR THE REGISTRATION OFMEMBERS OFTHE WORKER 'SFAMILY
AND THE KEEPING OF LISTS
Reg .1408171 :Art,19.2
Reg .574/72:Art .17.1 r2,3and4;Art 94.4
Thecompetent institution should complete part Aoftheform and issue two copies totheworker orsend them
—where necessary —through theliaison body totheinstitution oftheplace ofresidence iftheform was drawn
upatthatinstitution 'srequest .Where themembers oftheworker 'sfamily areresident intheUnited Kingdom ,the
competent institution should send thetwocopies totheDepartment ofHealth andSocial Security ,Overseas Group ,
Newcastle-upon-Tyne .Onreceipt ofthetwo copies ,theinstitution oftheplace ofresidence should complete part B
andreturn onecopy tothecompetent institution .Where themembers ofthefamily areresident indifferent countries ,
aseparate certificate should bedrawn upforeach ofthese countries .
A.Notification ofentitlement
pj IInstitution oftheplaceofresidence (2)
1.1 Name :
1.2 Address (3):
1.3 Reference :your form E107 of (date )
m (4)Q]Worker QSeasonal worker
2.1 Surname Forenames Maiden name Date ofbirth
2.2 Address (3):
2.3 Insurance number :
I3IMember ofthefamily (5)
3.1 Surname Forenames Maiden name Date ofbirth
3.2 Address (3):
4
5
ElThe members ofthefamily oftheabovementioned worker areentitled tosickness and maternity insurance
benefits inkind unless :
(4)Qthey arealready entitled tosuch benefits under thelegislation ofthecountry inwhich they reside
(4)Qthey arepursuing aprofessional ortrade activity (6).
This entitlement begins on
and continues
6-1 (4)L]until thiscertificate iscancelled
6.2 (4) forthree months from thedate ofissue ofthiscertificate (7)
6.3 (4)Quntil thedate onwhich theseasonal work ends ,i.e.
until unless notification ofcancellation isgiven before that date
©

E109
7 Competent institution
7.1 Name :
7.2 Address (3):
7.3 Stamp
7.4 Date :
7.5 Signature
B.Notification ofregistration (8)
8 Competent institution
8.1 Name :
8.2 Address (3):
9□(9)
9.1 The members ofthefamily oftheworker named inbox 2have notbeen registered because :
9.2 (4) nomember ofthefamily isentitled tobenefits
9.3 (4)Qallthemembers ofthefamily arealready entitled tobenefits inkindunder thelegislation ofourcountry
9-4 (4) thespouse ortheperson looking after thechildren pursues aprofessional ortrade activity inour
country (10)
9.5 (4)[Htherequired 'declaration offamily status 'hasnotbeen submitted
9-6 (4)□(11)
1°|□(9)
10.1 Thefollowing members ofthefamily oftheworker named inbox 2have been registered :
10.2 Surname Forenames Maiden name Date ofbirth
10.3
10.4
10.5
10.6
10.7
10.8
10.9
10.10 The cost ofthese benefits arepayable byyou ;thedate from which thelump sum referred toinArticle 94
ofReg .574/72should becalculated is:
©

E109
11 Institution oftheplace ofresidence
11.1 Name :
11.2 Address (3):
11.3Stamp
11.4 Date :
11.5 Signature
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .Itconsists ofthree
pages ,none ofwhich may beleftout even ifdoes notcontain anyrelevant information .
Information for the worker
a)Thisform enables themembers ofyour family toreceive benefits inkind incase ofsickness ormaternity inthecountry where they are
resident and under thelegislation ofthat country ,unless they arealready entitled tosuch benefits under that legislation .
b)Assoon asyou have received thetwo copies ofthisform ,youshould send them tothemembers ofyour family ,who should submit
them immediately tothesickness and maternity insurance institution oftheir place ofresidence ,i.e.
inBelgium ,the'mutualite '(local sickness insurance fund)oftheir choice ;
inDenmark ,thecompetent 'amtskommune '(local administration ).Inthecommune ofCopenhagen ,the'Magistral (municipal
administration );inthecommune ofFrederiksberg ,the'kommunalbestyrelse '(municipal administration );
inGermany ,the'Allgemeine Ortskrankenkasse '(AOK ,local general sickness fund);
inFrance ,the'Caisse primaire d'assurance-maladie '(local sickness insurance fund);
inIreland ,theHealth Board inwhose area thebenefit issought ;
inItaly ,theprovincial office ofthe'Istituto nazionale perI'assicurazione contro lemalattie '(INAM ,national sickness insurance
institute );
inLuxembourg ,the'Caisse nationale d'assurance-maladie des ouvriers '(national sickness insurance fund formanual workers );
intheNetherlands ,anysickness fund competent fortheplace ofresidence .
c)This form isvalid from thedate mentioned atpoint 5andfortheperiod indicated inbox6atthesquare marked with across .
d)You orthemembers ofyour family must inform theinstitution oftheplace ofresidence ofany change ofcircumstances which might
affect theright tobenefits inkind ,such astermination orchange ofemployment ,change ofyour place ofresidence orstay orofthat
ofamember ofyour family .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing part Aoftheform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;
F=France ;Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Complete only iftheform isdrawn upattherequest oftheinstitution oftheplace ofresidence .
(3)Postal code ,town ,street ,number ,country .
(4)Put across inthesquare preceding theappropriate subject .
(5)Complete forone member ofthefamily only .
(6)Put across inthepreceding square iftheform isaddressed toaDanish ,Irish orUnited Kingdom institution .
(7)Iftheform isdrawn upbyaFrench institution .
(8)Ifthiscertificate isissued inrenewal ofapreviously issued certificate which hasexpired ,theinstitution oftheplace ofresidence need
not complete part B.
(9)Complete box 9orbox 10asapplicable andput across inthecorresponding square .
(10)Put,ifapplicable ,across inthepreceding square ifpart Biscompleted byaDanish ,Irish orUnited Kingdom institution .
(11)Other reasons .
<D

3 Institution competent
3.1 forinsurance against accidents atwork (name andaddress )(2):
3.2 forinsurance against occupational diseases (name and address )(2)(3):
4 The undersigned certifies that theabovementioned worker hasbeen inhisemploy sinceEUROPEAN COMMUNITIES
Social Security RegulationsSee'Instructions 'onpage 3
E110 |I I(i)
CERTIFICATE CONCERNING WORKERS ININTERNATIONAL TRANSPORT
Reg .1408/71:Art .14.1.b;Art .22.1 .a.i;Art .22.3;Art.55.1 .a.i
Reg .574172 :Art .20.2 ;Art .62.2
Theform should becompleted and,ifnecessary ,signed forextension bytheemployer ,who should then give itto
theworker .
A.First certified statement
Worker 1
1.1 Surname Forenames Maiden name
1.2 Date ofbirth : Nationality :
1.3 Permanent address (2):
2 Members ofthefamily who accompany thehead ofhousehold
2.1 Surname Forenames Maiden name Date ofbirth

E110
5jEmployer
5.1 Name ofemployer orfirm :
5.2 Nature ofbusiness :
5.3 Address (2):
5.4 Stamp
5.5 Date :
5.6 Signature ofemployer orhis
representative
6 Institution competent forsickness and maternity insurance (4)(5)
6.1 Name :
6.2 Address (2):
6.3 Worker 'sinsurance number :
6.4 Date :
6.5 Worker 'ssignature 6.6 Signature ofemployer orhis
representative
B.Extensions (6)
7 The employer named inbox 5certifies that theabovementioned worker isstill inhisemploy onthedate
shown below :
8 Date 8.1 Signature ofemployer orhis
representative
(2)

E110
INSTRUCTIONS
Please complete thisform inblock letters ,writing onthedotted lines only .Itconsists ofthree pages ,
none ofwhich may beleftout even ifitdoes notcontain any relevant information .
Information for the worker
a)This document isvalid forthemonth during which itwasissued andthetwo calendar months following (seepoints 5.5and8).
b)During thisterm ofvalidity itenables youandthemembers ofyour family listed inbox2toreceive benefits inkind intheterritory of
theMember State where you arestaying whilst carrying outyour work .
c)When youneed benefits inkind ,youshould submit thisform assoon aspossible totheinsurance institution ofthecountry inwhich you
arestaying ,i.e.
—forbenefits incase ofsickness ormaternity :
inBelgium ,the'mutualité '(local sickness insurance fund)ofyour choice ;
inDenmark ,thecompetent 'amtskommune '(local administration ).Inthecommune ofCopenhagen ,the'magistrat (municipal
administration );inthecommune ofFrederiksberg ,the'kommunalbestyrelse '(municipal administration ).Assistance from adoctor ,
ordispensing chemist may besought without firstcontacting thesaid institutions .Particulars about doctors and dentists available
may beobtained from thelocal 'social -ogsundhedsforvaltning '(social andhealth authority );
inGermany ,the'Allgemeine Ortskrankenkasse '(AOK ,local general sickness fund);
inFrance ,the'Caisse primaire d'assurance-maladie '(local sickness insurance fund);
inIreland ,theHealth Board inwhose area thebenefit issought ;
inItaly ,theprovincial office ofthe'Istituto nazionale perl'assicurazione contro lemalattie '(INAM ,national sickness insurance
institute );
inLuxembourg ,the'Caisse nationale d'assurance-maladie desouvriers '(national sickness insurance fund formanual workers );
intheNetherlands ,the'Algemeen Nederlands Onderling Ziekenfonds '(ANOZ ,general sickness fund oftheNetherlands ),Utrecht .
Assistance from adoctor ,dentist ordispensing chemist may besought without firstcontacting ANOZ ;
intheUnited Kingdom ,themedical service (doctor ,dentist ,hospital ,etc.)from which treatment isrequested .
—forbenefits incase ofaccident atwork oroccupational disease :
inBelgium ,the'mutualité '(local sickness insurance fund)ofyour choice ;
inDenmark ,the'Sikringsstyrelse '(national office forsocial security ),Copenhagen ;
inGermany ,the'Allgemeine Ortskrankenkasse '(AOK ,local general sickness fund);
inFrance ,the'Caisse primaire d'assurance-maladie '(local sickness insurance fund);
inIreland ,theHealth Board inwhose area thebenefit issought ;
inItaly ,theprovincial office ofthe'Istituto nazionale perl'assicurazione contro gliinfortuni sullavoro '(INAIL,national institute for
insurance against accidents atwork);
inLuxembourg ,the'Association d'assurance contre lesaccidents '(accident insurance association );
intheNetherlands ,the'Algemeen Nederlands Onderling Ziekenfonds '(ANOZ ,general sickness fund oftheNetherlands ),Utrecht .
Assistance from adoctor ,dentist ordispensing chemist may besought without first contacting ANOZ ;
intheUnited Kingdom ,themedical service (doctor ,dentist ,hospital ,etc.)from which treatment isrequested .
d)Ifyour employer hasnotdone so,please complete box6oftheform .
e)Inorder toreceive benefits inkind ,youmay present form E111instead ofthisform .
NOTES
(1)Symbol ofthecountry where theundertaking has itsregistered office :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Postal code ,town ,street ,number ,country .
(3)Complete only ifdifferent from theinstitution mentioned atpoint 3.1 .
(4)Iftheemployer ,under thelegislation ofthecompetent country ,isnotobliged toknow which institution iscompetent forsickness and
maternity insurance ,this box should becompleted bytheworker .
(5)FortheNetherlands indicate thesickness fund ('ziekenfonds ').
(6)This part may only becompleted ifnochange hastaken place intheinformation given inpart A.
®

See Instructions "overleaf EUROPEAN COMMUNITIES
Social Security Regulations
E111 (1)
CERTIFICATE OF ENTITLEMENT TO BENEFITS INKIND DURING
ASTAY IN AMEMBER STATE
Reg .1408 /71:Art .22,1 .a.i;Art .22.3 ;Art .31.a
Reg .574172 :Art .20.5 ;Art .21.1 ;Art .23;Art .31.1 and 3
1 Institution oftheplace ofstay (2)
11 Name :
1.2 Address (3):
1.3 Reference :your form E107 of (date )
2|(4)ΠWorker Q]Pensioner
2.1 Surname Forenames Maiden name Date ofbirth
2.2 Permanent address (3):
2.3 Insurance number :
3 Members ofthefamily (5)
3.1 Surname Forenames ' Maiden name Date ofbirth
3.2 Permanent address (3)(6):
4 The abovenamed persons areentitled tobenefits inkind under sickness and maternity insurance .
These benefits may beprovided :
4.1 (7)Q]from to
4.2 (7)F]forallcases ofillness occurring upto inclusive
and for days v.weeks .
Competent institution 5
5.1 Name :
5.2 Address (3):
5.3 Stamp
5.4
5.5Date
Signature

E111
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .
Thecompetent institution or,where appropriate ,theinstitution oftheplace ofresidence ofthepensioner should
complete thisform andsend ittotheperson concerned ,orsend ittotheinstitution oftheplace ofstayiftheform
hasbeen drawn upatthelatter 'srequest .This form isnotrequired iftheperson concerned isstaying intheUnited
Kingdom .
Information fortheinsured person andthemembers ofhisfamily
a)This document enables
—theworker and themembers ofhisfamily named inbox 3,who arestaying temporarily inaMember State other than thecom­
petent State .
—thepensioner and themembers ofhisfamily named inbox 3,who arestaying temporarily inaMember State other than that in
which they habitually reside .
toobtain benefits inkind from insurance bodies inthecountry ofstay ,inthecase ofsickness ormaternity and,provisionally ,inthe
case ofanaccident atwork oroccupational disease .
b)When oneofthepersons concerned hastoseek benefits ,including hospitalization ,heshould submit thisform totheinsurance body
inthecountry inwhich heisstaying ,i.e.
inBelgium ,the'mutualité '(local sickness insurance fund)ofhischoice ;
inDenmark ,thecompetent 'amtskommune '(local administration ).Inthecommune ofCopenhagen ,the'magistrat (municipal
administration );inthecommune ofFrederiksberg ,the'kommunalbestyrelse '(municipal administration ).Assistance from adoctor ,
dentist ordispensing chemist may besought without first contacting thesaid institutions .Particulars about doctors and dentists
available may beobtained from thelocal 'social -ogsundhedsforvaltning '(social and health authority );
inGermany ,the'Allgemeine Ortskrankenkasse '(AOK ,local general sickness fund);
inFrance ,the'Caisse primaire d'assurance-maladie '(local sickness insurance fund);
inIreland ,theHealth Board inwhose area thebenefit issought ;
inItaly ,theprovincial office ofthe'Istituto nazionale perl'assicurazione contro lemalattie '(INAM,national sickness insurance insti­
tute);
inLuxembourg ,the 'Caisse nationale d'assurance-maladie desouvriers '(national sickness-insurance fund formanual workers );
intheNetherlands ,the'Algemeen Nederlands Onderling Ziekenfonds '(ANOZ ,general sickness fund oftheNetherlands ),Utrecht .
Assistance from adoctor ,dentist ordispensing chemist may besought without first contacting ANOZ .
(c)Forpersons insured inItaly ,benefits fortuberculosis canbeprovided only onproduction ofacertificate issued bythe'Istituto nazionale
del/aprevidenza sociale '(INPS ,national social welfare institute ).
NOTES
(1)Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ,I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Complete only iftheform isdrawn upattherequest oftheinstitution oftheplace ofstay .
(3)Postal code ,town ,street ,number ,country .
(4)Put across intheboxpreceding theappropriate subject .
(5)Include only those members ofthefamily who aretemporarily going toanother Member State .
(6)Complete only iftheaddress ofthemembers ofthefamily differs from thatoftheworker orpensioner .
(7)These two items arealternative .Give only thatwhich isapplicable andput across inthecorresponding box .
CD

EUROPEAN COMMUNITIES
Social Security RegulationsSee Instructions overleaf
E112 (1)
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
Reg .574172 :Art .22.1 and 3;Art .23
Thecompetent institution should issue thisform totheworker .Iftheworker isgoing totheUnited Kingdom ,one
copy oftheform should also besent totheDepartment ofHealth andSocial Security ,Overseas Group ,Newcastle­
upon-Tyne
1 Worker
1.1 Surname Forenames Maiden name Date ofbirth
1.2 Address inthecompetent country (2):
1.3 Address inthecountry towhich theworker isgoing (2)(3):
1.4 Insurance number :
2 Member ofthefamily going toanother Member State
2.1 Surname Forenames Maiden name Date ofbirth
2.2 Address inthecompetent country (2)(4):
2.3 Address inthecountry towhich theperson concerned isgoing (2):
3 Theperson shown (5)[jinbox 1[jinbox2
isauthorized toretain theright toreceive sickness andmaternity insurance benefits inkind
in (country ),where he/sheisgoing
3.1 (5)Q]totake uphis/herresidence there
3.2 (5)P]toreceive treatment there at/from :
(6)
4 These benefits may beprovided onproduction ofthiscertificate ,
4.1 until
©

E112
5 The report ofourexamining doctor
5-1 (5)[Jisattached tothisform inasealed envelope
5.2 (5)Q]wassent on to(7)
5.3 (5)Qwillbesent byusonrequest
5-4 (5)[~]hasnotbeen drawn up.
6 Competent institution
6.1 Name :
6.2 Address (2):
6.3 Stamp
6.4 Date :
6.5 Signature
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .
Information forthe insured person
Youshould submit thisform assoon aspossible tothesickness andmaternity insurance institution oftheplace where youaregoing ,i.e.
inBelgium ,themutualité '(local sickness insurance fund)ofyour choice ;
inDenmark ,thecompetent 'amtskommune '(local administration ).Inthecommune ofCopenhagen ,the'magistrat (municipal ad­
ministration );inthecommune ofFrederiksberg ,the'kommunalbestyrelse '(municipal administration ).Assistance from adoctor ,dentist
ordispensing chemist may may besought without firstcontacting thesaid institutions .Particulars about doctors and dentists available
may beobtained from thelocal 'social -ogsundhedsforvaltning '(social and health authority );
inGermany ,the'Allgemeine Ortskrankenkasse '(AOK ,local general sickness fund);
inFrance ,the'Caisse primaire d'assurance-maladie '(local sickness insurance fund);
inIreland ,theHealth Board inwhose area thebenefit issought ;
inItaly ,theprovincial office ofthe'Istituto nazionale perl'assicurazione contro lemalattie '(INAM,national sickness insurance institute );
inLuxembourg ,the'Caisse nationale d'assurance-maladie desouvriers '(national sickness insurance fund formanual workers );
intheNetherlands ,anysickness fund competent fortheplace ofresidence or,incase oftemporary stay ,the'Algemeen Nederlands
Onderling Ziekenfonds '(ANOZ ,general sickness fund oftheNetherlands ),Utrecht .Assistance from adoctor ,dentist ordispensing chemist
may besought without first contacting ANOZ ;
intheUnited Kingdom ,themedical service (doctor ,dentist ,hospital ,etc.)from which treatment isrequested .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Postal code ,town ,street ,number ,country .
(3)Indicate only iftheform concerns theworker himself .
(4)Indicate only iftheaddress ofthemember ofthefamily isdifferent from thatoftheworker .
(5)Put across inthesquare preceding theappropriate subject .
(6)Specify who will beproviding treatment ,ifknown .
(7)Name andaddress oftheinstitution towhich themedical report hasbeen sent .

See 'Instructions 'overle af EUROPEAN COMMUNITIES
Social Security Regulations
E113C1)
HOSPITALIZATION :NOTIFICATION OF ENTERING AND LEAVING HOSPITAL
Reg .1408 /71:Art .19;Art .22;Art .25.1 and 3.i;Art .31.a;Art .52.a ;Art .55.1
Reg .574/72:Art .17.6 ;Art .20.6 ;Art .21.2 ;Art .22.2 and 3;Art .23;Art .26.3 ;
Art .27;Art .31.2 and 3;Art .60.5 ;Art .62.8 ;Art .63.2
This form should bedrawn upintheevent ofrefund ofbenefits inkind onthebasis ofactual expenditure .Tobe
completed bytheinstitution oftheplace ofresidence orstay :part Atonotify entry into hospital ,part Btonotify
leaving hospital .Tobesent tothecompetent institution .Ifthecompetent institution isaninstitution oftheUnited
Kingdom ,this form isnotrequired .
1 Competent institution
1.1 Name :
1.2 Address (2):
(3)QjWorker j_|Pensioner
(3)[HUnemployed person QPension claimant2
2.1 Surname Forenames Maiden name Date ofbirth
2.2 Address inthecountry ofresidence orstay (2):
2.3 Insurance number :
3 Member ofthefamily who isinhospital
3.1 Surname Forenames Maiden name Date ofbirth
3.2 Address inthecountry ofresidence orstay (2)(4):
4 Reference :
4-1 (3)Qyour form
4.2 (3)□ourform E107 ofof (5)
(date ).
©

E113
A.Notification ofentry into hospital
5 Theperson shown (3)Qinbox2 Q]inbox3
5.1 entered hospital on (date),
5.2 namely (6) ,
5.3 because of (3)Q]sickness Qmaternity anaccident atwork (7)
(3)Qanoccupational disease (8).
5.4 He/shewill probably stay inhospital until :
5.5 Q(9)Supporting documents ormedical report attached .
B.Notification ofleaving hospital
6. The hospitalization notified
(3)Qbyourform E113dated
(3)QatpartAabove
ended on
I
7 Institution oftheplace ofresidence orstay
7.1 Name :
7.2 Address (2):
7.3 Stamp
7.4 Date :
7.5 Signature
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Postal code ,town ,street ,number ,country .
(3)Put across inthesquare preceding theappropriate subject .
(4)Tobeindicated iftheaddress ofthemember ofthefamily isdifferent from that mentioned inbox2.
(5)Number anddate ofissue oftheform certifying theinsured person 'sentitlement tobenefits .
(6)Name ofhospital .
(7)Ifthepatient isinsured inBelgium ,indicate intheboxbelow thename andaddress oftheemployer :
Name ofemployer orfirm :
Address (2):
(8)Indicate ifpossible .
(9)Put across inthis square ,ifapplicable .
©

See'Instructions 'onpage 3 EUROPEAN COMMUNITIES
Social Security Regulations
E114 (1)
GRANT OF PROSTHESES ,MAJOR APPLIANCES ,ETC .
Reg .1408/71:Art.19;Art .22;Art .24;Art .25.1 and3.i;Art .31.a;Art .52.a ;Art .55.1
Reg .574172 :Art.17.7;Art20.6;Art.21.2;Art .22.2 and3;Art.23;Art.26.3;
Art .27;Art .31.2 and 3;Art .60.6 ;Art .62.8 ;Art .63.2 and 3
This form should bedrawn upintheevent ofrefund ofbenefits inkind onthebasis ofactual expenditure .Theinsti­
tution oftheplace ofresidence orstay should complete part A,and send tothecompetent institution one ortwo
copies oftheform depending onwhether thisnotification concerns thecase provided foratpoint 7.1oratpoint
7.2.Ifthecompetent institution decides itmust oppose thegranting ofbenefits ,itshould complete part Bandreturn
acopy oftheform totheinstitution oftheplace ofresidence orstay .Ifthecompetent institution isaninstitution of
theUnited Kingdom ,thisform isnotrequired .
A.Notification
1|Competent institution
1.1 Name :
1.2 Address (2):
2J(3)(4)OWorker QUnemployed person QPensioner
2.1 Surname Forenames Maiden name Date ofbirth
2.2 Address inthecountry ofresidence orstay (2):
2.3 Insurance number :
m Member ofthefamily concerned
3.1 Surname Forenames Maiden name Date ofbirth
3.2 Address inthecountry ofresidence orstay (2)(5):
4 Reference :
4-1 (3)Qyour form
4.2 (3)□ourform E107ofof (6)
(date).
©

E114
5 Our medical service has recognized ,fortheperson shown
(3)EHinbox2 EH 'n^ox^
5.1 (3)EHthenecessity EHtheextreme urgency
5.2 ofthefollowing benefits :
6 [JPlease findattached thereport ofourexamining doctor (7).
7 The benefits mentioned atpoint 5.2
7.1 (3)EHhave already been provided inview oftheurgent nature ofthecase ,on
7.2 (3)EHwiHbeprovided unless wereceive anyreasons forobjection onyour partwithin fifteen days ofthe
date ofdespatch ofthis notification .
8 Institution oftheplace ofresidence orstay
8.1 Name :
8.2 Address (2):
8.3 Stamp
8.4 Date :
8.5 Signature
B.Reasons forobjection onthe part ofthe competent institution ,ifany
9 Institution oftheplace ofresidence orstay
9.1 Name :
9.2 Address (2):
10 With reference topoint 7.2above ,wehereby inform you that thebenefits indicated atpoint 5.2cannot be
granted .
Reason :
©

E114
11 Competent institution
11.1 Name :
11.2 Address (2):
11.3Stamp
11.4 Date :
11.5 Signature
INSTRUCTIONS
Please complete thisform inblock letters ,writing onthedotted lines only .Itconsists ofthree pages ,
none ofwhich may beleftout even ifitdoes notcontain any relevant information .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing partAoftheform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;
F=France ;Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Postal code ,town ,street ,number ,country .
(3)Put across inthesquare preceding theappropriate subject .
(4)Ifthepatient isinsured inBelgium ,give name andaddress ofemployer intheboxbelow :
Name ofemployer orfirm :
Address (2):
(5)Indicate only iftheaddress ofthemember ofthefamily isdifferent from that mentioned inbox2.
(6)Number and date ofissue oftheform certifying that theperson concerned isentitled tobenefits .
(7)Ifthemedical report isattached totheform ,putacross inthesquare provided .

EUROPEAN COMMUNITIES
Social Security RegulationsSee'Instructions 'onpage 3
E115 (1)
CLAIM 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
Iftheform isdrawn upforaworker inactive employment ,one copy only should becompleted andsent tothecom­
petent institution forsickness and maternity insurance orforinsurance against accidents atwork and occupational
diseases .However ,ifitconcerns anunemployed person ,two additional copies should bedrawn up,one ofwhich
should besent tothecompetent institution forunemployment insurance ,theother tothecorresponding institution
ofthecountry towhich theunemployed person hasgone toseek employment (seealso note 8).
1 Competent institution
1.1 Name :
1.2 Address (2):
2 (3)LJWorker FLUnemployed person
2.1 Surname Forenames Maiden name Date ofbirth
2.2 Address inthecompetent country (2):
2.3 Address inthecountry ofresidence orstay (2):
2.4 Insurance number :
2.5 holds form E119 issued on (4)
and form E303 issued on (4)
3JEmployer (5)
3.1 Name ofemployer orfirm :
3.2 Address (2):
3.3 Nature ofbusiness :
AmI I(6)Claim forbenefits
4 The person shown inbox 2applied on (date )
4.1forcash benefits forincapacity forwork due to
(3)Q]sickness (7) Qmaternity
(3)Qaccident atwork sustained on
(3)Q]occupational disease(date )
CD

E115
5 The certificate ofthedoctor treating him/her
(3)□isattached \~\could notbesupplied .
6 Intheopinion ofourexamining doctor , (3)Qwhose report isattached
(3) I Iwhose report will besent toyou
assoon aspossible ,
6.1 (3)Qtheincapacity forwork began on
and will probably continue until
6.2 (3)Qthere isnoincapacity forwork (8).
7 (3)MThe person concerned hasnotcomplied with theconditions ofourlegislation ,Explain below :
8 (3)[jTheincapacity forwork waspresumably caused byanaccident forwhich athird party was
responsible .
8.1 (3)QAreport onthisaccident with theaddress ofthethird party involved isattached tothisform .
9 (3)CHWearewilling toprovide cash benefits totheperson concerned onyour behalf .Willyouplease let
usknow ifyou agree tothis procedure and ,ifso,give usallinformation necessary forthepayment
ofthe benefits .
10 (3)nWearenotw'H'n9t0provide cash benefits totheperson concerned onyour behalf .
B M (6)Extension oftheincapacity forwork
11 with reference to
11.1 (3)Qourform E115of (date )
11.2(3)Qyour form E117 of (date )
11.3 wewish toinform you that ,intheopinion ofourexamining doctor
(3)Q]whose report isattached
(3)Qwhose report willbesent toyouassoon aspossible ,
theperson shown inbox 2willprobably remain incapable ofwork until
inclusive .
12 Institution oftheplace ofresidence orstay
12.1 Name :
12.2 Address (2):
12.3 Stamp
12.4 Date :
12.5 Signature
(D

E115
INSTRUCTIONS
Please complete thisform inblock letters ,writing onthedotted lines only .Itconsists ofthree pages ,
none ofwhich may beleftout even ifitdoes notcontain any relevant information .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Postal code ,town ,street ,number ,country .
(3)Put across inthesquare preceding theappropriate subject .
(4)Complete only iftheform concerns anunemployed person .
(5)Forunemployed persons ,indicate thelastemployer .
(6)Complete either partAorpart Band putacross inthesquare corresponding tothepartcompleted .
(7)Oraccident other than accident atwork .
(8)Please attach acopy ofform E118 sent totheperson concerned .

See'Instructions 'onpage 3 EUROPEAN COMMUNITIES
Social Security Regulations
E116 n
MEDICAL 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,l.b.ii and l.c.ii ;Art .25.1 .b;Art .52.b ;Art .55.1 .a.ii,1.b.iiand 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
Tobecompleted bythedoctor oftheinstitution which draws upform E115;tobeattached tothat form andsent
under sealed cover incase ofsickness ormaternity .ForBelgium ,thisform should always besent first totheBelgian
institution competent forsickness insurance .
1 Competent institution towhich theform isaddressed
1.1 Name :
1.2 Address (2):
1.3 Reference :our form E116 of (date )
2 Attached toform (date ) (3)□ E115of
I IUnemployed person (3)rjWorker 3
3.1 Surname Forenames Maiden Name Date ofbirth
3.2 Address inthecountry ofresidence orstay (2):
3.3 Insurance number :
4 [](4)Part A.First medical report
5 Itheundersigned , doctor ofmedicine ,after having examined theperson
mentioned above
on
5.1 consider that itis
(3)Q]acase ofsickness (5)Qacase ofmaternity
5.2 that itisprobably
(3)Qanaccident atwork anoccupational disease
5.3 and certify asfollows :
©

E116
6 Tobecompleted inthecase ofsickness (5),maternity ,oroccupational disease
6.1 Medical history and present symptoms (6):
6.2 Clinical examination :
6.3 General condition : Weight : Height : (6)
6.4 Other observations :
6.5 Special examinations (7):
6.6 Diagnosis :
6.7 Conclusions :
6.8 (3)QTheperson concerned hasnotbeen found unfit forwork
6.9 (3)QTheperson concerned hasbeen found tobeunfit forwork
from to
6.10 (3)Q]Theperson concerned willbegiven afurther medical examination
on
7 Tobecompleted inthecase ofaverified orpresumed accident atwork
7.1 This accident has resulted inthefollowing injuries (8):
7.2 These injuries (3)fjhave had Qwillhave thefollowing effects (9):
7.3 \_j (10)The person concerned needs medical treatment .
7.4 Hisincapacity forwork began on
7.5 The injured person isbeing treated
(3)Qathishome Qatthedoctor 'shome
(3)[Jinhospital Qelsewhere .
Address (2)(11):

E116
8 [_J (4)Part B.Final medical report (12)
9 The treatment ended on
10 The injuries
10.1 (3)Qwere consolidated on
without after-effects .
10.2 (3)Q]were consolidated on
and will probably have thefollowing consequences :
11 Detailed description oftheinjured person 'scondition after recovery orattheend ofthemedical treatment :
12 Part C
12.1 (10)QTheperson concerned needs further treatment .
12.2 (10) Theperson concerned isfitforwork from
131Institution oftheplace ofresidence orstay
13.1 Name :
13.2 Address (2):
13.3 Stamp
13.4 Date :
13.5 Doctor's signature
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .Itconsists ofthree pages ,
none ofwhich may beleft out even ifitdoes not contain any relevant information .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Postal code ,town ,street ,number ,country .
(3)Put across inthesquare preceding theappropriate subject .
(4)Complete either part Aorpart B,asapplicable ,and put across inthecorresponding square .
(5)Including accidents other than accidents atwork .
(6)Information tobegiven only where necessary .
(7)Indicate the type ofexamination and the date .
(8)Indicate thetype and nature oftheinjuries andthepart ofthebody injured :fracture ofarm ,bruising ofhead ,fingers ,internal injuries ,
asphyxia ,etc .
(9)Indicate thecertain orprobable consequences oftheinjuries verified :death ,permanent ortemporary incapacity ,total orpartial ,in
case oftemporary incapacity indicate theprobable duration .
(10)Put across inthis square ,ifapplicable .
(11)Iftheinjured person receives treatment inhospital ,please give name ofhospital .
(12)Tobecompleted inthecase ofaccident atwork .

See Instructions overleaf EUROPEAN COMMUNITIES
Social Security Regulations
E117 C)
GRANTING OF CASH BENEFITS INTHE CASE OF 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 .574172 :Art .18.6 and 8;Art .24;Art .26.7 ;Art .61.6 and 8;Art .64
Thecompetent institution should complete this form andsend ittotheinstitution oftheplace ofresidence orstay .
Thecompetent institution should also inform theworker ifcash benefits arepaid bytheinstitution oftheplace of
residence (Reg .574/72,Art .61.8).
1jInstitution oftheplace ofresidence orstay
1.1 Name
1.2 Address (2):
2 Reference :your form E115 of (date ).
3 (3)r~]Theworker [_]Theunemployed person named below
3.1 Surname Forenames Maiden name Date ofbirth
3.2 Address inthecountry ofresidence orstay (2):
3.3 Insurance number :
4
with possibility ofextension
4.1(3)[_Jisprovisionally entitled toreceive cash benefits
from to
(3)Qisnotentitled tocash benefits .
Reason :see E118 attached .
(3)Qisnolonger entitled tocash benefits from
Reason :see E118 attached .4.2 (date ).
5 These benefits will beprovided (4)
5-1 (3)Qbyusbyinternational money order totheaddress given atpoint 3.2
5.2 (3)Qbyusonthereturn oftheperson concerned toourcountry
5.3 (3)Qbyyouonourbehalf
5-4 (3)Qbytheemployer totheaddress given atpoint 3.2 (5)
5.5 (3)[~]bytheemployer ,from to (6
©

E117
6 (4)(7)
6.1 The allowance should bepaid :
6.2 forevery dayoftheweek ,except (3) Monday QTuesday jIWednesday
(3)j (Thursday I IFriday [[]Saturday j ISunday .
6.3 The daily netamount ofthisallowance is
(8)iftheinsured person isnotinhospital
(8)iftheinsured person isinhospital .
7 Please inform usassoon aspossible oftheresult of
7.1 (3)Qa examination (9).
7.2 (3)Qadministrative checks
7.3 (3)Qafurther medical examination ,tobecarried outabout (date):.
8ICompetent institution
8.1 Name :
8.2 Address (2):
8.3 Stamp
8.4 Date :
8.5 Signature
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Postal code ,town ,street ,number ,country .
(3)Put across inthesquare preceding theappropriate subject .
(4)Need notbecompleted forunemployed persons forwhom aform E119 hasbeen issued .
(5)Tobecompleted ,where appropriate ,byDanish institutions .
(6)Tobecompleted byGerman institutions .
(7)Complete only inthecase indicated atpoint 5.3 .
(8)Indicate theamount inthecurrency ofthecompetent country .
(9)Indicate thetype ofmedical examination requested (radiography ,analysis of ,etc.).
©

EUROPEAN COMMUNITIES
Social Security RegulationsSee 'Instructions 'overleaf
E118 n
NOTIFICATION OF NON-RECOGNITION OR OF END OF INCAPACITY FOR WORK
Reg .1408/71:Art .19.1.b;Art .22.1 .a.ii,b.ii,c.ii;Art .25.1 .b;Art .52.b;Art .55.1 .a.ii,b.ii,c.ii
Reg .574/72:Art .18.4 and 6;Art.24;Art .26.5 and 7;Art .61.4 and 6;Art .64
Ifthisform relates toaworker inactive employment ,theinstitution oftheplace ofresidence orstay(orthecompetent
institution )should draw uptwocopies oftheform ,oneofwhich should besent totheworker himself andtheother
tothesickness andmaternity insurance institution ortotheinstitution forinsurance against accidents atwork and
occupational diseases ofthecompetent country (oftheplace ofresidence orstay).Ifitrelates toanunemployed
person ,itisnecessary todraw up,inaddition tothecopies mentioned (oneofwhich isaddressed totheunemployed
person himself ),two extra copies ,oneofwhich should besent totheinstitution competent forunemployment insu­
rance andtheother totheinstitution ofthecountry towhich theunemployed person hasgone toseek employment .
j(2)Worker QUnemployed person
1.1 Surname Forenames Maiden name Dateofbirth I
1.2 Address inthecountry ofresidence orstay (3):
1.3 Insurance number :
m (2)QCompetent institution j IInstitution oftheplace ofresidence orstay
2.1 Name :
2.2 Address (3):
3 (2)QThefacts which have been brought toournotice
(2)Q]Theexamination carried outbyourdoctor on
show(s )
3.1 (2)Qthatyour incapacity forwork isonly partial
3.2 (2)Qthatyouarenotunfit forwork
3.3 (2)Q]thatyour incapacity forwork ended on (4)
The lastdayforwhich youwill receive cash benefits is
[7](2)QInstitution oftheplace ofresidence orstay I ICompetent institution
4.1 Name :
4.2 Address (3):
4.3 Stamp
4.4 Date :
4.5 Signature
©­

E118
INSTRUCTIONS
Please complete thisform inblock letters ,writing onthedotted lines only .Itconsists offour pages ,
including theAnnex ,none ofwhich may beleftouteven ifitdoes notcontain anyrelevant information .
Information fortheworker orunemployed person
Youmay appeal against thedecision which isnotified toyoubythisdocument totheauthority competent tohear your appeal inthecom­
petent State oryoumay send your appeal totheauthority competent tohear appeals inthecountry where you arestaying orwhere you
areresident .
Thenames ofthese authorities aregiven intheAnnex together with thetime-limits andprocedures forappeals .
Forprocedures andtime-limits forappeal indicated intheAnnex ,youshould follow theinstructions given forthecompetent State .
Inyour case ,theinstructions given under number apply­
NOTES
(1)Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Put across inthesquare preceding theappropriate subject .
(3)Postal code ,town ,street ,number ,country .
(4)Indicate thelastdayofincapacity forwork .
<D

E118 Annex
LEGAL REMEDIES AND PERIODS ALLOWED FOR APPEALS
Reg .574/72:Art .18.4 ;Art .61.4
1.BELGIUM
Ifyoudonotagree with thedecision attached ,you have theright tolodge anappeal inwriting ,dated andsigned ,to
besubmitted orsent byregistered letter totheoffice oftheclerk ofthecompetent labour court within aperiod ofone
month from thedate onwhich you received notification ofthedecision .
Competent labour courts are :
a)ifyou aredomiciled inBelgium ,thelabour court ofthedistrict where youaredomiciled ;
b)ifyou arenotornolonger domiciled inBelgium ,thelabour court ofthedistrict where you were lastdomiciled
orresident inBelgium ;
c)ifyouhave notbeen domiciled orresident inBelgium ,thelabour court ofthedistrict where youwere lastemployed
inBelgium .
2.DENMARK
Ifyouwish tocontest thedecision attached ,you may ,
a)asregards thedaily allowance payable during thefiveweeks following thefirst dayofabsence incases where
theemployer isbound toprovide thedaily allowance (employer 'speriod ),lodge anappeal with the 'dag
pengeudvalg '(daily allowances committee );
b)asregards thedaily allowance payable beyond the'employer 'speriod 'orincases where there isno'employer 's
period ',lodge anappeal with the 'Sikringsstyrelse '(national office forsocial security )within four weeks from
thedate onwhich you received notification ofthedecision .
3.GERMANY
You may ,within aperiod ofone month from thedate onwhich you received notification oftheattached decision ,
submit awritten appeal against thedecision totheGerman competent institution indicated inbox2orbox4ofform
E118ortotheinstitution oftheplace ofresidence orstay indicated inthesame boxes .
4.FRANCE
Ifyou wish tocontest thedecision attached ,you may ,within aperiod oftwo months from thedate onwhich you
received notification ofthedecision ,lodge anappeal with thechief physician ofthelocal sickness insurance fund
indicated inthe box below :
Name :...
Address :
5.IRELAND
Ifyoudonotagree with thedecision attached ,youmay submit arequest totheDepartment ofSocial Welfare ,Dublin ,
stating your wish thatyour case belaidbefore anAppeals Officer .Such arequest should bemade within 21days from
thedate onwhich you received this decision .
6.ITALY
Decisions ofINAM (sickness insurance )
Insured persons wishing tocontest adecision rejecting aclaim ,taken bythecompetent medical authority of INAM
('Primo Medico diSezione ')inmedical matters (existence ofastate ofillness ,incapacity forwork ,objective need
forabenefit ,etc.),may lodge anappeal within 15days from thedate onwhich notification ofthedecision
was received ,with the 'Collegio Medico Provinciale 'through the 'Sezione Territoriale INAM '.
<D

E118 Annex
Where appropriate ,theperson concerned should name inhisletter ofappeal adoctor ofhischoice who ,inthat case ,
willform partofthesaid 'Collegio 'attached tothecompetent provincial office ofINAM .
Inallcases ,thecost offees duetothedoctor designated bytheperson concerned andanytravel expenses incurred
byhimshould beborne bytheinsured person .
Ifthe'Collegio Medico Provinciale 'confirms theofficial medical decision ofthe'Primo Medico diSezione ',theperson
concerned may appeal ,within aperiod ofoneyear from thedate onwhich notification ofthedecision was received ,
tothe'Comitato Esecutivo 'ofINAM ,through the'Sede provinciale '(provincial office )(Art .6ofLaw No138of11
January 1943 ).
Any appeals against arejection ofaclaim forbenefits ongrounds ofnon-compliance with therequirements ofthe
legislation ofthecountry ofresidence should likewise besubmitted tothe'Comitato Esecutivo 'ofINAM .
Decisions ofINPS(tuberculosis )
Anappeal against adecision rejecting aclaim ,taken byINPS asregards benefits fortuberculosis ,may inthefirst
instance belodged ,within aperiod of90days from thedate onwhich notification ofthedecision was received ,
with the 'Comitato Provinciale 'attached totheprovincial office that took thedecision .
If,attheendoftheperiod of90days from thedate onwhich theappeal was submitted ,the'Comitato Provinciale
hasstillnotissued aruling ,theappeal must beregarded asrejected ;inthat case ,theperson concerned may ,within
90days from theendofthatperiod ,lodge anappeal inthesecond instance with the'Comitato speciale perI'assicura­
zione contro latubercolosi '.
If,within 90days from thedate onwhich itwassubmitted ,nodecision hasbeen taken onthesecond appeal ,theperson
concerned may ,within aperiod offiveyears ,take thematter tocourt .
Decisions ofINAIL (accidents atwork andoccupational diseases )
Aninsured person wishing tocontest adecision ofINAIL may ,within 60days from thereceipt ofthenotification
senttohim ,inform INAlL,byregistered letter with advice ofdelivery ornotice ofreceipt ,ofthereasons why heconsiders
thatthedecision isunjustified ;inthecase ofpermanent incapacity forwork ,heshould indicate theamount ofthe
allowance towhich hefeels entitled ;inallcases ,amedical certificate insupport ofhisclaim should besent with the
letter ofappeal .
Iftheperson concerned hasnotreceived areply within aperiod of60days from thedate oftheadvice ofdelivery
orthenotice ofreceipt referred toabove ,orifheisnotsatisfied with thereply ,hemay take INAIL tocourt over the
matter (Art .104ofthe 'Testo unico 'approved bypresidential decree DPR No1124 of30June 1965 ).
Theletter setting outthereasons why theinsured person does notagree with adecision ofINAIL may besenttoINAIL
either directly orthrough theinstitution oftheplace ofresidence orstay .
7.LUXEMBOURG
Ifyoudonotagree with thedecision attached ,you have theright tolodge anappeal inprinciple with the'Conseil
arbitral desassurances sociales 'inLuxembourg ,within aperiod of40days from thedate onwhich you received
notification ofthe decision .
Together with your appeal ,you should send adetailed statement from the 'Inspection desinstitutions sociales 'in
Luxembourg ,testifying thatyouhave already applied tothatinspectorate foranadministrative settlement ofthedispute .
8.NETHERLANDS
Ifyoudonotagree with thedecision attached ,youhave theright tolodge anappeal with thecompetent Netherlands
institution within areasonable period oftime .
9.UNITED KINGDOM
Ifyou donotagree with thedecision attached ,you may ,within 21days from thedate ofreceipt ofthedecision ,
lodge anappeal with theDepartment ofHealth and Social Security ,Overseas Group ,Newcastle-upon-Tyne ,or
theMinistry ofHealth and Social Services ,Overseas Branch ,Belfast ,asappropriate .
©

See'Instructions 'onpage 3 EUROPEAN COMMUNITIES
Social Security Regulations
E119 1
CERTIFICATE 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
Thecompetent institution should issue theform totheunemployed person ,orsend ittotheinstitution oftheplace
ofresidence orstay ifitwas drawn upatthelatter institution 'srequest .
pi IInstitution oftheplace ofresidence orstay (2)
1.1 Name :
1.2 Address (3):
1.3 Reference :your form (4)M E107of \_\ E115 of
2JUnemployed person
2.1 Surname Forenames Maiden name Date ofbirth
2.2 Address inthecountry where theperson concerned isseeking employment (3):
2.3 Insurance number :
3|Lastemployer
3.1 Name ofemployer orfirm :
3.2 Address (3):
4 The person concerned mentioned above isentitled tosickness and maternity insurance benefits (benefits
inkind andcash benefits forhimself ,benefits inkind forthemembers ofhisfamily ),provided that theunem­
ployment insurance institution ofthecountry where hehasgone toseek employment hassent tothesickness
and maternity insurance institution ofthat country aform E303 containing thecertified statement provided
forinArticle 26.2 ,first subparagraph ,ofRegulation 574/72.
5 Benefits inkind may beprovided
5-1 (4)Qforaperiod notexceeding thatfixed forentitlement tounemployment benefits
5.2 (4)Qforcases ofsickness that have occurred until inclusive
and for days weeks .
©

E119
6 Inthecase ofincapacity forwork ,cash benefits may beprovided
61 (4)Qforaperiod notexceeding thatfixed forentitlement tounemployment benefits
6.2 (4)Qforcases ofsickness thathave occurred until inclusive
and for days weeks .
7 These cash benefits will bepaid
7.1 (4)Qbyusbyinternational money order totheabove address
7.2 (4)r~]byyouonourbehalf .
8|(5)
8.1 The benefit should bepaid :
8.2 (4)Qforthesame days oftheweek asthose laiddown forunemployment insurance
8.3 (4)Qforevery dayoftheweek ,except (4)QMonday QTuesday
(4)[~]Wednesday Thursday [HFriday QSaturday F]Sunday .
9|(5)
9.1 The daily netamount ofthis benefit :
9.2 (4)Qisthesame asthat laiddown forunemployment insurance
9.3 (4)Qjis (6)iftheinsured person isnotinhospital
(6)ifheisinhospital .
10 Competent institution (7)
10.1 Name :
10.2 Address (3):
10.3 Stamp
10.4 Date :
10.5 Signature
<D

E119
INSTRUCTIONS
Please complete thisform inblock letters ,writing onthedotted lines only .Itconsists ofthree pages ,
none ofwhich may beleftout even ifitdoes notcontain any relevant information .
Information forthe unemployed person
a)Inorder toobtain sickness insurance benefits inkind foryourself andformembers ofyour family ,youshould apply tooneofthe
following institutions :
inBelgium ,the'mutualité '(local sickness insurance fund)ofyour choice ;
inDenmark ,thecompetent 'amtskommune '(local administration ).Inthecommune ofCopenhagen ,the'magistrat (municipal
administration );inthe commune ofFrederiksberg ,the'kommunalbestyrelse '(municipal administration ).Assistance from adoctor ,
dentist ordispensing chemist may besought without first contacting thesaid institutions .Particulars about doctors and dentists
available may beobtained from thelocal 'social -ogsundhedsforvaltning '(social and health authority );
inGermany ,the'Allgemeine Ortskrankenkasse '(AOK ,local general sickness fund);
inFrance ,the'Caisse primaire d'assurance-maladie '(local sickness insurance fund);
inIreland ,theHealth Board inwhose area thebenefit issought ;
inItaly ,theprovincial office ofthe'Istituto nazionale perl'assicurazione contro lemalattie '(INAM,national sickness insurance institute );
inLuxembourg ,the 'Caisse nationale d'assurance-maladie desouvriers '(national sickness insurance fund formanual workers );
intheNetherlands ,anysickness fund competent fortheplace ofresidence orstay;
intheUnited Kingdom ,themedical service (doctor ,dentist ,hospital ,etc.)from which treatment isrequested .
Inaddition tothisform E119,youshould have acopy ofform E303/3onwhich point 7willhave been completed bytheunemploy­
ment insurance institution ofthecountry where you areseeking employment .
b)Inorder toobtain cash benefits foryourself incase ofincapacity forwork orhospitalization ,youshould submit —except ifyou arein
theNetherlands —theforms mentioned atpoint a)above and acertificate ofincapacity forwork issued bythedoctor treating you:
—totheinsurance institution indicated under point a)above ifyou areinBelgium ,Germany ,France ,Italy orLuxembourg ;
—tothelocal 'social -ogsundhedsforvaltning '(social andhealth authority )and,inthecommunes ofCopenhagen ,Odense ,Ålborg
andÅrhus ,tothe'magistrat (municipal administration ),ifyouareinDenmark ;
—tothelocal agent oftheDepartment ofSocial Welfare ,Dublin ,ordirect totheDepartment ,ifyouareinIreland ;
—totheDepartment ofHealth andSocial Security ,Overseas Group ,Newcastle-upon-Tyne ,ortotheMinistry ofHealth and Social
Services ,Overseas Branch ,Belfast ,asappropriate ,ifyou areintheUnited Kingdom .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Complete only iftheform isissued attherequest oftheinstitution oftheplace ofresidence orstay .
(3)Postal code ,town ,street ,number ,country .
(4)Put across inthe square preceding theappropriate subject .
(5)Complete thisboxonly ifthecash benefits have tobepaid bytheinstitution oftheplace ofresidence orstay .
(6)Show theamount inthecurrency ofthecompetent country .
(7)Ifthisform isissued byaninstitution intheNetherlands ,thebenefits inkind arepayable bythe'Ziekenfondsraad '(sickness fund coun­
cil),Amstelveen ;thecash benefits arepayable bytheinstitution signing theform .

Sea 'Instructions 'onpage 4 EUROPEAN COMMUNITIES
Social Security Regulations
E120 (1)
CERTIFICATE 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
Thecompetent institution should complete part Aoftheform andissue two copies totheperson concerned ,who
should submit them totheinstitution ofhisplace ofresidence .Ifthepension claimant resides intheUnited Kingdom ,
both copies oftheform should besent direct totheDepartment ofHealth and Social Security ,Overseas Group ,
Newcastle-upon-Tyne .Onreceipt ofthecopies inquestion ,theinstitution oftheplace ofresidence should
complete part Bandsend oneofthecopies totheinstitution mentioned inbox6.Ifnecessary ,thetwocopies should
first besent totheinstitution thathastocomplete boxes 5and6.
ANotification ofentitlement
~nInstitution oftheplace ofresidence (2)
1.1 Name :
1.2 Address (3):
1.3 Reference :your form E107 of (date )
2 Pension claimant
Date ofbirth 2.1 Surname Forenames Maiden name
2.2 Address inthecountry ofresidence (3):
2.3 Insurance number :
3 Tobecompleted bytheinstitution towhich theclaim forapension hasbeen submitted
3.1 The claimant indicated above submitted on
aclaim forapension for
(4)Qoldage Qinvalidity Qsurvival
(4)Qaccident atwork [Joccupational disease .
3.2 (5)[]]]Theinvestigation ofthisclaim hasshown thattheperson concerned isentitled toreceive apension
from us.
©

©E120
4 Institution which completed box 3
4.1 Name :
4.2 Address (3):
4.3 Stamp
4.4 Date :
4.5 Signature
Tobecompleted bytheinstitution towhich theclaim forapension wassubmitted orbythesickness
5 andmaternity insurance institution ofthecountry inwhich thisclaim wassubmitted
5.1 Theclaimant indicated inbox 2andthemembers ofhisfamily areentitled tosickness andmaternity
insurance benefits inkind (6)
5.2 from (date): until thiscertificate iscancelled .
6 Institution which completed box 5
6.1 Name :
6.2 Address (3):
6.3 Stamp
6.4 Date :
6.5 Signature
B.Notification ofregistration ornon -registration
7 Competent institution
7.1 Name :
7.2 Address (3):

E120
8|(7>□
8.1 The claimant indicated inbox 2andthemembers ofhisfamily could notberegistered because :
PH <7)□
9.1 The claimant indicated inbox 2andthemembers ofhisfamily indicated below were registered on
(date ).
10|Registered members ofthefamily
Surname Forenames Maiden name Date ofbirth
10.1
10.2
10.3
10.4
10.5
10.6
10.7
10.8
11jInstitution oftheplace ofresidence
11.1 Name :
11.2 Address (3):
11.3Stamp
11.4 Date :
11.5 Signature

E120
INSTRUCTIONS
Please complete thisform inblock letters ,writing onthedotted lines only .Itconsists offour pages ,
none ofwhich may beleftout even ifitdoes notcontain any relevant information .
Information for the worker
a)This certificate gives youand themembers ofyour family theright toreceive benefits inkind incase ofsickness ormaternity inyour
country ofresidence .
b)Youshould ,assoon aspossible ,submit thetwocopies ofthiscertificate inyour possession tooneofthefollowing insurance institutions :
inBelgium ,themutualité '(local sickness insurance fund)ofyour choice ;
inDenmark ,thecompetent 'amtskommune '(local administration ).Inthecommune ofCopenhagen ,the'magistrat (municipal
administration );inthecommune ofFrederiksberg ,the'kommunalbestyrelse '(municipal administration );
inGermany ,the'Allgemeine Ortskrankenkasse '(AOK ,local general sickness fund);
inFrance ,the'Caisse primaire d'assurance-maladie '(local sickness insurance fund);
inIreland ,theHealth Board inwhose area thebenefit issought ;
inItaly ,theprovincial office ofthe'Istituto nazionale perl'assicurazione contro lemalattie '(/NAM ,national sickness insurance institute );
inLuxembourg ,the'Caisse nationale d'assurance-maladie desouvriers '(national sickness insurance fund formanual workers );
intheNetherlands ,anysickness fund competent fortheplace ofresidence .
c)You must inform theinsurance institution towhich yousubmit theform ofanychange ofcircumstances which might affect theright
tobenefits inkind ,such asthegrant ofpension claimed orachange ofyour place ofresidence orstay orofthatofamember ofyour
family .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing partAoftheform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;
F=France ;Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Complete only iftheform isissued attherequest oftheinstitution oftheplace ofresidence .
(3)Postal code ,town ,street ,number ,country .
(4)Put across inthesquare preceding theappropriate subject .
(5)Put across inthis square ,ifapplicable .
(6)Ifthecertificate isissued byanItalian insurance institution ,theright tobenefits fortuberculosis should becertified bythe'Istituto
nazionale della previdenza sociale '(INPS ,national social welfare institute ).
(7)Complete box8orbox 9,asappropriate ,andputacross inthecorresponding square .
©

See Instructions 'onpage 4 EUROPEAN COMMUNITIES
Social Security Regulations
E121 (1
CERTIFICATE FOR THE REGISTRATION OF PENSIONERS
AND THE KEEPING OF LISTS
Reg .1408/71:Art .28.1 .a
Reg .574/72:Art .29.1,2and3;Art .95.4
Theinstitution which hastodraw upthiscertificate inaccordance with Art.29.2 ofRegulation 574/72should com­
plete partAoftheform andissue twocopies tothepensioner orsend them totheinstitution oftheplace ofresidence
iftheform was requested bythelatter institution .Ifthepensioner resides intheUnited Kingdom ,thetwo copies
oftheform should besent direct totheDepartment ofHealth andSocial Security ,Overseas Group ,Newcastle­
upon-Tyne .Where appropriate ,thetwo copies should first besent totheinstitution which hastocomplete boxes
5and6.Theinstitution oftheplace ofresidence should ,onreceiving thetwo copies ,complete part Bandsend one
copy totheinstitution shown inbox6.
A.Notification ofentitlement
m Institution oftheplace ofresidence (2)
1.1 Name :
1.2 Address (3):
1.3 Reference :your form E107 of (date )
mPensioner
2.1 Surname Forenames Maiden name Date ofbirth
2.? Address inthecountry ofresidence (3):
2.3 Date oftransfer ofresidence ,ifapplicable :
Insurance number : 2.4
3 Tobecompleted bytheinstitution responsible forpayment ofthepension
3.1 The person concerned indicated above hasbeen entitled toapension for
(4)Qoldage Qinvalidity Qsurvival
(4)Qaccident atwork |~]occupational disease
3.2 since :
3.3 Pension number :
©

E121
4 Institution which completed box 3
4.1 Name :
4.2 Address (3):
4.3 Stamp
4.4 Date :
4.5 Signature
Tobecompleted bytheinstitution responsible forpayment ofthepension orbythesickness and
^ maternity insurance institution ofthecountry responsible forpayment ofthepension
5.1 The person concerned indicated inbox2andthemembers ofhisfamily areentitled tosickness and maternity
insurance benefits inkind from (date )
5.2 The cost ofthebenefits tobeprovided intheir country ofresidence -unless they reside inthecompetent
country -will beborne byus
5.3 from (date ) until this certificate iscancelled .
5-4 (5)Q]With theissue ofthiscertificate ,form E120of
(date ) isnolonger valid .
6|Institution which completed box5
6.1 Name :
6.2 Address (3):
6.3 Stamp
6.4 Date :
6.5 Signature
B.Notification ofregistration ornon-registration
7 Institution indicated inbox 6
7.1 Name :
7.2 Address (3):
(D

E121
8|(«)□
8.1 The person concerned indicated inbox 2and members ofhisfamily could notberegistered
8.2 (4)Qbecause theperson concerned isalready entitled tobenefits inkind under thelegislation ofour
country .
8.3 (4)\~\Other reasons :
9 <e)□
9.1 The person concerned indicated inbox 2and themembers ofhisfamily have been registered .
9.2 Registered members ofthefamily (7):
9.3 Surname Forenames Maiden name Date ofbirth
9.4
9.5
9.6
9.7
9.8
9.9
9.10
9.11
9.12Thecost ofthese benefits should beborne byyou ;thedate from which thelump sum provided forinArt .95
ofRegulation 574/72should becalculated is:
10jInstitution oftheplace ofresidence
10.1 Name :
10.2 Address (3):
10.3 Stamp
10.4 Date :
10.5 Signature

E121
INSTRUCTIONS
Please complete thisform inblock letters ,writing onthedotted lines only .Itconsists offour pages ,
none ofwhich may beleftout even ifitdoes notcontain any relevant information .
Information forthe pensioner
a)Youshould ,assoon aspossible ,send thetwo copies ofthisform tooneofthefollowing insurance institutions :
inBelgium ,the'mutuality (local sickness insurance fund)ofyour choice ;
inDenmark ,thecompetent 'amtskommune '(local administration ).Inthecommune ofCopenhagen ,the'magistrat (municipal
administration );inthecommune ofFrederiksberg ,the'kommunalbestyrelse '(municipal administration );
inGermany ,the'Allgemeine Ortskrankenkasse '(AOK ,local general sickness fund);
inFrance ,the'Caisse primaire d'assurance-maladie '(local sickness insurance fund);
inIreland ,theHealth Board inwhose area thebenefit issought ;
inItaly ,theprovincial office ofthe'Istituto nazionale perl'assicurazione contro lemalattie '(INAM,national sickness insurance institute );
inLuxembourg ,the'Caisse nationale d'assurance-maladie desouvriers '(national sickness insurance fund formanual workers );
intheNetherlands ,anysickness fund competent fortheplace ofresidence .
b)Youmust inform theinsurance institution towhich yousubmit theform ofanychange ofcircumstances which might afffect theright
tobenefits inkind ,such assuspension orwithdrawal ofpension ,orchange ofyour place ofresidence orofthatofamember ofyour
family .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing partAoftheform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;
F=France ;Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Complete only iftheform isdrawn upattherequest oftheinstitution oftheplace ofresidence .
(3)Postal code ,town ,street ,number ,country .
(4)Put across inthesquare preceding theappropriate subject .
(5)Put across inthissquare ,ifapplicable .
(6)Complete box 8orbox 9,asapplicable ,andput across inthecorresponding square .
(7)Tobecompleted byNetherlands institutions only .

See Instructions 'onpage 3 EUROPEAN COMMUNITIES
Social Security Regulations
E122 n
CERTIFICATE FOR THE GRANT OF BENEFITS INKIND TO MEMBERS
OF THE FAMILY OF PENSIONERS
Members ofthe family residing inanother Member State than the pensioner
Reg .1408 /71:Art .29.1 .a
Reg .574/72:Art .30.1
Thesickness insurance institution oftheplace ofresidence ofthepensioner should complete part Aoftheform and
issue two copies tothepensioner ,orsend them totheinstitution oftheplace ofresidence ofthemsmbers ofthe
family iftheform isdrawn upattherequest ofthelatter institution .Ifthemembers ofthefamily reside intheUnited
Kingdom ,thetwo copies oftheform should besent direct totheDepartment ofHealth and Social Security ,Over­
seas Group ,Newcastle-upon-Tyne .The institution oftheplace ofresidence should ,onreceiving thetwo copies
inquestion ,complete part Bandsend onecopy tothesickness insurance institution oftheplace ofresidence ofthe
pensioner .Ifthemembers ofthefamily reside inseveral different countries ,aseparate certificate should bedrawn up
foreach ofthese countries .
A. Notification ofentitlement
ri I(2)Institution towhich theform isaddressed
1.1 Name :
1.2 Address (3):
1.3 Reference :your form E107 of(date )
2|Pensioner
2.1 Surname Forenames Maiden name Date ofbirth
2.2 Address (3):
2.3 Insurance number :
3 Member ofthefamily (4)
3.1 Surname Forenames Maiden name Date ofbirth
3.2 Address (3):
4 The person concerned isentitled toreceive sickness and maternity insurance benefits inkind forhimself
and forthemembers ofhisfamily .
5 Forthegranting ofthese benefits tothemembers ofthefamily ,this certificate isvalid
(5)Qfrom until receipt ofnotification ofitscancellation
(5) I Ifor12months from itsdate ofissue (6).
CD

E122
6 Competent institution
6.1 Name :
6.2 Address (3):
6.3 Stamp
6.4 Date :
6.5 Signature
B.Notification ofregistration
7ICompetent institution
7.1 Name :
7.2 Address (3):
8 (7)MThe members ofthefamily ofthepensioner indicated inbox 2have notbeen registered .Reason :
9 (7) Thefollowing members ofthefamily ofthepensioner indicated inbox2have been becanse :
10 Registered members ofthefamily
Surname Forenames Maiden name Date ofbirth
10.1
10.2
10.3
10.4
10.5
10.6
10.7
10.8
©

E122
11 Institution oftheplace ofresidence ofthemembers ofthefamily
11.1 Name :
11.2 Address (3):
11.3Stamp
11.4 Date :
11.5Signature
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .Itconsists ofthree pages ,
none ofwhich may beleftout even ifitdoes notcontain any relevant information .
Information forthe pensioner
a)Thisform gives themembers ofyour family theright toreceive sickness andmaternity insurance benefits inkind intheir country of
residence under thelegislation ofthatcountry ,unless they arealready entitled tosuch benefits under thatlegislation .
b)Assoon asyouhave received thetwo copies ofthisform ,youshould send them tothemembers ofyour family who should present
them immediately toasickness andmaternity insurance institution oftheir place ofresidence ,i.e.:
inBelgium ,the'mutualité '(local sickness insurance fund)oftheir choice ;
inDenmark ,thecompetent 'amtskommune '(local administration ).Inthecommune ofCopenhagen ,the'magistrat (municipal
administration );inthecommune ofFrederiksberg ,the'kommunalbestyrelse '(municipal administration );
inGermany ,the'Allgemeine Ortskrankenkasse '(AOK ,local general sickness fund);
inFrance ,the'Caisse primaire d'assurance-maladie '(local sickness insurance fund);
inIreland ,theHealth Board inwhose area thebenefit issought ;
inItaly ,theprovincial office ofthe'Istituto nazionale perl'assicurazione contro lemalattie '(INAM ,national sickness insurance institute );
inLuxembourg ,the'Caisse nationale d'assurance-maladie desouvriers '(national sickness insurance fund formanual workers );
intheNetherlands ,anysickness fund competent fortheplace ofresidence .
c)Thisform isvalid from thedate andfortheperiod indicated atpoint 5.
d)Themembers ofyour family must inform theinsurance institution towhich they have submitted theform ofanychange ofcircumstances
which might affect theright tobenefits inkind ,inparticular achange oftheir place ofresidence .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing partAoftheform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;
F=France ;Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Complete only iftheform isdrawn upattherequest oftheinstitution oftheplace ofresidence ofthemembers ofthefamily .
(3)Postal code ,town ,street ,number ,country .
(4)Complete only ifthemembers ofthefamily reside intheUnited Kingdom ;give details forone member ofthefamily only .
(5)Put across inthesquare preceding theappropriate subject .
(6)Iftheform isissued byaFrench institution .
(7)Complete point 8or9,asappropriate ,andput across inthecorresponding square .
<D

EUROPEAN COMMUNITIES
Social Security RegulationsSee'Instructions overleaf
E1231
CERTIFICATE OF ENTITLEMENT TO BENEFITS INKIND UNDER INSURANCE
AGAINST ACCIDENTS AT WORK AND OCCUPATIONAL DISEASES
Reg .1408/71:Art .52.a ;Art .55.1 .a.i,b.i.andc.i
Reg .574/72:Art .60.1;Art.62.4 and 7;Art .63.1and 3
Iftheform hasbeen requested bytheinstitution oftheplace ofresidence orstayoftheperson concerned bymeans
ofform E107ritshould besent tothesaid institution ;otherwise itshould beissued totheworker .Iftheworker
goes totheUnited Kingdom ,acopy oftheform should alsobesent totheDepartment ofHealth andSocial Security ,
Overseas Group ,Newcastle-upon-Tyne .
1 Institution oftheplace ofresidence orstay (2)
1.1 Name :
1.2 Address (3):
1.3 Reference :your form E107 of(date )
2 Worker
2.1 Surname Forenames Maiden name Date ofbirth
2.2 Address inthecompetent country (3):
2.3 Address inthecountry where theperson concerned isgoing (3):
2.4 Insurance number :
3 Onthegrounds of
3-1 (4)LJ^einformation supplied onyour form E107of(date )
(date ) 3.2 (4)[_]theaccident atwork sustained on
which had thefollowing consequences :
(date ) 3.3 (4)\_jtheoccupational disease diagnosed on
which had thefollowing consequences :
3-4 (4)LJtheauthorization which wehave granted totheperson concerned toretain therighttobenefits inkind
in (country )where heisgoing
(4)□totake uphis/herresidence there Qtoreceive medical treatment
©

E123
theabovementioned worker may receive benefits inkind
4 (4)LDforaccident atwork Qforoccupational disease
4.1 (4)Qforaperiod laiddown intheprovisions ofthelegislation ofhiscountry ofresidence
4.2 (4)□until
4.3 (4)Qforamaximum ofthree months
4.4 (4)Qforanunlimited period .
|5jThereport ofourexamining doctor
5-1 (4)Qisattached inasealed envelope
5.2 (4)Qhasbeen senton to(5)
5.3 (4)Qmay beobtained from usonrequest
5-4 (4)Qhasnotbeen drawn up.
6JCompetent institution
6.1 Name :
6.2 Address (3):
6.3 Stamp
6.4 Date :
6.5 Signature
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .
Information forthe insured person
Youshould Present thiscertificate assoon aspossible totheinsurance institution ofthecountry where youhave gone ,i.e.
inBelgium ,the'mutuality (local sickness insurance fund)ofyour choice ;
inDenmark ,the'Sikringsstyrelse '(national office forsocial security ),Copenhagen ;
inGermany ,the 'Allgemeine Ortskrankenkasse '(AOK ,local general sickness fund);
'nFrance ,the'Caisse primaire d'assurance-maladie '(local sickness insurance fund);
inIreland ,theHealth Board inwhose area thebenefit issought ;
inItaly ,theprovincial office ofthe'Istituto nazionale perl'assicurazione contro gliinfortuni sullavoro '(INAIL ,national institute forinsurance against accidents atwork);
inLuxembourg ,the'Association d'assurance contre lesaccidents '(accident insurance association );
intheNetherlands ,anysickness fund competent fortheplace ofresidence or,incase oftemporary residence ,the'Algemeen Nederlands Onderling Ziekenfonds '(ANOZ
general sickness fund oftheNetherlands ),Utrecht .Assistance from adoctor ,dentist ordispensing chemist may besought without firstcontacting ANOZ ;
intheUnited Kingdom ,themedical service (doctor ,dentist ,hospital ,etc.)from which treatment isrequested .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;Irl=Irleand ;I=Italy ;
L-Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Complete only iftheform isdrawn upattherequest oftheinstitution oftheplace ofresidence orstay oftheperson concerned .
(3)Postal code ,town ,street ,number ,country .
(4)Put across inthesquare preceding theappropriate subject .
(5)Name andaddress oftheinstitution towhich themedical report hasbeen sent .

See Instructions'overleaf EUROPEAN COMMUNITIES
Social Security Regulations
E1241
CLAIM FOR DEATH GRANT
Reg .1408171 :Art 65
Reg .574/72:Art 78
1 Itheundersigned ,
1.1 Surname Forenames Maiden name Date ofbirth
1.2 Insurance number (2):
1.3 Institution with which Iaminsured (2)(3):
1.4 Family relationship with thedeceased :
1.5 Address (4):
2 hereby claim agrant byreason ofthedeath oftheundermentioned
(5)Q]worker I Ipensioner
3
(5)Q]member ofmyfamily I Ipension claimant
3.1 Surname Forenames Maiden name Date ofbirth
3.2 Insurance number (2):
3.3 Date ofdeath :
3.4 Cause ofdeath :
(5)Q]illness Ijaccident Qaccident atwork
(5)Qoccupational disease I Iother causes .
3.5 Institution with which thedeceased was insured (2)(3):
4 Itheundersigned (5)Qwas \_jwas not adependant ofthedeceased .
5 Thedeceased person (5)Qwas Qwas not adependant ofmine .
6 The cost ofthefuneral was (6) ;ithasbeen paid
by
7 You will find attached thefollowing documents :
8 Date :
8.1 Signature
©

E124
INSTRUCTIONS
Please complete this form inblock letters ,writing onthe dotted lines only .
Information for the claimant
a)Inorder toreceive adeath grant youshould ,bymeans ofthisform ,submit aclaim :
—either tothe competent insurance institution ,
—ortotheinsurance institution oftheplace where you are,i.e.:
inBelgium ,a'mutuality (local sickness insurance fund )ofyour choice ;
inDenmark ,the 'Sikringsstyrelse '(national office forsocial security ),Copenhagen ;
inGermany ,the'Allgemeine Ortskrankenkasse '(AOK ,local general sickness fund);
inFrance ,the'Caisse primaire d'assurance-maladie '(social sickness insurance fund);
inIreland ,theDepartment ofSocial Welfare ,Dublin ;
inItaly ,theprovincial office oftheINAM ,theINPS ortheINAIL ,asappropriate ;
inLuxembourg ,the'Caisse nationale d'assurance-maladie desouvriers '(national sickness insurance fund formanual workers );
intheUnited Kingdom ,theDepartment ofHealth andSocial Security ,Overseas Group ,Newcastle-upon-Tyne ,ortheMinistry ofHealth andSocial Services ,
Overseas Branch ,Belfast ,asappropriate .
b)Together with your claim youshould send thefollowing documents :
inBelgium ,anextract ofthedeath certificate ,issued bythemunicipal administration ;
thereceipted bills relating tofuneral expenses ;
inDenmark ,thedeath certificate ;
thereceipted bills relating tofuneral expenses ;
inGermany ,thedeath certificate ;
inFrance ,
—inevery case ,the'bulletin dedices '(death certificate )oftheinsured person ;
—inaddition ,asappropriate ,
—iftheinsured person was your husband orwife ,the'fiche familiale d'état -civil'(family card oftheRegistry ofbirths ,deaths ,and marriages );
—ifyouarehis/herdescendant (son,daughter ,grandson ,etc.),the'fiche familiale d'état-civil '(family card oftheRegistry ofbirths ,deaths and marriages ),showing
your family relationship tothedeceased ;
—ifyouarehis/herascendant (father ,mother ,grandfather ,etc.),his/her'fiche individuelle d'état-civil '(individual card oftheRegistry ofbirths ,deaths and mar­
riages );
—ifyou were his/herdependant inanyother way ,astatutory declaration testifying that you were factually ,wholly andconstantly supported bythedeceased ;
inIreland ,the death certificate ;
themarriage certificate ,ifappropiate ;
theundertakers 'account orestimate orthereceipt forfuneral expenses ifpaid byyou;
inItaly ,the death certificate ;
thedocument ofinsurance registration ;
ifappropriate ,adeclaration offamily status ;
inLuxembourg ,thedeath certificate ;
thereceipted bills relating tofuneral expenses ;
ifappropriate ,adeclaration from themunicipal administration testifying cohabitation ashusband and wife;
inthe United Kingdom ,thedeath certificate ;
ifappropriate ,the marriage certificate ;
theundertaker 'saccount orestimate forfuneral expenses .
NOTES
0)Symbol ofthecountry ofresidence oftheclaimant ofthegrant :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;Irl=Ireland ;I=Italy ;L=Luxembourg ;
N=Netherlands ;UK=United Kingdom .
(2)Indicate only ifitconcerns aworker ,pensioner ,orpension claimant .
(3)Give name and address .
(4)Postal code ,town ,street ,number ,country .
(5)Putacross inthesquare preceding theappropriate subject .
(6)Indicate theamount inthecurrency ofthecountry ofresidence oftheclaimant .

See Instructions 'overleaf EUROPEAN COMMUNITIES
Social Security Regulations
E125 n
INDIVIDUAL RECORD OF ACTUAL EXPENDITURE
Reg .1408/71:Art .36.1 and 2;Art .63.1;Art .87.1
Reg .574/72:Art .93.1 ,2,4and 5;Art .105.1
Aseparate form should becompleted foreach recipient .Italian institutions should also complete Annex 1orAnnex 2
asappropriate .
1 Invoice No (2) (3)\_\ 1sthalfyear P]2ndhalfyearofthefinancial year 19 .
2 Competent institution towhich theform isaddressed
2.1 Name :
2.2 Address (4):
3 Insured person
3.1 Surname Forenames Maiden name Date ofbirth
3.2 Insurance number :
4 Member ofthefamily (5)
4.1 Surname Forenames Maiden name Date ofbirth
5 Theperson indicated (3)[_Jinbox3 Qinbox4hasreceived benefits
under Article
5.1 (3)□19.1 LJ22.1 □25.1 ,3 n26n29.1N31□52□55.1
and 2 and 3 and 4
ofRegulation 14087 /71
onthebasis ofthefollowing forms which were sent tous:
5.2 (3)□form E of □form E117of
(date ) (date )
©

E125
6 EXPENDITURE INCURRED 6.1Amount (6)
from to 6.2 For benefits inkind provided
6.3 Medical treatment
6.4 Dental treatment
6.5 Medicaments
6.6 Hospitalization
6.7 Other benefits (7)from
fromto
to
6.8 Total benefits inkind
6.9 Medical examinations (8)
to 6.10 For cash benefits provided from
6.11 TOTAL EXPENDITURE
7 Creditor institution
7.1 Name :
7.2 Address (4):
7.3 Stamp
7.4 Date :
7.5 Signature
8 Reserved fortheinstitution ofthecompetent country
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .
NOTES
H Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands .
(2)Tobeindicated ifthecreditor institution needs thisinformation .
(3)Put across inthesquare preceding theappropriate subject .
(4)Postal code ,town ,street ,number ,country .
(5)Complete only when theaccount refers toamember ofthefamily oftheinsured person .
(6)Indicate theamount innational currency .
(7)Indicate thekind ofbenefits :confinement ,dentures ,orthopaedic protheses ,spatreatment ,ambulance ,etc.
(8)Indicate thekind ofmedical examinations carried out .
©

Tobecompleted byItalian institutions only E125 Annex 1
Details ofexpenditure forbenefits inkind provided forsickness ormaternity
Amount inlire
1 Treatment bygeneral practitioners
1.1 Examinations atsurgery :
1.2 Home visits
1.3 Additional benefits :(number ) each lire
(number ) each lire
(number ) each lire
1.4 Total treatment bygeneral practitioners
Treatment byspecialists 2
2.1
2.2
2.3each lire
each lire
each lire(1)
(1)
V)
4
5
6
6.1
6.22.4 Total treatment byspecialists
3 Total treatment bygeneral practitioners andspecialists
Dental treatment : (number ofbenefits )
Medicaments : (number ofprescriptions )
Hospitalization
Number ofdays spent inhospital each lire
Medical fees each lire
6.3 Total hospitalization
Other benefits (2) 7
7.1 Total other benefits
8 GRAND TOTAL
9 Stamp
10 Date :
11 Signature
(1)Indicate thekind ofbenefit :examination ,operation ,X-ray ,etc.
(2)Indicate thekind ofbenefit :confinement ,dentures ,orthopaedic prostheses ,spatreatment ,ambulance ,etc.
©

Tobecompleted byItalian institutions onlyE125 Annex 2
Details ofexpenditure foraccidents atwork and occupational diseases
Amount inlire
days each lire
days each lire
days each lire1 Benefits inkind
2 Medical treatment
3 Medicaments
4 Hospitalization fortreatment :
4.1 from to
4.2 from to
4.3 from to
5 Orthopaedic appliances (1)
6 Physiotherapy (1)
7 Other benefits (2)
8 Total benefits inkind
9 Medical examinations
10 Doctor 'sfees
11 Specialist 'sfees :
11.1 (3)
11.2 (3)
12 Examinations byspecialists :
12.1 Number ofX-ray photographs
12.2 Tomography
12.3 Electrocardiogram
12.4 Electroencephalogram
12.5 Laboratory tests
12.6 Examination ofrespiratory function
12.7 Other examinations andtests (1)
13 Hospitalization forobservation from to
days each lire
14 Total medical examinations and tests
(1)
(2)
(3)Specify the kind ofbenefit .
Specify thekind ofbenefit :reimbursement oftravel expenses ,compensation forlossofwages orsalary ,ambulance ,etc.
Specify specialty .
©

E125 Annex 2
Amount inlire
15 Cash benefits
16 Daily allowances fortheinsured person :
16.1 while under out-patient treatment , from to
16.2 while undergoing hospital in-patient treatment from to
17 Daily allowances formembers ofthefamily , from to
18 Total cash benefits
19 TOTAL EXPENDITURE

See Instructions overleaf EUROPEAN COMMUNITIES
Social Security Regulations
E126 (1)
RATES FOR REFUND OF BENEFITS INKIND
Reg .1408/71:Art .22.1 .a.i;Art .22.3;Art .31.a
Reg .574/72:Art.34
Thecompetent institution should complete part Aoftheform andsend ,either directly orthrough theliaison body ,
two copies totheinstitution which would have had toprovide thebenefits totheperson concerned inthecountry
ofstay .Theinstitution oftheplace ofstay ,after completing part Boftheform ,should return onecopy tothecom­
petent institution .
A.Request
~1|Institution towhich theformisaddressed (2)
1.1 Name :
1.2 Address (3):
2(4)QWorker [_]Member ofthefamily ofaworker
(4)r~]Pensioner [HMember ofthefamily ofapensioner
2.1 Surname Forenames Maiden name Date ofbirth
3 The abovementioned person concerned ,
3.1 during astay in (country )
3.2 at (town ),
3.3 himself paid forthebenefits which herequired .
3.4 Theperson (4)Q]awidower /widow Qaninvalid (5)
concerned is
3.5 andearns anincome of (5)
4 Please indicate onthereceipts attached ,foreach benefit separately ,theamount toberefunded totheperson
concerned according totherates administered bytheinstitution oftheplace ofstay .
5 Attached : receipts .
6|Competent institution
6.1 Name :
6.2 Address (3):
6.3 Stamp
6.4 Date :
6.5 Signature
©

NOTES
(1)Symbol ofthecountry towhich institution completing part Aoftheform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;
F=France ;Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands .
(2)Ifitisnotknown which institution would have hadtoprovide thebenefits inkind ,theform may besent totheliaison body ofthe
country ofstay ,i.e.
—inBelgium ,the'Institut national d'assurance maladie-invalidité '(INAMI ,national sickness and invalidity insurance institute ),
Brussels ;
—inDenmark ,the'Sikringsstyrelsen '(national office forsocial security ),Copenhagen ;
—inGermany ,the'Bundesverband derOrtskrankenkassen '(national federation oflocal sickness funds ),Bonn -BadGodesberg ;
—inFrance ,the'Centre desécurité sociale destravailleurs migrants ',(centre forthesocial security ofmigrant workers ),Paris ;
—inIreland ,theDepartment ofHealth ,Dublin ;
—inItaly ,the'Istituto nazionale perl'assicurazione contro lemalattie ,Direzione generale '(directorate-general ofthenational sickness
insurance institute ),Rome ;
—inLuxembourg ,the 'Ministère dutravail etdelasécurité sociale '(ministry oflabour andsocial security ),Luxembourg ;
—intheNetherlands ,the 'Algemeen Nederlands Onderling Ziekenfonds '(ANOZ ,general sickness fund oftheNetherlands ),Utrecht .
(3)Postal code ,town ,street ,number ,country .
(4)Put across inthesquare preceding theappropriate subject .
(5)Complete only iftherequest issent toaBelgian institution .
©E126
B.Reply
I7ICompetent institution
7.1 Name :
7.2 Address (3):
8 Attached : receipts indicating therequested rates .
Remarks : 9
10 Institution oftheplace ofstay
10.1 Name :
10.2 Address (3):
10.3 Stamp
10.4 Date :
10.5 Signature
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .

See 'instructions 'overleaf EUROPEAN COMMUNITIES
Social Security Regulations
E127 (1)
INDIVIDUAL RECORD OF MONTHLY LUMP-SUM PAYMENTS
Reg .1408171 :Art .36.1 and 2
Reg .574/72:Art .94;Art .95
21
Record No 3fyear 19 (2)
Competent in<stitution
?1 Name :
2.2 Address (3):
3The right tobenefits inkind hasbeen acquired forthe
(4)[~]worker named below Qpensioner named below
3.1 Name Forenames Maiden name Date ofbirth
3.2 Insurance number allocated bythecompetent institution :
4 Address oftheworker sfamily oraddress ofthepensioner and hisfamily (3)
5 Theright tobenefits inkind isheld bythemembers ofthefamily oftheworker named above orbythepensioner
named above and themembers ofhisfamily ,ascertified byyour form
E of (date ).
6 Fortheperiod during which this right existed
(from to ),
6.1 thenumber ofmonthly lump-sum payments ,
(4)Qperfamily orperpensioner andfamily Qperfamily member Qperindividual ,
was
7ICreditor institution
7.1 Name :
7.2 Address (3):
7.3 Stamp
7.4 Date :
7.5 Signature
©

E127
8 Tobecompleted bythecompetent institution
INSTRUCTIONS
Please complete three copies ofthis form inblock letters ,writing onthedotted lines only .
Theinstitution oftheplace ofresidence should draw uptheform foronecalendar year andsend ittothecompetent
institution through thebody designated fortheimplementation ofArticle 102.2 ofRegulation No574/72.
NOTES
(1)Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)The year tobeindicated here isthat inwhich thebenefits were provided .
(3)Postal code ,town ,street ,number ,country .
(4)Put across inthesquare preceding theappropriate subject .
©

See Instructions overleaf EUROPEAN COMMUNITIES
Social Security Regulations
E201 m
CERTIFICATE CONCERNING THE AGGREGATION OF PERIODS OF INSURANCE
OR PERIODS OF RESIDENCE
Reg .1408/71:Art .9.2;Art .15.3
Reg .574172 :Art .6.2
This certificate should bedrawn upattherequest oftheperson concerned bytheinstitution orinstitutions ofthe
Member States where he/shewas insured .He/sheshould send ittotheinstitution oftheMember State inquestion
with aview tohis/heradmission tovoluntary oroptional continued insurance forinvalidity ,oldageanddeath (pension .)
1 Worker
1.1 Surname Forenames Maiden name
1.2 Place ofbirth Date ofbirth Sex Nationality (2)
1.3 Address (3):
1.4 Insurance number :
2 Last employment entailing compulsory insurance (4)
2.1 Type ofoccupation (manual ,clerical ,miner ,etc.):
2.2 Name ofemployer orfirm :
2.3 Address (3):
3 The worker named inbox 1 (5)□ is was insured byus
from/to periods (6) as(4)7type ofinsurance
(8)fortherisks of(9)
I
I
I
4 The worker named inbox 1completed thefollowing periods ofresidence (10)
from toDuration
Years Months Days
©

E201
5
5.1 Theperson concerned (5)\_\has \_jhasnot
submitted anapplication inanother Member State forregistration forvoluntary oroptional continued
insurance .
Ifhe/shehas,state :
5.2 thecountry :
5.3 therisk (9):
6|Institution issuing thecertificate
6.1 Name :
6.2 Address (3):
6.3 Stamp
6.4 Date :
6.5 Signature
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Where applicable ,indicate thedate ofnaturalization .
(3)Postal code ,town ,street ,number ,country .
(4)Ifthecertificate isissued byaBelgian ,French ,Irish orUnited Kingdom institution ,theinformation given isbased onparticulars sup­
plied bytheworker himself .
(5)Put across inthesquare preceding theappropriate subject .
(6)Indicate thenumber ofquarters ,months ,weeks ,days ,inaccordance with theprovisions ofnational laws .
(7)Complete only iftheform isbeing sent toaGerman orItalian institution .
(8)Indicate thetype ofinsurance byusing thefollowing symbols :
A=compulsory
B=voluntary
C=optional continued .
(9)Indicate therisks covered byusing thefollowing symbols :
D=invalidity
E=oldage
F=death .
(10)Complete only ifthecertificate isissued byaDanish institution .
©

See'Instructions 'onpage 5 EUROPEAN COMMUNITIES
Social Security Regulations
E202 n
Country Insurance number (2) Institution concerned (where applicable ,liaison body )
1)
2)
3)
4)
5)
INVESTIGATION OF ACLAIM FOR AN OLD-AGE PENSION
Reg .1408/71:Art .44to50
Reg .574172 :Art.36to38;Art.41to43;Art .45to47;Art .49;Art .111
Theinvestigating institution should complete thisform and send one copy toeach oftheinstitutions with which
theworker hasbeen insured (institutions concerned )ortotheliaison body .
1 Institution towhich theform isaddressed (institution concerned orliaison body ,asapplicable )
1.1 Name :
1.2 Address (3):
A.Information concerning the insured person
2
2.1 Surname Forenames Maiden name
2.2 Place ofbirth Date ofbirth Sex Nationality (4)
!widow /widower 2.3 Civil status : (5)(_]single married
(5)[Jdivorced Qseparated
2.4 Address onthedate ofsubmission oftheclaim (3)(6):
2.5 Insurance number with theinvestigating institution :
2.6 Filereference oftheinvestigating institution :
©

©E202
3.1 (5)[_]Theinsured person isstillpursuing aprofessional ortrade activity
3.2 (5)QTheinsured person ceased topursue aprofessional ortrade activity on
3.3 (5)r~]Theinsured person intends toretire from gainful employment on
3.4 (5)[JTheinsured person isengaged ingainful employment (8)
3.5 (5)QTheinsured person intends toengage ingainful employment (9).
3.6 Amount ofannual earnings and ,where applicable ,ofany other income (10)
3.7 Nature ofother income : (10)
R
4.1 The claimant
(5)QJdraws Qdoes notdraw apension
(5)Qhasbeen Q]hasnotbeen inreceipt ofapension .
Ifinthe affirmative ,indicate :
4.2 Type ofpension :
4.3 Pension number :
4.4 Institution responsible forpension payment :
4.5 Date onwhich pension became orwill become payable :
4.6 Where applicable ,date when pension payment ceased orwill cease :
5 Theclaimant (5)[_]hasreceived Q]hasnotreceived
unemployment benefits since submitting hisclaim .
Information tobesupplied only iftheform istobesent toFrench institutions 6
6.1 The claimant
6.2 The claiment(5)\_jdeclares that heisunfit forwork
(5)Qdoes notdeclare that heisunfit forwork .
(5)Qdeclares heneeds constant attendance fortheperformance ofone ofthe
ordinary activities ofeveryday life
(5)Qdoes notdeclare thatheneeds constant attendance fortheperformance ofone
oftheordinary activities ofeveryday life .
7jInformation tobesupplied onlyiftheformistobesenttoFrench orItalian institutions
7.1 Theclaimant (5)Qhasbeen receiving anincrease forspouse since (date )
(5)P]does notreceive anincrease forspouse .

E202
B.Information concerning themembers oftheinsured person 'sfamily
|8JSpouse
8.1 Surname Forenames Maiden name Sex
8.2 Date ofbirth : Place ofbirth :
8.3 Address (3):
8.4 Date ofmarriage :
8.5 Thespouse (5)[Hpursues Qdoes notpursue aprofessional ortrade activity .
8.6 Ifintheaffirmative ,state amount of(11):
(5)Qweekly earnings Qannual earnings
8.7 The spouse aged between 60and 65declares tobe
(5)Qfitforwork Qunfitforwork (12)
8.8 Thespouse (5)Qreceives Qdoes notreceive apension .
Ifintheaffirmative ,indicate :
8.9 Type ofpension :
8.10Institution responsible forpension payment :
8.11 Amount (5)Q]monthly Qquarterly Qannually :
8.12 Thespouse (5)Qreceives Qdoes notreceive other benefits (13),namely for:
(5)Qunem - Qsickness [jinvalidity Qother .
ployment
8.13 Other known resources :
Children .(Complete only iftheclaimant isnotentitled tosupplements inrespect ofchildren under the
^ legislation ofthecountry where heresides ).
9.1 Surname Forenames Date ofbirth Relationship
1
2
3
4
9.2 Address (3)(14):
9.3 Remarks (15):
CD

E202
C.Miscellaneous information
10 (5)[JDate ofsubmission ofclaim :
(5)F]Date from which thepension was payable ifitwasawarded automatically :
11 Theclaimant (5)[Jhasrequested Qhasnotrequested
deferment oftheaward ofanold-age pension towhich hewould beentitled .Ifintheaffirmative ,indicate
thecountry :
12 Theinvestigating institution (5)Qcan Q]cannot
make provisional payments ofbenefit under Article 45.1 ofRegulation 574/72.
12.1 Ifinthenegative ,theinstitutions concerned arerequested toinvestigate thepossibility ofmaking provisional
payments ofbenefit under Article 45.2 ofRegulation 574/72 .
13 (3)OThere aregrounds Q]there arenogrounds formaking deductions tocompen -.
sate foroverpayment inaccordance with Article 111 ofRegulation 574/72.
14 Attached is: (5)□ E205 □ E206 □ E207
15 Investigating institution
15.1 Name : I
15.2 Address (3):
15.3 Stamp
15.4 Date :
15.5 Signature
©

E202
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .Itconsists offive pages ,
none ofwhich may beleft out even ifitdoes notcontain any relevant information .
NOTES
(1)Symbol ofthecountry towhich theinvestigating institution belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Iftheform isbeing sent toaDanish institution ,indicate theCPR number and ,where applicable ,theATP number .
(3)Postal code ,town ,street ,number ,country .
(4)Where applicable ,indicate thedate ofnaturalization .
(5)Putacross inthesquare preceding theappropriate subject .
(6)Iftheform isbeing sent toaDanish institution ,give theclaimant 'slastaddress inDenmark intheboxbelow :
Address (3):
(7)Complete only iftheform isbeing sent toaUnited Kingdom institution .
(8)Complete only iftheform isbeing sent toanIrish orUnited Kingdom institution .
(9)Complete only iftheform isbeing sent toanIrish institution .
(10)Complete only iftheform isbeing sent toaDanish institution .
(11)Complete only iftheform isbeing sent toaFrench ,Italian ,Luxembourg orUnited Kingdom institution .
(12)Complete only iftheform isbeing sent toaFrench institution .
(13)Complete only iftheform isbeing sent toaBelgian ,French orUnited Kingdom institution .
(14)Indicate thecommon address .Ifoneofthechildren lives atadifferent address ,indicate intheboxbelow :
Surname and forenames :
Address (3):
(15)Indicate ifthechild ismarried ,invalid ,deceased (date ofdeath ),apprenticed ,orcontinuing studies .
©

See Instructions 'onpage 5 EUROPEAN COMMUNITIES
Social Security Regulations
E2031
Country Insurance number (2) Institution concerned (orliaison body ,ifapplicable )
1) L. ...
2)
3)
4)
5)
INVESTIGATION OF ACLAIM FOR ASURVIVOR 'SPENSION
Reg .1408/71:Art44to50
Reg .574172 :Art36to38;Art 41to43;Art 45to47;Art.49;Art 111
Theinvestigating institution should complete theform and send one copy toeach oftheinstitutions with which
theworker hasbeen insured (institutions concerned )ortotheliaison body .
1|Institution towhich theformisaddressed (institution concerned orliaison body ,asapplicable )
1.1 Name :
1.2 Address (3):
A.Information concerning the deceased insured person
2
2.1 Surname Forenames Maiden name
2.2 Place ofbirth Date ofbirth Sex Nationality (4)
2.3 Civil status atdateofdeath : (5)Qsingle [[[]married
(5)Qwidow /widower Qdivorced Q]separated .
2.4 Address atdate ofdeath (3)(6):
2.5 Insurance number with theinvestigating institution :
2.6 Filereference oftheinvestigating institution :
3 Atthedate ofdeath ,thedeceased insured person
(5)□wasstillpursuing []]nolonger pursued aprofessional ortrade activity .
©

E203
Z!
4.1 Date and place ofdeath :
4.2 Thedeath (5)Qisassumed Qisnotassumed
tohave been theresult ofanaccident atwork oranoccupational disease .
4.3 Thedeath (5)Qisassumed Q]isnotassumed
tohave been caused byathird party .
4.4 Inthecaseofamissing person :(5)Qdate lastheard of:
(5)□date ofdeath officially presumed :
5
5.1 Thedeceased insured person (5)\_\was Qjwasnotreceiving apension at
thedate ofhis/hermarriage .
5.2 Thedeceased insured person (5)[Jwas [Jwas notreceiving apension
atthedate ofhis/herdeath .
Ifintheaffirmative ,indicate :
5.3 Type ofpension :
5.4 Pension number :
5.5 Institution responsible forpayment ofpension :
5.6 Date from which thepension was due :
5.7 Date when payment ceased ,where applicable :
6 Thedeceased insured person (5)Qhadrequested Qhadnotrequested
deferment oftheaward ofanold-age pension towhich hewould have been entitled .
(Ifintheaffirmative ,indicate thecountry : ).
B.Information concerning theclaimants
7jWidow ,widower ,orotherclaimants ,excluding children (7)
7.1 Surname Forenames Maiden name
7.2 Place ofbirth Date ofbirth Sex Nationality
7.3 Address (3)(8):
7.4 Date ofmarriage :
7.5 Where applicable ,date ofdivorce :
7.6 Where applicable ,date ofremarriage :
7.7 Name and forenames ofnew spouse :
7.8 Relationship (forclaimants other than widow orwidower ):
©

E203
8
8.1 The person named inbox 7
8.2 (5)Qisengaged in Q]isnotengaged inpaidemployment
8.3 (5)Qis □isnot self-employed .
8.4 Ifintheaffirmative ,state amount ofannual income : (9)
8.5 The person named inbox 7
8.6 (5)Qwas Qwasnotadependant ofthedeceased insured person
8.7 (5)Q]is □isnot
(5)Qpermanently unfit forwork
(5)Qtemporarily unfit forwork ,namely formore than three months (10)
8.8 (5)Qneeds Q]does notneed constant attendance .
8.9 The person named inbox 7
(5)Q]receives Qdoes notreceive apension .
Ifintheaffirmative ,indicate :
8.10 Type ofpension :
8.11 Pension number :
8.12 Institution responsibleforpaymentof pension :
8.13 Date from which pension was due :
8.14 Date when payment ceased ,whereapplicable :
8.15Ifthewidow named inbox 7ispregnant ,give theexpected date ofherconfinement :
i (11)
9 Other known resources (amount andtype ):
~io~|Children Γ2)
10.1 Surname
1Forenames Date ofbirth Relationship
2
3
4
10.2 Address (3)(13):
10.3 Remarks (14):
(D

E203
11 The children residing inthecountry oftheinvestigating institution
(5) ]areentitled [Harenotentitled toabenefit under Article 78ofRegulation 1408/71.
C.Miscellaneous information
12 (5)LjDate ofsubmission ofclaim :
(5)nDate from which thepension was dueifitwas awarded automatically :
13 The investigating institution
(5)fncan  ]cannot make provisional payment ofbenefits under Article 45.1ofRegulation 574/72,
13.1 Ifitcannot ,theinstitutions concerned arerequested toinvestigate thepossibility ofmaking provisional
payment ofbenefits under Article 45.2 ofRegulation 574/72.
[|there arenogrounds formaking deductions tocompensate for
overpayment inaccordance with Article 111ofRegulation 574/72.14 (5)LJThere aregrounds
15 Attached forms : (5)□ E205 □ E206 □ E207 .
16 Investigating institution
16.1 Name :
16.2 Address (3):
16.3 Stamp
16.4 Date :
16.5 Signature
©

E203
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .Itconsists offive pages ,
none ofwhich may beleftout even ifitdoes notcontain any relevant information .
NOTES
(1)Symbol ofthecountry towhich theinvestigating institution belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;Irl=
Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Iftheform istobesent toaDanish institution ,indicate theCPR number and ,where applicable ,theATP number ofthedeceased
insured person .
(3)Postal code ,town ,street ,number ,country .
(4)Ifapplicable ,indicate thedate ofnaturalization .
(5)Put across inthesquare preceding theappropriate subject .
(6)Iftheform istobesent toaDanish institution ,indicate intheboxbelow thedeceased insured person 'slastaddress inDenmark :
Address (3):
(7)Ifthere areseveral persons tobeindicated inbox 7,insert additional copies ofpages 2and3asnecessary .
(8)Iftheform istobesent toaDanish institution ,indicate theclaimant 'saddress inDenmark .
(9)Complete only iftheform istobesent toDanish orFrench institutions .
(10)Complete only iftheform istobesent toNetherlands institutions .
(11)Complete only iftheform istobesent toUnited Kingdom institutions .
(12)Complete only iftheform istobesent toDanish ,French ,Irish ,Netherlands orUnited Kingdom institutions .
(13)Indicate thecommon address .Ifoneofthechildren lives atadifferent address ,indicate intheboxbelow :
Surname and forenames :
Address (3):
(14)Indicate ifthechild ismarried ,invalid ,deceased (date ofdeath ),apprenticed ,orcontinuing studies .
©

See 'Instructions !onpage 6 EUROPEAN COMMUNITIES
Social Security Regulations
E204 n
Country Insurance number (2)Institution concerned
(orliaison body ,ifapplicable )
1)
2).
3)
4)
5)
INVESTIGATION OF ACLAIM FOR AN INVALIDITY PENSION
Reg .1408/71:Art .44to50
Reg .574/72:Art .36to38;Art .41to43;Art .45to47;Art .49;Art .111
Theinvestigating institution should complete thisform and send one copy toeach oftheinstitutions with which
theworker hasbeen insured (institutions concerned )ortotheliaison body .
1jInstitution towhich theform isaddressed (institution concerned orliaison body ,asapplicable )
1.1 Name :
1.2 Address (3):
A.Information concerning theinsured person
3
2.1 Surname Forenames Maiden name
2.2 Place ofbirth Date ofbirth Sex Nationality (4)
2.3 Civil status : (5)\_jsingle Qmarried Qwidow /widower
(5)Qdivorced Qseparated .
2.4 Address atthedate oftheclaim (3)(6):
2.5 Insurance number with theinvestigating institution :
2.6 Filereference oftheinvestigating institution :
©

E204
3 Date which hasbeen determined asthecommencement ofinvalidity :
3.1 Date ofcommencement ofincapacity forwork followed byinvalidity :
3.2 The person concerned
(5)Qisstillengaged in Qisnolonger engaged in
(5)Opaid employment Qself-employment .
3.3 Ifheisengaged inpaid employment (7),indicate :
Amount ofwage orsalary : Weekly hours ofwork :
3.4 Date ofcessation ofnormal professional ortrade activity :
3.5 Type ofactivity :
3.6 Ifheisself-employed ,indicate theamount ofprofessional income (8):
3.7 Other known resources (amount and nature )(9):
3.8 The invalidity
(5)r~lisassumed j~]isnotassumed tohave been caused byathird party .
4 Since thecommencement ofhisincapacity forwork ,theperson concerned
(5)Qhasfollowed occupational rehabilitation courses
(5)\~\hasnotfollowed occupational rehabilitation courses .
Ifhehas,indicate :
4.1 forwhat new occupation :
4.2 theemployer forwhom heworked inthis new occupation :
Name ofemployer orfirm :
Address (3):
4.3 thedate ofcommencement and oftheend ofthisemployment :
4.4 Theperson concerned (5)Qhasbeen receiving Qdoes notreceive anincrease forspouse .
Ifintheaffirmative ,indicate since when :
©

E204
m
5.1 Before thecommencement ofinvalidity benefit ,theperson concerned
(5)Qwas Qwas notreceiving
(5)Qaninvalidity pension Qanold-age pension
(5)Qabenefit foraccident atwork oroccupational disease .
5.2 Ifinthe affirmative ,indicate :
theperiod during which these benefits were orwillbepaid :
institution responsible forpayment :
5.3 Since thecommencement ofhisincapacity ,theperson concerned
(5)Qhasclaimed Qhasnotclaimed
(5)Qisentitled toreceive Qisnotentitled toreceive
(5)Qcash sickness insurance benefits
(5)Qanold-age pension
(5)Qasurvivor 'spension
(5)Qbenefits foraccident atwork oroccupational disease
(5)Qunemployment benefits .
5.4 Ifinthe affirmative ,indicate :
theperiod during which these benefits were orwill bepaid :
institution responsiblefor payment :
5.5 Since thecommencement ofinvalidity benefit ,theperson concerned
(5)Qhasbeen receiving Qhasnotreceived
(5)Qcash sickness insurance benefits
(5)Qanold-age pension
(5)Qunemployment benefits .
5.6 Ifinthe affirmative ,indicate :
theperiod during which these benefits were orwill bepaid :
institution responsiblefor payment :

E204
B.Information concerning themembers oftheinsured person 'sfamily
6ISpouse
6.1 Surname Forenames Maiden name Sex
6.2 Date ofbirth :
6.3 Date ofmarriage :
6.4 The spouse (5)j Iis jjisnotpursuing aprofessional ortrade activity .
6.5 Ifintheaffirmative ,indicate amount ofannual income (7):
6.6 The spouse (5)Qreceives [_]does notreceive apension .
6.7 Ifjn theaffirmative ,indicate :
type ofpension :
institution responsible forpayment :
amount : (5)IImonthly | |quarterly ||annually
6.8 The spouse (5)[_|hasbeen receiving Qdoes notreceive other social benefits (10),namely :
(5)Q]forunemployment Qforsickness
(5)\^]forinvalidity Qother .
6.9 Other known resources :
Children (Tobecompleted only iftheclaimant isnotentitled tosupplements inrespect ofchildren under
^ thelegislation ofhiscountry ofresidence )
7.1 Surname Forenames Date ofbirth Relationship
1
2 ;
3
4
7.2 Address (3)(11):
7.3 Remarks (12):
©

E204
8 Dependent ascendants (13)
8.1 Surname Forenames Date ofbirth Relationship
8.2 Address (3)(11):
8.3 Remarks :
C.Miscellaneous information
9 (5)LJDate ofsubmission ofclaim :
(5)n^ate commencement ofpension ifawarded automatically :
10 Iftheperson concerned canobtain another pension ,indicate :
type ofthis pension : ,
institution responsible forpayment :
11 The investigating institution
(5)Q]can Qcannot make provisional payment ofbenefits under Article 45.1 ofRegulation
No574/72 .
12 Ifinthenegative ,theinstitutions concerned arerequested toinvestigate thepossibility ofmaking provisional
payment ofbenefits under Article 45.2 ofRegulation 574/72.
13 (5)QThere are QThere arenogrounds formaking deductions tocompensate foroverpayment in
grounds accordance with Article 111ofRegulation No574/72.
14 Attached forms : (5)□ E205□ E206n E207□ E213□ E214 (14)
15jInvestigating institution
15.1 Name :
15.2 Address (3):
15.3 Stamp
15.4 Date :
15.5 Signature
©

E204
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .Itconsists ofsixpages ,
none ofwhich may beleftout even ifitdoes notcontain any relevant information .
NOTES
(1)Symbol ofthecountry towhich theinvestigating institution belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Iftheform istobesent toaDanish institution ,indicate CPR number .
(3)Postal code ,town ,street ,number ,country .
(4)Ifapplicable ,indicate thedate ofnaturalization .
(5)Put across inthesquare preceding theappropriate subject .
(6)Iftheform istobesent toaDanish institution ,indicate theclaimant 'slastaddress inDenmark intheboxbelow :
IAddress (3): : I
(7)Complete only iftheform istobesent toDanish ,French ,Irish ,Luxembourg ,Netherlands orUnited Kingdom institutions .
(8)Complete only iftheform istobesent toBelgian ,Danish ,Irish ,Luxembourg orNetherlands institutions .
(9)Complete only iftheform istobesent toDanish institutions .
(10)Complete only iftheform istobesent toBelgian ,Irish orUnited Kingdom institutions .
(11)Indicate thecommon address .Ifoneofthechildren oroneoftheascendants lives atadifferent address ,indicate intheboxbelow :
Surname and forenames :
Address (3):
(12)Indicate ifthechild ismarried ,invalid ,deceased (date ofdeath ),apprenticed ,orcontinuing studies .
(13)Complete only iftheform istobesent toBelgian ,German orUnited Kingdom institutions .
(14)Ifform E204 isissued byaGerman orNetherlands institution ortobesent toaGerman orNetherlands institution ,form E213 and
form E214 should beattached .

EUROPEAN COMMUNITIES
SocialSecurityRegulationsSee'Instructions 'onpage3
E205BV)
CERTIFICATE CONCERNING INSURANCE RECORDINBELGIUM
Reg.1408/71:Art.38;Art.45;Art.48;Art.57.3.C
Reg.574172:Art.42.1;Art.43.1to3;Art.69
Tobedrawnupbytheinvestigating institutionforinsuranceperiodscompletedunderthelegislationwhichitad­
ministers;tobeattachedtoformsE202,E203orE204,asapplicable .Eachinstitutionconcernedshoulddrawup
aformfortheperiodscompletedunderthelegislationwhichitadministersandsendittotheinvestigating institution .
1jInstitutiontowhichtheformisaddressed(institutionconcernedorinvestigatinginstitution,asapplicable)
1.1Name:
1.2Address(2):
2|Filereferences
2.1ofinvestigating institution : :
2.2ofinstitutionconcerned :
3Worker
3.1Surname Forenames Maidenname
3.2Placeofbirth Dateofbirth Sex Nationality
3.3Address(2):
3.4Insurancenumber:
4Personwhohasentitlement (3)
4.1Surname Forenames Maidenname
4.2Placeofbirth Dateofbirth Sex Nationality
4.3Address(2):
©

E205B
5
Periodsduringwhichinsuranceperiodsand
periodstreatedassuchwerecompletedInsurance
periods
(Years)Periods
treatedas
insurance
periods(4)
(Years)Insurance
schemeOccupation (5)
Year|from to
5.1TotallengthofperiodofinsuranceunderBelgiansocialsecurityschemesforemployedpersons:
5.2Remarks :
L2J

(DE205 B
6Theinsuredpersonshowingproofthathehascompleted aninsurance periodoflessthanoneyear
(6)Qmayreceive Qmaynotreceive
apensionundernationallegislation (Art.48.1ofReg.1408/71).
7Institution completing theform
7.1Name :
7.2Address (2):
7.3Stamp
7.4Date:
7.5Signature
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.Itconsistsofthreepages,none
ofwhichmaybeleftoutevenifitdoesnotcontainanyrelevantinformation .
NOTES
(1)Symbolofthecountrytowhichtheinstitution completing theformbelongs(B=Belgium).
(2)Postalcode,town,street,number ,country .
(3)Tobecompleted ifapplicable .
(4)Specifyatpoint5.2thetypeofperiodsthataretreatedasinsurance periods .
(5)Forworkerswhohavebeenemployed inminesorsimilarundertakings ,attachformE206.
(6)Putacrossinthesquarepreceding theappropriate subject .

See'Instructions 'onpage3 EUROPEAN COMMUNITIES
SocialSecurityRegulations
E205DK(1
CERTIFICATE CONCERNING PERIODS OFINSURANCE ANDPERIODS
OFRESIDENCE INDENMARK
Reg.1408/71:Art.38;Art.45;Art.48;Art.57.3.C
Reg.574172:Art.42.1;Art.43.1to3;Art.69
Tobedrawnupbytheinvestigating institutionforinsuranceperiodscompletedunderthelegislationwhichitad­
ministers;tobeattachedtoformsE202,E203orE204,asapplicable .Eachinstitutionconcernedshoulddrawup
aformfortheperiodscompletedunderthelegislationwhichitadministersandsendittotheinvestigating institution .
1Institutiontowhichtheformisaddressed (institutionconcernedorinvestigating institution ,asapplicable)
1.1Name:
1.2Address(2):
2Filereferences
2.1ofinvestigating institution :
2.2ofinstitutionconcerned :
3jWorker
3.1Surname Forenames Maidenname
3.2Placeofbirth Dateofbirth Sex Nationality
3.3Address(2):
3.4CPRnumber: ATPnumber:
4Personwhohasentitlement (3)
4.1Surname Forenames Maidenname
4.2Placeofbirth Dateofbirth Sex Nationality
4.3Address(2):
4.4CPRnumber:

E205DK
5j
Periodsduringwhichperiodsof
residenceandperiodstreatedassuch
werecompletedunderthelaw
onsocialpensionsPeriodsof
residencePeriods
treatedas
periodsof
residencePeriodsinwhichinsuranceperiods
werecompletedunderthelawonsupplementary
pensions (ATP)
Year from toNumber Number
ofyearsofyearsYearIfromItoNumber
ofvears
5.1TotallengthofperiodofinsuranceunderDanishsocialsecurityschemesforemployedpersons:
5.2Remarks :

E205DK
6Theinsuredpersonshowingproofthathehascompleted aninsurance periodoflessthanoneyear
(4)Q]mayreceive Qmaynotreceive
apensionundernationallegislation (Art.48.1ofReg.1408/71).
7Institution completing theform
7.1Name :
7.2Address (2):
7.3Stamp
7.4Date:
7.5Signature
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.Itconsistsofthreepages,none
ofwhichmaybeleftoutevenifitdoesnotcontainanyrelevantinformation .
NOTES
(1)Symbolofthecountrytowhichtheinstitution completing theformbelongs (Dk=Denmark).
(2)Postalcode,town,street,number ,country .
(3)Tobecompleted ifapplicable .
(4)Putacrossinthesquarepreceding theappropriate subject .
(D

See'Instructions 'onpage3 EUROPEAN COMMUNITIES
SocialSecurityRegulations
E205Dr
CERTIFICATE CONCERNING INSURANCE RECORDINGERMANY
Reg.1408/71:Art.38;Art.45;Art.48;Art.57.3.C
Reg.574/72:Art.42.1;Art.43.1to3;Art.69
Tobedrawnupbytheinvestigating institutionforinsuranceperiodscompletedunderthelegislationwhichitad­
ministers;tobeattachedtoformsE202,E203orE204,asapplicable .Eachinstitutionconcernedshoulddrawup
aformfortheperiodscompletedunderthelegislationwhichitadministersandsendittotheinvestigating institution .
1|Institutiontowhichtheformisaddressed(institutionconcernedorinvestigatinginstitution,asapplicable)
1.1Name:
1.2Address(2):
2JFilereferences
■2.1ofinvestigating institution :
2.2ofinstitutionconcerned :
3|Worker
3.1Surname Forenames Maidenname
3.2Placeofbirth Dateofbirth Sex Nationality
3.3Address(2):
3.4Insurancenumber:
4jPersonwhohasentitlement(3)
4.1Surname Forenames Maidenname
4.2Placeofbirth Dateofbirth Sex Nationality
4.3Address(2):

E205D
5I
Periodsduringwhichinsuranceperiodsand
periodstreatedassuchwerecompletedInsurance
periods(4)Periodstreated
asinsurance
periods(5)Insurance
schemeOccupation (6)
WeeksMonths Year from to WeeksMonths
5.1TotallengthofperiodofinsuranceunderGermansocialsecurityschemesforemployedpersons:
5.2Remarks :

(DE205D
6Theinsuredpersonshowingproofthathehascompleted aninsurance periodoflessthanoneyear
(7)Qmayreceive Q]maynotreceive
apensionundernationallegislation (Art.48.1ofReg.1408/71).
7jInstitutioncompletingtheform
7.1Name :
7.2Address (2):
7.3Stamp
7.4Date:
7.5Signature
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.Itconsistsofthreepages,none
ofwhichmaybeleftoutevenifitdoesnotcontainanyrelevantinformation .
NOTES
(1)Symbolofthecountrytowhichtheinstitution completing theformbelongs(D=Germany).
(2)Postalcode,town,street,number ,country .
(3)Tobecompleted ifapplicable .
(4)Write'P'afternumberofweeksormonthsofperiodsofcompulsory insurance ('Pflichtversicherung ')todistinguish themfromperiods
ofvoluntary insurance .
(5)Write'E'afternumberofweeksormonthsofsubstitute periods('Ersatzzeiten ')todistinguish themfrominterrupted periods .Atpoint
5.2thetypeofperiodsthataretreatedasinsurance periodsshouldbespecified .
(6)Forworkerswhohavebeenemployed inminesorsimilarundertakings ,attachformE206.
(7)Putacrossinthesquarepreceding theappropriate subject .

See'Instructions 'onpage3 EUROPEAN COMMUNITIES
SocialSecurityRegulations
E205F(1
CERTIFICATE CONCERNING INSURANCE RECORDINFRANCE
Reg.1408/71:Art.38;Art.45;Art.48;Art.57.3.C
Reg.574172:Art.42.1;Art.43.1to3;Art.69
Tobedrawnupbytheinvestigating institutionforinsuranceperiodscompletedunderthelegislationwhichitad­
ministers;tobeattachedtoformsE202,E203orE204,asapplicable .Eachinstitutionconcernedshoulddrawup
aformfortheperiodscompletedunderthelegislationwhichitadministersandsendittotheinvestigating institution .
1Institutiontowhichtheformisaddressed(institutionconcernedorinvestigating institution ,asapplicable)
1.1Name:
1.2Address(2):
2jFilereferences
2.1ofinvestigating institution :
2.2ofinstitutionconcerned :
3|Worker
3.1Surname Forenames Maidenname
3.2Placeofbirth Dateofbirth Sex Nationality
3.3Address(2):
3.4Insurancenumber :
4Personwhohasentitlement (3)
4.1Surname Forenames Maidenname
4.2Placeofbirth Dateofbirth Sex Nationality
4.3Address(2):

E205F
U
Periodsduringwhichinsuranceperiodsand
periodstreatedassuchwerecompletedInsurance
periods(4)
QuartersPeriods
treatedas
insurance
periods(5)
QuartersInsurance
schemeOccupation (6)
YearIfrom to
5.1TotallengthofperiodofinsuranceunderFrenchsocialsecurityschemesforemployedpersons:
5.2Remarks :

E205 F
6Theinsuredpersonshowingproofthathehascompleted aninsurance periodoflessthanoneyear
(7)(Z]mayreceive [Jmaynotreceive
apensionundernationallegislation (Art.48.1ofReg.1408/71).
7Institution completing theform
7.1Name :
7.2Address (2):
7.3Stamp
7.4Date:
7.5Signature
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.Itconsistsofthreepages,none
ofwhichmaybeleftoutevenifitdoesnotcontainanyrelevantinformation .
NOTES
C1)Symbolofthecountrytowhichtheinstitution completing theformbelongs(F=France).
(2)Postalcode,town,street,number,country .
(3)Tobecompleted ifapplicable .
(4)Write'V'afterperiodsofvoluntaryinsurance todistinguish themfromperiodsofcompulsory insurance .
(5)Specifyatpoint5.2thetypeofperiodsthataretreatedasinsurance periods .
(6)Forworkerswhohavebeenemployed inminesorsimilarundertakings ,attachformE206.
(7)Putacrossinthesquarepreceding theappropriate subject .
<D

EUROPEAN COMMUNITIES
SocialSecurityRegulationsSee'Instructions 'onpage3
E205RL(1
CERTIFICATE CONCERNING INSURANCE RECORDINIRELAND
Reg.1408/71:Art.38;Art.45;Art.48;Art.57.3.c
Reg.574/72:Art.42.1;Art.43.1to3;Art.69
Tobedrawnupbytheinvestigating institutionforinsuranceperiodscompletedunderthelegislationwhichitad­
ministers;tobeattachedtoformsE202,E203orE204,asapplicable .Eachinstitutionconcernedshoulddrawup
aformfortheperiodscompletedunderthelegislationwhichitadministersandsendittotheinvestigating institution .
1jInstitutiontowhichtheformisaddressed(institutionconcernedorinvestigatinginstitution,asapplicable)
1.1Name:
1.2Address(2):
2|Filereferences
2.1ofinvestigating institution :
2.2ofinstitutionconcerned :
3Worker
3.1Surname Forenames Maidenname
3.2Placeofbirth Dateofbirth Sex Nationality
3.3Address(2):
3.4Insurancenumber:
4jPersonwhohasentitlement(3)
4.1Surname Forenames Maidenname
4.2Placeofbirth Dateofbirth Sex Nationality
4.3Address(2):

E205IRL
Il
Periodsduringwhichinsuranceperiodsand
periodstreatedassuchwerecompletedInsurance
periods(4)Periods
treatedas
insurance
periodsReasonfor
treating
these
periodsas
insurance
periods(5)Occupation (6)(7)
Yearjfrom to|Weeks[Weeks
5.1TotallengthofperiodofinsuranceundertheIrishsocialsecurityschemeforemployedpersons:
5.2Remarks :

E205IRL
6Theinsuredpersonshowingproofthathehascompleted aninsurance periodoflessthanoneyear
(8)Q]mayreceive Qmaynotreceive
apensionundernationallegislation (Art.48.1ofReg.1408/71).
7Institution completing theform
7.1Name :
7.2Address (2):
7.3Stamp
7.4Date:
7.5Signature
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.Itconsistsofthreepages,none
ofwhichmaybeleftoutevenifitdoesnotcontainanyrelevantinformation .
NOTES
(1)Symbolofthecountrytowhichtheinstitution completing theformbelongs (Irl=Ireland).
(2)Postalcode,town,street,number ,country .
(3)Tobecompleted ifapplicable .
(4)Write'V'afternumberofweekstoindicatevoluntary insurance ,ifapplicable .
(5)Statewhetherperiodsofsickness ,unemployment ,etc.
(6)Forworkerswhohavebeenemployed inminesorsimilarundertakings ,attachformE206.
(7)Thisinformation canonlybegivenfromstatements madebytheworker .
(8)Putacrossinthesquarepreceding theappropriate subject .

EUROPEAN COMMUNITIES
SocialSecurityRegulationsSee'Instructions onpage3
E205I(1)
CERTIFICATE CONCERNING INSURANCE RECORDINITALY
Reg.1408/71:Art.38;Art.45;Art.48;Art.57.3.C
Reg.574/72:Art.42.1;Art.43.1to3;Art.69
Tobedrawnupbytheinvestigating institutionforinsuranceperiodscompletedunderthelegislationwhichitad­
ministers;tobeattachedtoformsE202,E203orE204,asapplicable .Eachinstitutionconcernedshoulddrawup
aformfortheperiodscompletedunderthelegislationwhichitadministersandsendittotheinvestigating institution .
1Institutiontowhichtheformisaddressed(institutionconcernedorinvestigating institution ,asapplicable)
1.1Name:
1.2Address(2):
2Filereferences
2.1ofinvestigating institution :
2.2ofinstitutionconcerned :
3Worker
3.1Surname Forenames Maidenname
3.2Placeofbirth Dateofbirth Sex Nationality
3.3Address(2):
3.4Insurancenumber :
4Personwhohasentitlement (3)
4.1Surname Forenames Maidenname
4.2Placeofbirth Dateofbirth Sex Nationality
4.3Address(2):

E205I
5
Periodsduringwhichinsuranceperiodsand
periodstreatedassuchwerecompleted -Insurance
periods(4)Periodstreated
asinsurance
periods(5)Insurance
schemeOccupation (6)
Year from to WeeksMonthsWeeksMonths
5.1TotallengthofperiodofinsuranceunderItaliansocialsecurityschemesforemployedpersonsandfor
self-employed personstreatedasemployedpersons:
5.2Remarks :

E205 I
6Theinsuredpersonshowingproofthathehascompleted aninsurance periodoflessthanoneyear
(7)Qmayreceive Qmaynotreceive
apensionundernationallegislation (Art.48.1ofReg.1408/71).
7Institution completing theform
7.1Name :
7.2Address (2):
7.3Stamp
7.4Date
7.5Signature
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.Itconsistsofthreepages,none
ofwhichmaybeleftoutevenifitdoesnotcontainanyrelevantinformation .
NOTES
C)Symbolofthecountrytowhichtheinstitution completing theformbelongs(I=Italy).
(2)Postalcode,town,street,number ,country .
(3)Tobecompleted ifapplicable .
(4)Write'P'afternumberofweeksormonthsofperiodsofcompulsory insurance todistinguish themfromperiodsofvoluntary insurance .
(5)Specifyatpoint5.2thetypeofperiodsthataretreatedasinsurance periods .
(6)Forworkerswhohavebeenemployed inminesorsimilarundertakings ,attachformE206.
(7)Putacrossinthesquarepreceding theappropriate subject .

EUROPEAN COMMUNITIES
SocialSecurityRegulationsSee'Instructions 'onpage3
E205LD
CERTIFICATE CONCERNING INSURANCE RECORDINLUXEMBOURG
Reg.1408/71:Art.38;Art.45;Art.48;Art.57.3.C
Reg.574/72:Art.42.1;Art.43.1to3;Art.69
Tobedrawnupbytheinvestigating institutionforinsuranceperiodscompletedunderthelegislationwhichitad­
ministers;tobeattachedtoformsE202,E203orE204,asapplicable .Eachinstitutionconcernedshoulddrawup
aformfortheperiodscompletedunderthelegislationwhichitadministersandsendittotheinvestigating institution .
1IInstitutiontowhichtheformisaddressed(institutionconcernedorinvestigatinginstitution,asapplicable)
1.1Name:
1.2Address(2):
2Filereferences
2.1ofinvestigating institution :
2.2ofinstitutionconcerned :
3Worker
3.1Surname Forenames Maidenname
3.2Placeofbirth Dateofbirth Sex Nationality
3.3Address(2):
3.4Insurancenumber:
4IPersonwhohasentitlement(3)
4.1Surname Forenames Maidenname
4.2Placeofbirth Dateofbirth Sex Nationality
4.3Address(2):

E205L
Ll
Periodsduringwhichinsuranceperiodsand
periodstreatedassuchwerecompletedInsurance
periodsPeriodstreated
asinsurance
periods(4)Insurance
schemeOccupation (5)
Year from toDaysjMonthsDaysMonths
5.1TotallengthofperiodofinsuranceunderLuxembourg socialsecurityschemesforemployedpersons:
5.2Remarks :
i

E205 L
6Theinsuredpersonshowingproofthathehascompleted aninsurance periodoflessthanoneyear
(6)[Jmayreceive Q]maynotreceive
apensionundernationallegislation (Art.48.1ofReg.1408/71).
7Institution completing theform
7.1Name :
7.2Address (2):
7.3Stamp
7.4Date:
7.5Signature
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.Itconsistsofthreepages,none
ofwhichmaybeleftoutevenifitdoesnotcontainanyrelevantinformation .
NOTES
(1)Symbolofthecountrytowhichtheinstitution completing theformbelongs(L=Luxembourg ).
(2)Postalcode,town,street,number ,country .
(3)Tobecompleted ifapplicable .
(4)Specifyatpoint5.2thetypeofperiodsthataretreatedasinsurance periods .
(5)Forworkerswhohavebeenemployed inminesorsimilarundertakings ,attachformE206.
(6)Putacrossinthesquarepreceding theappropriate subject.
@

EUROPEAN COMMUNITIES
SocialSecurityRegulationsSee'Instructions 'onpage3
E205N(1)
CERTIFICATE CONCERNING INSURANCE RECORDINTHENETHERLANDS
Reg.1408/71:Art.38;Art.45;Art.48;Art.57.3.C
Reg.574172:Art.42.1;Art.43.1to3;Art.69
Tobedrawnupbytheinvestigating institutionforinsuranceperiodscompletedunderthelegislationwhichitad­
ministers;tobeattachedtoformsE202,E203orE204,asapplicable .Eachinstitutionconcernedshoulddrawup
aformfortheperiodscompletedunderthelegislationwhichitadministersandsendittotheinvestigating institution .
1Institutiontowhichtheformisaddressed (institutionconcernedorinvestigating institution ,asapplicable)
1.1Name:
1.2Address(2):
2Filereferences
2.1ofinvestigating institution :
2.2ofinstitutionconcerned :
3Worker
3.1Surname Forenames Maidenname
3.2Placeofbirth Dateofbirth Sex Nationality
3.3Address(2):
3.4Insurancenumber :
4Personwhohasentitlement (3)
4.1Surname Forenames Maidenname
4.2Placeofbirth Dateofbirth Sex Nationality
4.3Address(2):

E205N
5
Insuranceperiods
.underAOW/AWW(4)Insuranceperiods
underWAO(4)Numberof
Type(5)
from to from toYearsMonths Days
5.1TotallengthofperiodofinsuranceintheNetherlands underAOW,AWWandWAO(6):
years, months, days.

E205 N
6Theinsuredpersonshowingproofthathehascompleted aninsurance periodoflessthanoneyear
(7)Qmayreceive Qmaynotreceive
apensionundernationallegislation (Art.48.1ofReg.1408/71).
7Institution completing theform
7.1Name :
7.2Address (2):
7.3Stamp
7.4Date:
7.5Signature
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.Itconsistsofthreepages,none
ofwhichmaybeleftoutevenifitdoesnotcontainanyrelevantinformation .
NOTES
C)Symbolofthecountrytowhichtheinstitution completing theforrpbelongs(N=Netherlands ).
(2)Postalcode,town,street,number ,country .
(3)Tobecompleted ifapplicable .
(4)AOW=lawongeneralold-ageinsurance .
AWW=lawongeneralwidows 'andorphans 'insurance .
WAO=lawoninsurance againstprotracted incapacity forwork.
(5)Toindicateperiodsofinsurance underAOWandAWW,usethefollowing symbols :
P=compulsory insurance ;
F=voluntary insurance ;
G=periodstreatedasequivalent .
(6)Deletewhichever isnotapplicable .As,undertheNetherlands insurance scheme ,theinsuredarenotregistered ,itispossiblethat
thelistatpoint5includesperiodsduringwhichthepersonconcerned wasonlypresumed tohavebeeninsuredintheNetherlands .
Ifitisfoundthat,intheinsurance periodsintheNetherlands asindicated inthatlist,thepersonconcerned wasinfactinsuredunder
thelegislation ofyourcountry ,youmay,withoutfirstconsulting us,subtracttheseperiodsfromthetotallengthofinsurance periods
intheNetherlands indicated atpoint5.1.
(7)Putacrossinthesquarepreceding theappropriate subject­

See'Instructions 'onpsge3 EUROPEAN COMMUNITIES
SocialSecurityRegulations
E205UK(1)
CERTIFICATE CONCERNING INSURANCE RECORDINTHEUNITEDKINGDOM
Reg.1408/71:Art.38;Art.45;Art.48;Art.57.3.C
Reg.574172:Art.42.1;Art.43.1to3;Art.69
Tobedrawnupbytheinvestigating institutionforinsuranceperiodscompletedunderthelegislationwhichitad­
ministers;tobeattachedtoformsE202,E203orE204,asapplicable .Eachinstitutionconcernedshoulddrawup
aformfortheperiodscompletedunderthelegislationwhichitadministersandsendittotheinvestigating institution .
1Institutiontowhichtheformisaddressed(institutionconcernedorinvestigating institution ,asapplicable)
1.1Name:
1.2Address(2):
2|Filereferences
2.1ofinvestigating institution :
2.2ofinstitutionconcerned :
3Worker
3.1Surname Forenames Maidenname
3.2Placeofbirth Dateofbirth Sex Nationality
3.3Address(2):
3.4Insurancenumber:
4Personwhohasentitlement (3)
4.1Surname Forenames Maidenname
4.2Placeofbirth Dateofbirth Sex Nationality
4.3Address(2):

E205UK
5
Periodsduringwhichinsuranceperiodsand
periodstreatedassuchwerecompletedInsurance
periods(4)Periods
treatedas
insurance
periodsReasonfor
treating
these
periodsas
insurance
periods(5)Occupation (6)(7)
Yearfrom JtoWeeks Weeks
5.1TotallengthofperiodofinsuranceundertheUnitedKingdomsocialsecurityschemeforemployedpersons:
5.2Remarks :

E205UK
6Theinsuredpersonshowingproofthathehascompleted aninsurance periodoflessthanoneyear
(8)Qmayreceive Q]maynotreceive
apensionundernationallegislation (Art.48.1ofReg.1408/71).
7Institution completing theform
7.1Name :
7.2Address (2):
7.3Stamp
7.4Date:
7.5Signature
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.Itconsistsofthreepages,none
ofwhichmaybeleftoutevenifitdoesnotcontainanyrelevantinformation .
NOTES
(1)Symbolofthecountrytowhichtheinstitution completing theformbelongs (UK=UnitedKingdom).
(2)Postalcode,town,street,number ,country .
(3)Tobecompleted ifapplicable .
(4)Write'V'afternumberofweekstoindicatevoluntary insurance .
(5)Statewhetherperiodsofsickness ,unemployment ,etc.
(6)Forworkerswhohavebeenemployed inminesorsimilarundertakings ,attachformE206.
(7)Thisinformation canonlybegivenfromstatements madebytheworker .
(8)Putacrossinthesquarepreceding theappropriate subject .

SeeInstructions anpage3 EUROPEAN COMMUNITIES
SocialSecurityRegulations
E2061
CERTIFICATE CONCERNING PERIODSOFEMPLOYMENT INMINES
ANDSIMILARUNDERTAKINGS
Reg.1408/71:Art.38;Art.45;Art.48;Art.57.3.C
Reg.574/72:Art.42.1;Art.43.1to3;Art.69
Tobedrawnupbytheinvestigating institutionforinsuranceperiodscompletedunderthelegislationwhichitad­
ministers;tobeattachedtoformsE202,E203orE204,asapplicable .Eachinstitutionconcernedshoulddrawup
aformfortheperiodscompletedunderthelegislationwhichitadministersandsendittotheinvestigatinginstitution .
1Institutiontowhichtheformisaddressed(institutionconcernedorinvestigatinginstitution,asapplicable)
1.1Name:
1.2Address(2):
2Filereferences
2.1ofinvestigating institution :
2.2ofinstitutionconcerned :
3Worker
3.1Surname Forenames Maidenname
3.2Placeofbirth Dateofbirth Sex Nationality
3.3Address(2):
3.4Insurancenumber:
4jPersonwhohasentitlement(3)
4.1Surname Forenames Maidenname
4.2Placeofbirth Dateofbirth Sex Nationality
4.3Address(2):

E206
5
Lengthofeachperiod Periodsofemployment
orperiodstreated
assuchUndertakings (4)overall underground work Typeofwork
performed (5)
YearsMonthsDaysYearsMonthsDays from to
5.1 Total

E206
6Theperiodsofemployment shownatpoint5wereinterrupted asfollows(6):
Periodsofinterruption
from I toReasonforinterruption (sickness ,leave,militaryservice,
activeservice,unemployment ,medical treatment ,
retraining ,unpaidleave,etc.)Day/Month/Year|Day/Month/Year
7Institution completing theform
7.1Name :
7.2Address (2):
7.3Stamp
7.4Date:
7.5Signature
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.Itconsistsofthreepages,
noneofwhichmaybeleftoutevenifitdoesnotcontainanyrelevantinformation .
NOTES
(1)Symbolofthecountrytowhichtheinstitution completing theformbelongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France;
Irl=Ireland;I=Italy;L=Luxembourg ;N=Netherlands ;UK=UnitedKingdom .
(2)Postalcode,town,street,number ,country .
(3)Tobecompleted ifapplicable .
(4)Indicatetheundertakings inwhichthepersonconcerned wasemployed andthesubstance extracted orprocessed .
(5)Specifytypeofworkandindicatewhetherperformed atthesurfaceorunderground ,orwhetheritconcerns periodstreatedasperiods
ofemployment
(6)Complete onlyiftheformistobesenttoGermaninstitutions .

SeeInstructions 'onpage3 EUROPEAN COMMUNITIES
SocialSecurityRegulations
E207n
INFORMATION CONCERNING THEWORKER'S INSURANCE HISTORY
Reg.1408/71:Art.38;Art.45;Art.48;Art.57.3.C
Reg.574172:Art.42.1;Art.69
Tobecompletedwherenecessarybytheinvestigating institutionandtobeattachedtoformsE202,E203andE204
exceptiftheseformsaresenttoaUnitedKingdominstitution .
Theinformationinbox3hasbeenobtainedfromthepersonconcernedandwillbesenttotheinstitutionconcerned
foritsrecord.
1Worker
1.1Surname Forenames Maidenname
1.2Placeofbirth Dateofbirth Sex Nationality
1.3Address(2):
1.4Insurancenumber:
(Informationrelatingtoeachperiod:seepage2)
2jInvestigatinginstitution
2.1Name:
2.2Address(2):
2.3Stamp
2.4Date:
2.5Signature

3 Information relating to each period E 207 
Periods (3) 
Type of work (*) Name of employer and place of 
registered office Place and country 
of actual employment a) Insurance institution or scheme 
b) Insurance number (5) 
c) Type of insurance (6) Place of residence 
during period 
of employment from to Type of work (*) Name of employer and place of 
registered office Place and country 
of actual employment a) Insurance institution or scheme 
b) Insurance number (5) 
c) Type of insurance (6) Place of residence 
during period 
of employment 
1 2 3 4 5 6 7 
1 
a) , 
b) 
c) 
2 
a) 
b) 
c) 
3 
a) 
b) 
c) 
4 
a) 
b) 
c) -
5 
a) 
b) 
c) 
6 
a> : 
b) 
c) : 
7 
a) 
b) 
c) 
8 
a) ' 
b) 
c) 

E207
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .Itconsists ofthree pages ,
none ofwhich may beleft out even ifitdoes not contain any relevant information .Ifthe space
provided onpage 2isnotsufficient toindicate allstages ofthe insurance history ofthe person
concerned ,insert one ormore identical pages ,changing the numbers atthe extreme left-hand side
(replacing 1,2,3...by9,10,11 ...).
NOTES
(1)Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Postal code ,town ,street ,number ,country .
(3)Iftheform istobesent toaDanish orNetherlands institution ,indicate allperiods ofresidence completed bytheworker inDenmark
orintheNetherlands respectively .
(4)Indicate thetype ofwork performed (employed orself-employed ),e.g. mechanic ,shop assistant ,self-employed farmer .Where
applicable :military service (country ),school orvocational training ,periods without paid employment (e.g. housewife ,unemployed ,
sickness ,etc.).
(5)Iftheform istobesent toaDanish institution ,indicate CPR number and ,where applicable ,ATP number .
(6)Specify whether compulsory insurance ,voluntary insurance ,optional continued insurance orperiod uninsured .

SeeInstructions'onpage3 EUROPEAN COMMUNITIES
SocialSecurityRegulations
E208 C)
DETERMINATION OFRIGHTSTOPENSION
to(2)[]anold-agepensionQ]invaliditypensionQ]survivor'spension
in(3)
Reg.1408/71:Art.46.1and2;Art.49.2and3
Reg.574172:Art.43.2and3;Art.46
Tobesentbytheinstitutionconcernedtotheinvestigating institution .
1Investigating institutiontowhichtheformisaddressed
1.1Name:
1.2Address(4):
2Filereferences
2.1ofinvestigating institution :
2.2ofinstitutionconcerned :
3Insuredperson
3.1Surname Forenames Maidenname
j3.2Dateofbirth Sex Insurancenumber
3.3Address(4):
4Personwhohasentitlement (5)
4.1Surname Forenames Maidenname
4.2Dateofbirth Sex
4.3Address(4):
4.4Relationship tothedeceasedinsuredperson
5Dateofpensionclaim:

E208
6Iftheclaimisrejected(6)
Reason:
7Ifapensionisawarded(6)
7.1Annualamount(7)ofthenationalpensionreferredtoinArt.46.1(firstsubparagraph )ofRegulation
1408/71whichthepersonconcernedmayclaimforperiodsofinsurance(compulsory ,voluntaryor
optionalcontinued)andperiodstreatedassuchcompletedinthecountryconcerned ,evenifsomeofthese
periodsoverlapwithperiodscompletedinanothercountry:
7.2Actualannualamount(7)ofthetheoreticalpensionreferredtoinArt.46.2ofRegulation1408/71which
wouldbepayableifallinsuranceperiodsandperiodstreatedassuch,determinedinaccordancewiththe
ruleslaiddowninArt.15ofRegulation574/72,hadbeencompletedinthecountryconcerned :
7.3Actualannualamount(7)oftheproportionalpensionreferredtoinArt.46.2.b,canddofRegulation
1408/71,calculatedbytakingintoconsideration periodscompletedinthecountryconcerned,excluding
periodsofvoluntaryoroptionalcontinuedinsuranceoverlappingwithperiodsofinsurancecompletedin
anothercountry:
7.4Actualannualamount(7)oftheproportionalpensionreferredtoinArt.46.2.b,canddofRegulation
1408/71,calculatedbytakingintoconsideration periodscompletedinthecountryconcerned,including
periodsofvoluntaryoroptionalcontinuedinsuranceoverlappingwithperiodsofinsurancecompletedin
anothercountry:
7.5Datefromwhichbenefitsarepayable:
8Institutionconcerned
8.1Name:
8.2Address(4):
8.3Stamp
8.4Date:
8.5Signature

E208
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .Itconsists ofthree pages ,
none ofwhich may beleftout even ifitdoes notcontain any relevant information .
NOTES
(1)Symbol ofthecountry towhich theinstitution concerned belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Putacross inthesquare preceding theappropriate subject .
(3)Indicate thecountry .
(4)Postal code ,town ,street ,number ,country .
(5)Tobecompleted only inthecase ofaclaim forasurvivor 'spension .
(6)Complete box 6or7asapplicable .
(7)The annual amount isequal tothetotal oftheamounts tobepaid inthecourse ofone year ,calculated onthebasis oftherateof
benefit applicable atthedate ofcommencement ofthepension .

See'Instructions 'onpage3 EUROPEAN COMMUNITIES
SocialSecurityRegulations
E2091)
DETERMINATION OFPENSION AMOUNTS
(2)Dold-agepension[]invaliditypension[]survivor'spension
REGARDING THEPOSSIBLE APPLICATION OFARTICLE46.3OFREGULATION 1408/71
Theinvestigating institutionshouldcompletethisformandsendacopytoeachoftheinstitutionsconcerned .
1Institutionconcernedtowhichtheformisaddressed
1.1Name:
1.2Address(3):
2Filereferences
2.1ofinvestigating institution :
2.2ofinstitutionconcerned :
3IInsuredperson
3.1Surname Forenames Maidenname
3.2Placeofbirth Dateofbirth Sex Nationality
4Personwhohasentitlement (4)
4.1Surname Forenames Maidenname
4.2Dateofbirth: Sex:
4.3Address(3):
4.4Relationship tothedeceasedinsuredperson:
(Determination ofamounts :seepage2)
5Investigating institution
5.1Name:
5.2Address(3):
5.3Stamp
5.4Date:
5.5Signature

E209
EL Determination ofpension amounts on (date )
Annual amount inthecurrency ofthecountry ofthe
competent institution (5)Annual amount inthecurrency ofthecountry ofthe
investigating institution
Highest amount incolumns 3or4(7) Country responsible
forthepayment
ofthebenefitAnnual amount inthecurrency
ofthecountry ofthe,competent
institution (5)
(Pension after application
ofArt.46.3 ofReg .1408/71)(S)National pension
(Art.46.1 first sub­
paragraph ofReg .
1408 /71)Proportional pension (6)
(Art.46.2.b ofReg .
1408 /71)Theoretical pension
(Art.46.2.a ofReg .
1408 /71)Product of
multiplication ofthe
amounts incol.6by
reduction coefficient
(seebox7)(8)Theoretical pension
(Art.46.2.a ofReg .
1408 /71)Amounts incol.3
(Art.46.1 first sub­
paragraph ofReg .
1408/71)Amounts incol.4
(Art.46.2.b ofReg .
1408/71)
1 2 3 4 5 6 7 8 9
1.
2.
3.
4.
5.
Total A B
Repeat oftotal Bfrom col.7 B
8 Parities (10)
Total pensions duefrom allcountries (C=A+B) CCurrency ofthecountry ofthe
competent institutionCurrency ofthecountry ofthe
investigating institution
D Highest theoretical pension from col.5
E Difference (C-D =E)DM .100 x
Bfrs .100 x
FF.100 x
Lit.100 x
Lfrs .100 x
Fl.100 x
Dkr .100 x
UK.£100 x
Ir.£100 x—IDetermination ofreduction coefficient pursuant toArt.46.3 ofReg .1408/71(Coefficient used for
7Icalculation ofamounts incol.8ofbox6)(8)
A Total amount ofnational pensions (col.6)
Amount ofthedifference E
© A-EReduction coefficient F=AF

E209
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .Itconsists ofthree pages ,
none ofwhich may beleft out even ifitdoes not contain any relevant information .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Put across inthesquare preceding theappropriate subject .
(3)Postal code ,town ,street ,number ,country .
(4)Tobecompleted only inthecase ofaclaim forasurvivor 'spension .
(5)State which currency .
(6)Calculated without reference toperiods ofvoluntary oroptional continued insurance coinciding with periods ofcompulsory insurance
completed inanother country .
(7)Iftheamount incolumn 3isthesame asthat incolumn 4thisamount should beindicated incolumn 7.
(8)Complete only iftheamounts atAand Eincolumn 6arepositive .
(9)Totheamount incolumn 7should beadded ,where applicable ,theincrease ofpension provided forinArt .46.1 ofReg .574/72,
corresponding toperiods ofvoluntary oroptional continued insurance coinciding with periods ofinsurance completed inanother
country .
(10)See Reg .574/72,Art .107 .
<D

SeeInstructions onpage3EUROPEAN COMMUNITIES
SocialSecurityRegulations
E210 (1)
NOTIFICATION OFDECISION CONCERNING ACLAIMFORPENSION
for(2)Q]oldage[]invalidity Q]survivor
(awardorrejection)
Reg.574/72:Art.48
Eachoftheinstitutionsconcernedshouldcompletethisformmduplicate,sendingthemtotheinvestigating insti­
tutionandattachingtwocopiesoftheformaldecision.Ifthereismorethanoneinstitutionconcerned,oneextra
copyshouldbeaddedforeachadditionalinstitutionconcerned .
1Investigating institutiontowhichtheformisaddressed
1.1Name:
1.2Address(3):
2Filereferences
2.1ofinvestigating institution :
2.2ofinstitutionconcerned :
3Insuredperson
3.1Surname Forenames Maidenname
v
3.2Placeofbirth Dateofbirth Sex Nationality
3.3Address(3):
3.4Insurancenumber:
4Personwhohasentitlement (4)
4.1Surname Forenames Maidenname
4.2Placeofbirth Dateofbirth Sex Nationality
4.3Relationship todeceasedinsuredperson:
4.4Address(3):

IE210
5jTheclaimisrejected(5)
Reason:
6jApensionisawarded(5)
6.1Annualamount:
6.2Whereappropriate ,deductionundertheprovisionsonthepreventionof
overlapping (Art.12ofReg.1408/71andArt.7ofReg.574/72):
Reason:
6.3Amountdue:
6.4Payablefrom(date):
7ADanishpensionisawarded(6)
7.1Annualamountunderthelegislationonsocialpensions:
7.2Annualamountunderthelegislationonsupplementary pensionsforemployed
persons(ATP):
7.3Totalannualamount:
7.4Whereappropriate ,deductionundertheprovisionsonthepreventionofover­
lapping(Art.12ofReg.1408/71andArt.7ofReg.574/72):
Reason:
7.5Amountdue(socialpension):
7.6Amountdue(ATPpension):
7.7Datefromwhichsocialpensionispayable:
7.8DatefromwhichATPpensionispayable:
8Legalremediesandperiodsallowedforappeals:seeformE212
9IInstitutionconcerned
9.1Name:
9.2Address(3):
9.3Stamp
9.4Date:
9.5Signature

E210
INSTRUCTIONS
Please complete thisform inblock letters ,writing onthedotted lines only .Itconsists ofthree pages ,
none ofwhich may beleftout even ifitdoes notcontain any relevant information .
NOTES
(1)Symbol ofcountry towhich theinstitution concerned belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;Irl=Ireland ;
I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Put across inthesquare preceding theappropriate subject .
(3)Postal code ,town ,street ,number ,country .
(4)Tobecompleted only inthecase ofaclaim forasurvivor 'spension .
(5)Complete box 5orbox 6,asappropriate .
(6)Tobecompleted only byDanish institutions .

See'Instructions'overleaf EUROPEAN COMMUNITIES
SocialSecurityRegulationsE211Ii(n
SUMMARY OFDECISIONS
Reg.574/72:Art.48
Theinvestigatinginstitutionshouldcompletethisformandsendacopytotheclaimantinhisownlanguage,attach­
ingacopyofeachofthedecisionsofawardorrejection(formE210)togetherwithanoticeoflegalremediesand
periodsallowedforappeals(formE212)andacopyoftheformaldecisions .Theinvestigatinginstitutionshould
alsosendacopyofformE211toeachoftheinstitutionsconcerned,attachingacopyofthedecisionsoftheother
institutions (formE210).
1Claimant
1.1Surname Forenames Maidenname
1.2Placeofbirth Dateofbirth Sex Nationality
1.3Address(2):
2Yourclaimforapensionfor
2.1(3)Qoldage Qinvalidity Qsurvivor
2.2hasbeenexaminedbythefollowinginstitutions :
3HInstitutionsconcerned
Country Institution Filereference
3.1
3.2
3.3
3.4
3.5
4Theseinstitutionshavetakenthefollowingdecisions(seeformsE210attached):
5Yourclaimhasbeenrejected
5.1asregards(4):
Reason:
5.2asregards(4):
Reason:

E211
6IApensionhasbeenawardedtoyou
asregards(4) Annualamountincurrencyofcountry Payablefrom(date):
responsible forpayment (5)(6)
6.1
6.2
6.3
6.4
6.5
7Ifyouwishtoappealagainstthedecisions giveninyourcasebyoneormoreoftheseinstitutions ,youmay
dosoinaccordance withtheprocedures andwithinthetime-limits indicated onformE212.
8Investigating institution
8.1Name :
8.2Address (2):
8.3Stamp
8.4Date:
8.5Signature
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.
NOTES
(1)Symbolofthecountrytowhichtheinvestigating institution belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France;
Irl=Ireland;I=Italy;L=Luxembourg ;N=Netherlands ;UK=UnitedKingdom .
(2)Postalcode,town,street,number,country .
(3)Putacrossinthesquarepreceding theappropriate subject .
(4)Indicatecountryandwherenecessary theschemeconcerned .
(5)Whereratesofpensions areupgraded byvirtueofnationallegislation ,theamountindicated abovewillbechangedwithoutnotification
ofthenewamount .
(6)Itispossiblethatthisamountisreducedbytaxesandcontributions payablebythepensioner .

Sea Instructions 'overleaf EUROPEAN COMMUNITIES
Social Security Regulations
E212 (i)
LEGAL REMEDIES AND PERIODS ALLOWED FOR APPEALS
Reg .574/72:Art .48
A—Ifyoudonotagree with thedecision ordecisions taken ,youmay appeal .Forthispurpose youshould ,foreach
contested decision :
1.State clearly inaletter thegrounds ofyour appeal .
2.State thereferences onthenotification relating tothecontested decision .Attach acopy ofthisdecision (2).
3.Sign theletter .Ifyou cannot sign ,make across and have theletter ofappeal signed bytwo persons of
age,giving their surnames ,forenames and addresses (3).
B— 1.Anappeal against aBelgian decision should ,within one month from thedate ofreceiving notification
ofit,either besent byregistered letter ,ordelivered totheoffice oftheclerk ofthelabour court inthearea
ofjurisdiction where youreside ,ifyouareresident inBelgium (labour court of:
orinthearea ofjurisdiction ofyour lastdomicile orresidence inBelgium ,ifyou areresident abroad .
2.Anappeal against aDanish decision relating toapension under thelegislation onsocial pensions should
besent ,within aperiod offour weeks from thedate ofreceiving notification ofit,to'Den sociale Ankesty­
relse '(social appeals board ),Copenhagen .
Anappeal against aDanish decision relating toentitlement toapension under thelegislation onsup­
plementary pensions foremployed persons (ATP )should belodged ,within aperiod offour weeks of
receipt ofitsnotification ,with the 'Ankenaevnet forArbejdsmarkedets Tillaegspension '(ATP appeals
board ),Ministry ofLabour ,Copenhagen .
3.Anappeal against aGerman decision taken byaninstitution forpension insurance formanual orclerical
workers should belodged within aperiod ofonemonth ifthatdecision was notified intheterritory ofthe
Federal Republic ofGermany ,including West Berlin ;theappeal should belodged within aperiod ofthree
months from itsnotification ifitwas notified outside theterritory oftheFederal Republic ofGermany ,
including West Berlin .
Anappeal against adecision taken byaninstitution forpension insurance forminers should belodged within
aperiod ofone month from thenotification ofthat decision .
Theletters ofappeal should besent induplicate :
—either totheGerman institution whose address appears ontheGerman decision (E210 ,column 8);
—ortothe 'Sozialgericht '(social court )of:
—ortoaconsular authority oftheFederal Republic ofGermany ;
—or,ifitconcerns insurance forseamen ,alsotoaGerman 'Seemannsamt '(seamen 'sregistration office )in
thecountry concerned .
4.Anappeal against aFrench decision should besent ,within aperiod oftwo months from thedate of
receiving notification ofit,to'Mr.lePresident delaCommission derecours gracieux delaCaisse desecurity
sociale ',whose address isgiven ontheFrench notification .
5.Anappeal against anIrish decision should besent totheSecretary ,Department ofSocial Welfare ,Dublin ,
within aperiod of21days from thedate ofitsnotification .
6.Anappeal against anItalian decision oftheINPS should besent tothe'Comitato provinciale 'attached to
theprovincial office oftheINPS in:
notlater than 90days from receipt oftheSummary ofDecisions (form E211).
Ifnodecision hasbeen received from the'Comitato provinciale 'attheendoftheperiod of90days ,the
appeal must beregarded asrejected ;inthat case ,theperson concerned may ,within 90days from theend
oftheperiod inwhich thefirstappeal should have been decided ,send asecond appeal to:
©

E212
The above appeal procedures apply toclaims forpensions which have been decided bytheINPSinthe
framework ofgeneral compulsory invalidity ,old-age and survivor 'sinsurance .Appeals against decisions
taken inthe framework ofspecial schemes ofthe INPSorofother institutions aresubject todifferent
procedures ofwhich theinsured person will benotified separately .
7.Anappeal against aLuxembourg decision should besent induplicate tothe'Conseil arbitral desassurances
sociales 'inLuxembourg ,within aperiod of40days from thedate ofreceiving notification ofit.
8.Anappeal against aNetherlands decision should besent induplicate to:
within onemonth from thedate when youcould reasonably have taken note ofthat decision .
9.Anappeal against adecision ofaUnited Kingdom institution should besent ,within aperiod of21days
from thedate ofitsnotification ,totheDepartment ofHealth andSocial Security ,Overseas Group ,Newcastle­
upon-Tyne ,ortotheMinistry ofHealth and Social Services ,Overseas Branch ,Belfast ,asappropriate .
N.B.
These time-limits runfrom thedate ofnotification ;itshould benoted ,however ,that under Article 86ofRegulation
1408/71appeals submitted within thetime-limits prescribed bythelegislation ofaMember State areadmissible if
they aresubmitted within thesame time-limit tothecorresponding court orauthority ofanother Member State .
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .
NOTES
(1)Symbol ofthecountry towhich theinvestigating institution belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;Irl=Ire
land ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Except asregards Germany ,Belgium andtheUnited Kingdom .
(3)Postal code ,town ,street ,number ,country .

See'Instructions 'onpage8 EUROPEAN COMMUNITIES
SocialSecurityRegulations
E213 (1)
DETAILED MEDICAL REPORT
Reg.1408/71:Art.39to41andArt.87
IfthisformisintendedforaGermanorNetherlandsinstitutionorifitisdrawnupbyaGermanorNetherlands doctor
orattherequestofaninstitutionofanotherMemberState,formE214concerningassessmentoffunctionalabilities
andlimitationsshouldbeattached .
1Institutiontowhichthereportisaddressed
1.1Name:
1.2Address(2):
2Personexamined
2.1Surname Forenames Maidenname
2.2Placeofbirth Dateofbirth Sex Nationality
2.3Address(2):
2.4Lastoccupation :
2.5(3)QInsurancenumber: QPensionnumber:
2.6Filenumber:
2.7Dateofsubmissionofpensionclaim:
2.8Dateofsubmissionofrequestforreviewongroundsofaggravation :
3Doctorwhodrewupthereport
3.1Surname : Forenames :...
3.2Address(2):
3.3Examiningdoctorof:

E213
PARTI—QUESTIONNAIRE COMMON TOALLCASES
A.Medicalhistory
1.Personalandfamilyhistory:
2.Presentillness(complaintsofpersonconcerned ,beginningofillness,development ,treatmentgiventodate):
B.Objectiveexamination
1.Generalcondition
Height: Weight:
Generalappearance (senile,calm,agitated,etc.):
Constitution (strong,average,weak):
Posture: Carriage:
Movements :
Musculature :
Colourofmucousmembranes :
Nutritional condition :
Face(pale,cyanotic):
Conditionofmouthandteeth:
2.Senseorgans
Hearing:
Vision:
Smell:

E213
3.Respiratorysystem
Upperrespiratorytracts,lungs,chestmeasurement ,appearanceofthorax,macroscopic andmicroscopic
examinationofsputum,testforKoch'sbacillus,X-rayexamination ,etc):
Reportonradiographicexamination ,withdate(whereapplicable,attachformE214)(4):
Otherinformation :
4.Circulatorysystem
(Heart,aorta,bloodvessels,enlargement ofheart,auscultation ,pulse,bloodpressure,dyspnoea,oedema,
conditionofperipheralbloodvessels,varicoseveins,radiological (X-ray)evidence,etc.):
Pulse
perminuteTestof
cardiocirculatory
functionBlood
pressure
(R.R.)Respiration
perminuteOtherobservations
afterexertion
—afterprolonged
rest
—after
leg-bendsin:
sees.
—immediately
—after2mins.
—after4mins.
—after6mins.—Dyspnoea?
(3)□Yes□No
Ifyes,howlong?
—Labialcyanosis?
(3)□Yes□No
—Extrasystoles ?
(3)□Yes□No
—Iftherewerealreadyextrasystoles atrest,
dotheybecomemorefrequent?
(3)□Yes□No
orlessfrequent?
(3)□Yes□No
ordisappearcompletely?
(3)□Yes□NoOtherdisturbances ofrhythmafterexertion?
•Specialobservations :

E213
Reportonelectro-cardiographic examination ,withdate:
Reportonelectro-oscillographic examination ,withdate:
5.Digestivesystem
(Abdominalwall,hernias,palpationofabdomen,scarsfromsurgicaloperations,liver,spleen,ganglions,etc.):
ReportonX-rayexaminations ,withdate:
6.Locomotorsystem
(Bones,muscles,structureandmobilityofjointsandvertebralcolumn,Lasèguesign,comparativemeasure­
mentsoflimbs;degreeofanyfunctionaldiminutionofjointmovements):
7.Genito-urinary system
Resultofurinetestsandothernecessarytests(azotemy,pyelography ,gynaecological examination ,etc.),
withdate:

E213
8.Centralnervoussystem
(pupillaryandperipheralreflexes,palsies,paralysis,significantdisordersofsensation,psychicpeculiarities):
Reportonelectro-diagnosis orelectro-encephalography :
9.Otherorgansandsystems:
10.Bloodtests,withdate;haemoglobin rateanderythrocytecount,etc.:
11.Resultsofothertests,withdates(sedimentation ,reactiontodiagnosisforsyphilis,etc.):
(3)Q]arenecessary Qarenotnecessary Otherspecificexaminations
Intheaffirmative,which?
Dateofrequestforexaminations :
C.Diagnosisandinterpretation
1.Diagnosis,withreasonsandassessment :
2.Theconditionofthepersonconcerned (3)Qis CH'snotstabilized
3.Dateofcommencement ofincapacityforwork(5):

E213
4.Dateofcommencement ofpresentinvalidity(6):
5.Thepersonconcerned (3)Qis
6.Occupational (3)Qis
rehabilitation
7.Thepersonconcerned (3)Qis||isnotcapableofperforminganoccupation
otherthanthatlastperformed .
||isnotpossible.
||isnotabsolutelyincapableofmovingabout.
||isnotinhospital. 8.Thepersonconcerned (3)Qis
Ifso,probablelengthofstayinhospital:
Ifknown,dateofdischargefromhospital:
9.Constantattendancefromathirdperson
(3)Q]isessential Qisnotessential
forhimtobeabletoperformnormaleverydayactivities.
10.Theinvalidityis(3)Q]temporary Qpermanent.
11.Dateofprobableendofthistemporaryinvalidity:
12.Sincethegrantingofpension,theconditionofthepersonconcerned
(3)Q]hasimprovedQhasremainedthesameQ]hasdeteriorated .
Remarks:
13.Thepersonconcerned (3)Qshould Qneednotbere-examined .
Ifheshould,indicatethedate:

E213
PARTII—QUESTIONNAIRE RESERVED FORCERTAINCASES
1.Subjecttotheopinionofthecompetentadministration andinthelightoftheopinionofthepractitionerwhois
completingthisform,compensation forthepatient'sinjuryordisease »
(3)Q]can Qcannot
beregardedascomingwithinthelegislationonaccidentsatworkandoccupationaldiseases.
Ifthepersonconcernedpreviouslybenefitedfromlegislationonaccidentsatwork,occupational diseases,
militarypensions,pensionsforcivilianwarvictims,indicate:
—natureofthisinjuryofdisease:
—degreeofinvalidityproposed:
2.Incaseofaccident,stateexpecteddateof
consolidation ofinjuries:
3.Treatmentnecessary :
Thepersonconcerned (3)Qagrees Qdoesnotagreetosuchtreatment.
4.Thecontinuation ofmedicaltreatment
(3)□is Qisnotlikelytobringaboutanimprovementinthepatient'scondition
(3)Qis Qisnotlikelytoeffectrecovery.
5.Degreeofinvalidityforminework(onlyifaminerisconcerned)(7):
underground work: surfacework
(Whereappropriate ,attachformE214).
6.Thepersonconcerned (3)Qneeds Qdoesnotneed
(3)Qtoceaseminework
(3)Q]tochangehisoccupation .
Remarks:

E213
PARTIII—CONCLUSIONS
1Dateonwhichthepersonconcerned ceasedwork:
2Theinvalidity forthelastoccupation is
(3)Q]total Qpartial
Ifpartial,indicatethedegree :
3Degreeofinvalidityforanyotherworkwithreference totheaptitudes ofthepersonconcerned (8):
4Category ofinvalidity (9):....
5
5.1Date:
5.2Doctor'ssignature :
6Institution whichcalledfortheexamination
6.1Name:
6.2Address (2):
6.3Stamp
6.4Date:
6.5Signature
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.Itconsistsofeightpages,
noneofwhichmaybeleftoutevenifitdoesnotcontainanyrelevantinformation .
NOTES
(1)Symbolofthecountrytowhichtheinstitution completing theformbelongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France;
Irl=Ireland;I=Italy;L=Luxembourg ;N=Netherlands ;UK=UnitedKingdom .
(2)Postalcode,town,street,number ,country .
(3)Putacrossinthesquarepreceding theappropriate subject .
(4)Theinformation inthesesections isessentialwhentheclaimforinvalidity pensioniswhollyorpartlybasedonadiseaseofthe
respiratory system .
(5)IfthereportistobesenttoordrawnupbyaNetherlands institution ,indicatethefirstdayofthecurrentperiodofabsencethrough
sickness .
(6)IfthereportistobesenttoaNetherlands institution ,indicatethefirstdayonwhichinvaliditybenefitwasgranted .
(7)DoesnotconcerntheNetherlands ,IrelandortheUnitedKingdom .
(8)DoesnotconcerntheNetherlands .
(9)Complete onlyifthemedicalexamination wascarriedoutinviewofthedecisiontobetakenonapensionclaim.

See'Instructions'onpage4 EUROPEAN COMMUNITIES
SocialSecurityRegulations
E214 (1
MEDICAL REPORTCONCERNING ASSESSMENT OFFUNCTIONAL
ABILITIES ANDLIMITATIONS
Reg.1408/71:Art.39to41andArt.87
TobeattachedtoformE213whenthelatterisdrawnupbyadoctorofaGermanorNetherlandsinstitutionoris
intendedforaGermanorNetherlandsinstitution,orwhenaninstitutionofanotherMemberStaterequestsit
1IInstitutiontowhichthereportisaddressed
1.1Name:
1.2Address(2):
2Personexamined
2.1Surname Forenames Maidenname
2.2Placeofbirth Dateofbirth Sex Nationality
2.3Address(2):
2.4Lastoccupation :
2.5(3)Q]Insurancenumber: Q]Pensionnumber:
3Doctorwhodrewupthereport
3.1Surname : Forenames :....
3.2Address(2):
3.3Examiningdoctorof:
4Attachedforms: (3)Q]E204QE213.

E214
Questions Answers(3)InstructionsOccasionally
Frequently
Full-time
Part-timeYes
No
5Cantheinsuredperson:
5.1performheavywork?
5.2performfairlyheavywork?
5.3performlightwork?
5.4workmainlystandingorwalking?
5.5workmainlyseated?hoursperday
hoursperday
hoursperday 5.6workalternatelystanding,seatedandwalking?
5.7workstooping?
5.8workcrouching?
5.9workkneeling?
5.10worklyingdown?
5.11workwitharmsraised?
5.12workinadryatmosphere ?
5.13workinahumidatmosphere ?
5.14workinacoldatmosphere?
5.15workinahotatmosphere ?
5.16workinaveryhotatmosphere ?
5.17workinwater?
5.18beexposedtosuddenchangesoftemperature ?
5.19workoutdoors?
5.20workindoors?
5.21workinconfinedspaces(pipes,placeswhichhave
tobeenteredbycrawling,etc.)?
5.22climbstaircases?
5.23useladders?
5.24climbonroofs?
liftandcarryloadsoccasionally orrepeatedly
(loadingandunloading,etc.):
5.25heavyweights(over25kg)?
5.26mediumweights(10-25kg)?
5.27lightweights(5-10kg)?
5.28verylightweights(under5kg)?

E214
Questions Answers (3)InstructionsOccasionally
Frequently
Part-timeFull-timeYes
No
Ifyes,saywhichsub­
stancesandwhat
precautions aretobe
taken.
Ifyes,givedetails.
...km
...km
...km
...km
...km5.29Doestheinsuredpersonhavetouseaparticular
techniqueforliftingandcarryingloads(e.g.back
straightandkneesbent?
5.30Isheallergictocertainsubstances ?
5.31Doesheneedspecialaccessoriesforwork
(e.g.adjustable ,polyfunctional chair,etc.)?
5.32Canheusepublictransport?
Whatdistance,approximately ,canhetravel:
5.33onfoot?
5.34bybicycle?
5.35bylight-weight motorcycle ?
5.36bycar?
5.37bywheelchair ?
5.38bysmallmotorizedinvalidcar?
5.39Canheworkwithotherpeople?
5.40Canheusemachineryorapparatuspresentingsome
hazard?
5.41Canheundertakemanagement ,supervisory or
organizational tasks,ashewouldifthebusiness
belongstohim?
5.42Shouldonetakeaccountofanypsychological
peculiarities forcertainjobs?
5.43Arethereanyreservations concerning working
tempo?
5.44Takingaccountoftherepliestotheabovequestions ,
andevenassumingappropriateworkingconditions ,
shouldoneexpectprolongedorfrequentabsences
duetophysicalormentaldeficiencies ?Ifyes,saywhich,and
forwhatjobs.
Ifyes,sayforwhat
reason.
6
Date: Doctor'ssignature :

E214
Institution whichcalledfortheexamination 7
7.1Name :
7.2Address (2):
7.3Stamp
7.4Date:
7.5Signature
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.Itconsistsoffourpages,
noneofwhichmaybeleftoutevenifitdoesnotcontainanyrelevantinformation .
NOTES
C)Symbolofthecountrytowhichtheinstitution completing theformbelongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France;
Irl=Ireland;I=Italy;L=Luxembourg ;N=Netherlands ;UK=UnitedKingdom .
(2)Postalcode,town,street,number,country .
(3)Putacrossintheappropriate squareorsquares .

EUROPEAN COMMUNITIES
SocialSecurityRegulationsSeeInstructions'onpage3
E301 (1
CERTIFICATE CONCERNING THEPERIODSTOBETAKENINTO
ACCOUNT FORTHEGRANTOFUNEMPLOYMENT BENEFITS
Reg.1408/71:Art.67;Art.68;Art.71.1.a.ii;Art.71.1.b.ii
Reg.574/72:Art.80;Art.81;Art.84.2
Tobeissuedbythecompetentunemployment institutionortheinstitutiondesignatedbythecompetentauthority
ofthecountrywheretheunemployedpersonwaspreviouslyinsured.
1jWorker
1.1Surname Forenames Maidenname
1.2Dateofbirth Placeofbirth Nationality
2Theworkernamedabovecompletedthefollowingperiodsinthecourseof
2.1(3)Qtheyear(2)Qthetwoyears(2)Qthethreeyears(2)
precedingtheendofhislastemployment .
3Periodsofinsuranceandperiodstreatedassuch(4):
3.1Periodsofinsurance(5):
from to
3.2Periodstreatedasperiodsofinsurance(6):
from to Reasonfortreatingassuch(7)
4.Periodsofemploymentandperiodstreatedassuch(4):
4.1Periodsofemployment (5)(8):
from to Occupation (9)
4.2Periodstreatedasperiodsofemployment (6)(8):
from to Reasonfortreatingassuch(7)

E301
5Periodsofinsuranceandperiodsofemployment (1°):
from to
5.1Periodstreatedasperiodsofinsuranceorofemployment (11):
from to Reasonfortreatingassuch(7)
6Periodsofinsuranceandperiodstreatedassuch(8):
6-1(3)IIlessthan52weeks,namely:
from to
6.2(3)Q52weeksormore.Lastdayofemployment :
7Detailsoflastemployment engagedin:
BranchofactivityNatureofworkcarriedout(e.g.
'bricklayer'not'building
worker')Approximate average
weeklywage(12)
7.1Reasonforceasing(13):
8Thepersonconcerned
8.1(3)Qhasreceivedorisduetoreceivewagesfortheperiodfollowingthecessationofwork,upto:
8.2(3)Qhasreceivedorisduetoreceive,oncessationofwork,compensationorothersimilar
payment,amountingto:
8.3(3)Qhasreceivedorisduetoreceivepaymentinlieuofannualleave,amounting
to for days(14)
8-4(3)Q]haswaivedthefollowingrightswhichheenjoysunderhiscontractofemployment (15):
Reason:

E301
9Sincethecommencement ofthefirstperiodshownabove,thepersonconcerned receivedunemployment
benefits (16):
from to
10Thepersonconcerned isnotentitledtobenefitsunderArticle69ofRegulation 1408/71
10.1(3)Q]becausehehasnoentitlement underthelegislationadministered bytheinstitution issuingthis
certificate
10.2(3)Q]becausehedidnotremainavailabletoemployment servicesofthecompetent countryforfourweeks
afterbecoming unemployed ,andhewasnotauthorized toleavebeforetheendofthisperiod .
11Thepersonconcerned isnotentitledtoreceivebenefitsunderArticle 17.1.a.iorArticle71.1.b.iofRegulation
1408/71fromtheinstitution issuingthiscertificate .
12JInstitutionissuingthecertificate
12.1Name:
12.2Address (17):
12.3Stamp
12.4Date:
12.5Signature
INSTRUCTIONS
Pleasecompletethisforminblockletters,writingonthedottedlinesonly.Itconsistsofthreepages,
noneofwhichmaybeleftoutevenifitdoesnotcontainanyrelevantinformation .
NOTES
0)Symbolofthecountrytowhichtheinstitution completing theformbelongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France;
Irl=Ireland;I=Italy;L=Luxembourg ;N=Netherlands ;UK=UnitedKingdom .
(2)Oneyearifthecertificate istobesenttoaFrench,Luxembourg orNetherlands institution ;twoyearsifitistobesenttoanItalian
institution ;threeyearsifitistobesenttoaBelgian ,Danish,German,IrishorUnitedKingdominstitution .
(3)Putacrossinthesquarepreceding theappropriate subject .
(4)Ifseparatedetailsoftheitemsaskedforatpoints3.1and3.2,4.1and4.2arenotavailable ,showthetotalatpoint3.1or4.1,as
thecasemaybe.
(5)Tobecompleted ifthecertificate istobesenttoaBelgian,Danish,German,French,Irish,Netherlands orUnitedKingdominstitution .
(6)Tobecompleted ifthecertificate istobesenttoaBelgian ,Danish,GermanorNetherlands institution .
(7)E.g.sickness ,maternity ,accidentatwork,militaryservice,vocational training,recordedunemployment .
(8)Tobecompleted ifthecertificate istobesenttoanItalianinstitution .
(9)Tobecompleted ifthecertificate istobesenttoaFrenchorItalianinstitution .
(10)Tobecompleted ifthecertificate istobesenttoaLuxembourg institution .
(11)Tobecompleted ifthecertificate istobesenttoaFrenchorLuxembourg institution .
(12)Tobecompleted ,ifpossible ,ifthecertificate istobesenttoaGerman ,FrenchorNetherlands institution .
(13)E.g.expiryofcontractofemployment ,resignation ,dismissal ,dismissalwithoutnoticeasaresultof
(14)Tobecompleted ifthecertificate isbeingsenttoaBelgian ,Danish,French,ItalianorNetherlands institution .
(15)Tobecompleted ifthecertificate istobesenttoaBelgian,Danish,ItalianorNetherlands institution .
(16)Tobecompleted ifthecertificate istobesenttoaFrench,GermanorItalianinstitution .Ifthecertificate istobesenttoanItalian
institution ,itisnecessary toshowalltheperiodsforwhichthepersonconcerned receivedunemployment benefitsinthecourseof
theyearpreceding theissueofthecertificate .
(17)Postalcode,town,street,number ,country .

EUROPEAN COMMUNITIES
SocialSecurityRegulationsSeeInstructions overleaf
E3021
CERTIFICATE RELATING TOMEMBERS OFTHEFAMILYOFANUNEMPLOYED
PERSONWHOMUSTBETAKENINTOACCOUNT FOR
THECALCULATION OFBENEFITS
Reg.1408/71:Art.68.2
Reg.574/72:Art.82
Tobeissuedbythedesignatedinstitutionofthecountryofresidenceofthemembersofthefamily.
1Unemployed person
1.1Surname Forenames Maidenname
1.2Dateofbirth Placeofbirth Nationality
2Membersofthefamily
Order
numberSurname Forenames DateofbirthRelationshipPlaceof
residence
1
2
3
4
5
6
7
8
3Whereappropriate ,incomeofmembersofthefamily(natureandmonthlyamount,includingsocial
benefits)(2)
Number
(3)Members
ofthefamilyNatureofincome Amount
4Untilhebecameunemployed ,theunemployed personmaintainedthemembersofhisfamilyshownatthe
ordernumbers :
(2).

E302
4.1Thememberofthefamilyshownatordernumber
isunable,duetophysicalormentaldisability ,toprovideforhisownkeepby
working (4).
4.2Thefamilysupplements forthemembersofthefamilyshownatordernumbers
havebeenpaidtoanotherpersonatthesametimeasunemployment benefitsfortheperiod
from to
4.3Information requiredonlybyGermanorUnitedKingdom institutions :
Withtheexception oftheperiodofemployment in
(5)QGermany ||theUnitedKingdom,theunemployed personandhis/herspouse
(5)QhavebeenlivingunderthesameroofQ]havenotbeenlivingunderthesameroof.
4.4Thiscertificate isvalidfortwelvemonthsfromthedateofissue.
5Institution issuingthecertificate
5.1Name :
5.2Address (6):
5.3Stamp
5.4Date:
5.5Signature
6Statement oftheunemployed person(7)
6.1Theunemployed personnamedinbox1declaresthatthemembersofhisfamilyshownatnumbers
ofbox2
(5)Qare Qarenot
takenintoconsideration forthecalculation ofunemployment benefitsduetoanotherpersonunderUnited
Kingdom legislation .
6.2Date:
6.3Signature oftheunemployed person
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.
NOTES
(1)Symbolofthecountrytowhichtheinstitution completing theformbelongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France;
Irl=Ireland;I=Italy;L=Luxembourg ;N=Netherlands ;UK=UnitedKingdom .
(2)Thisinformation issuperfluous iftheformistobesenttoaGermaninstitution .
(3)Foreachmemberofthefamilymentioned inthisbox,retaintheordernumbershowninbox2.
(4)Complete onlyiftheformistobesenttoaBelgian,FrenchorUnitedKingdominstitution .
(5)Putacrossinthesquarepreceding theappropriate subject .
(6)Postalcode,town,street,number ,country .
(7)Tobecompleted bytheunemployed persononlyifthecertificate wasissuedbyaUnitedKingdominstitution .

SeeInstructions 'overleaf EUROPEAN COMMUNITIES
SocialSecurityRegulations
E303/0n
CERTIFICATE CONCERNING THERETENTION OFTHE
RIGHTTOUNEMPLOYMENT BENEFITS
Reg.1408/71:Art.69
Reg.574/72:Art.26.2;Art.83.1to3;Art.97
1IUnemployed person Insurancenumber:.
1.1Surname Forenames Maidenname
1.2Dateofbirth Placeofbirth Nationality
2UndertheprovisionsofArticle69ofRegulation1408/71,theunemployed personnamedaboveisentitledtounemployment benefits .
3Hecanreceivebenefitsfrom (date) ,providedthathehasregisteredasbeingin
searchofemployment atthelatestby withtheemployment services(2)ofthecountry;
whereheislookingforwork.
4Theunemployed personisentitledtobenefitsforaperiodof days,
providedthattheperioddoesnotextendbeyond(date)
4.1Thebenefitsaregrantedforeverydayoftheweek,except
(3)□Monday□Tuesday□Wednesday□Thursday□Friday□Saturday□Sunday.
4.2Dailyamountofunemployment benefits:
net,whichincludesanincreasefordependants of: net
andfrom date: ,
net,whichincludesanincreasefordependants of: net.
5Thepaymentofbenefitsmustbesuspendedinthefollowingcircumstances (Regulation574/72,Art.83.1andArt.83.3):
5.1—whentheunemployed personhastakenup'permanent'gainfulemployment (4)orbecomesself-employed ;
5.2—whentheunemployed personisreceivingoccasionalearningsfromanactivityotherthanthoseshownat5.1above(in
thiscase,thepaymentofbenefitsmustbesuspendedforthenumberofdaysduringwhichthepersonconcernedisreceiving
theseoccasionalearnings);
5.3—whentheunemployed personrefusesanofferofemployment orrefusestoattendforaninterviewwiththeemployment services,
5.4—whentheunemployed personrefusesanofferofvocationalretrainingorfailstoparticipatetherein(5);
5.5—whentheunemployed persondoesnotsubmitornolongersubmitstocontrolproceduresandchecks;
5.6—whentheunemployed personissufferingfrompermanentincapacityforwork(6);
5.7—whentheunemployed personissufferingfromtemporaryincapacityforwork(inthiscase,thepaymentofbenefitsissuspended
untilre-registration );
5.8—whentheunemployed personisnotorisnolongeravailabletotheemployment services;
5.9—whenthenumberofthemembersofthefamilygivingentitlementtoincreasefordependants decreases,orwhenoneofthese
membersreceivesanincomereferredtoonformE302(inthiscase,thebenefitistobepaidwithdeductionofthefamilyincrease)
6IInstitutioncompletingtheform
6.1Name:
6.2Address(7)
6.3Stamp
6.4Date:
6.5Signature

INSTRUCTIONS
Thecompetent institution ofthelastcountry ofemployment should complete therelevant sections oftheseries offorms E303/0toE303/4;itshould keep E303/0and
send therest oftheseries totheunemployed person ,including E303/5,or,ifappropriate ,send ittothecompetent unemployment institution oftheplace where theun­
employed person isseeking employment .
Please complete this form inblock letters ,writing onthe dotted lines only .
NOTES
(')Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;Irl=Ireland ;I=Italy ;L=Luxem­
bourg ;N=Netherlands ;UK =United Kingdom .
(2)InItaly and theNetherlands ,theunemployed person must inaddition submit aclaim forbenefits tothecompetent unemployment insurance institution through
the employment office .
(3)Putacross inthesquare preceding theappropriate subject .
(4)Under Italian legislation ,permanent employment ('occupazione non occasionale ')isany employment ofmore than five days ;under Belgian and Netherlands
legislation ,permanent employment ('volledige tewerkstelling ')isany employment ofatleast one normal working day .
(5)This situation does notentail suspension ofbenefits ifthecertificate was issued byaDanish institution .
(6)Orwhen theunemployed person isreceiving anold-age orinvalidity pension ,ifthecertificate isdrawn upbyaGerman orLuxembourg institution .
(7)Postal code ,town ,street ,number ,country .

SeeInstructions'overleaf EUROPEAN COMMUNITIES
SocialSecurityRegulations
E303/1r
CERTIFICATE CONCERNING THERETENTION OFTHE
RIGHTTOUNEMPLOYMENT BENEFITS
Reg.1408/71:Art.69
Reg.574/72:Art.26.2;Art.83.1to3;Art.97
Thiscopyshouldbesenttotheunemployment insuranceinstitutionoftheplacewheretheunemployedpersonisseekingemployment .
Itmustbeusedasthebasisforpaymentofunemployment benefits(Reg.574j72:Art.83.1).
1IUnemployedperson Insurancenumber:.
1.1Surname Forenames Maidenname
1.2Dateofbirth Placeofbirth Nationality
2UndertheprovisionsofArticle69ofRegulation 1408/71,theunemployedpersonnamedaboveisentitledtounemployment benefits.
3Hecanreceivebenefitsfrom (date) ,providedthathehasregisteredasbeingin
searchofemploymentatthelatestby withtheemploymentservices(2)ofthecountry;
whereheislookingforwork.
4Theunemployed personisentitledtobenefitsforaperiodof days,
providedthattheperioddoesnotextendbeyond(date)
4.1Thebenefitsaregrantedforeverydayoftheweek,except
(3)□Monday□Tuesday□Wednesday□Thursday□Friday□Saturday□Sunday.
4.2Dailyamountofunemployment benefits:
net,whichincludesanincreasefordependantsof: net
andfrom date: ,
net,whichincludesanincreasefordependantsof: net.
5Thepaymentofbenefitsmustbesuspendedinthefollowingcircumstances (Regulation574/72,Art.83.1andArt.83.3):
5.1—whentheunemployedpersonhastakenup'permanent'gainfulemployment (4)orbecomesself-employed ;
5.2—whentheunemployed personisreceivingoccasionalearningsfromanactivityotherthanthoseshownat5.1above(in
thiscase,thepaymentofbenefitsmustbesuspendedforthenumberofdaysduringwhichthepersonconcernedisreceiving
theseoccasionalearnings);
5.3—whentheunemployedpersonrefusesanofferofemploymentorrefusestoattendforaninterviewwiththeemploymentservices;
5.4—whentheunemployedpersonrefusesanofferofvocationalretrainingorfailstoparticipatetherein(5);
5.5—whentheunemployedpersondoesnotsubmitornolongersubmitstocontrolproceduresandchecks;
5.6—whentheunemployedpersonissufferingfrompermanentincapacityforwork(6);
5.7—whentheunemployedpersonissufferingfromtemporaryincapacityforwork(inthiscase,thepaymentofbenefitsissuspende^
untilre-registration );
5.8—whentheunemployedpersonisnotorisnolongeravailabletotheemploymentservices;
5.9—whenthenumberofthemembersofthefamilygivingentitlementtoincreasefordependantsdecreases,orwhenoneofthese
membersreceivesanincomereferredtoonformE302(inthiscase,thebenefitistobepaidwithdeductionofthefamilyincrease)
6|Institutioncompletingtheform
6.1Name:
6.2Address(7)
6.3Stamp
6.4Date:
6.5Signature

INSTRUCTIONS
Thecompetent institution ofthelastcountry ofemployment should complete therelevant sections oftheseries offorms E303/0toE303/4;itshould keep E303/0and
send therest oftheseries totheunemployed person ,including E303/5,or,ifappropriate ,send ittothecompetent unemployment institution oftheplace where theun­
employed person isseeking employment .
Please complete this form inblock letters ,writing onthe dotted lines only .
NOTES
(')Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;Irl=Ireland ;I=Italy ;L=Luxem­
bourg ;N=Netherlands ;UK =United Kingdom .
(2)InItaly and theNetherlands ,theunemployed person must inaddition submit aclaim forbenefits tothecompetent unemployment insurance institution through
the employment office .
(3)Putacross inthesquare preceding theappropriate subject .
(4)Under Italian legislation ,permanent employment ('occupazione non occasionale ')isany employment ofmore than five days ;under Belgian and Netherlands
legislation ,permanent employment ('volledige tewerkstelling ')isany employment ofatleast one normal working day .
(5)This situation does notentail suspension ofbenefits ifthecertificate was issued byaDanish institution .
(6)Orwhen theunemployed person isreceiving anold-age orinvalidity pension ,ifthecertificate isdrawn upbyaGerman orLuxembourg institution .
(7)Postal code ,town ,street ,number ,country .
©

SeeInstructions 'overleaf EUROPEAN COMMUNITIES
SocialSecurityRegulations
E303/2r
CERTIFICATE CONCERNING THERETENTION OFTHE
RIGHTTOUNEMPLOYMENT BENEFITS
Reg.1408/71:Art.69
Reg.574/72:Art.26.2;Art.83.1to3;Art.97
Thiscopymustbereturnedtothecompetentinstitutiontoinformitoftheregistrationoftheunemployed personandofthecommence­
mentofpaymehtofbenefits(Reg.574/72:Art.83.3).
1Unemployed person Insurancenumber :.
.1Surname Forenames Maidenname
1.2Dateofbirth Placeofbirth Nationality
2UndertheprovisionsofArticle69ofRegulation 1408/71,theunemployed personnamedaboveisentitledtounemployment benefits.
3Hecanreceivebenefitsfrom (date) providedthathehasregisteredasbeingin
searchofemployedatthelatestby withtheemployment services(2)ofthecountry
whereheislookingforwork.
4Theunemployed personisentitledtobenefitsforaperiodof days,
providedthattheperioddoesnotextendbeyond(date)
4.1Thebenefitsaregrantedforeverydayoftheweek,except
(3)□Monday□Tuesday □Wednesday□Thursday□Friday□Saturday□Sunday.
4.2Dailyamountofunemployment benefits:
net,whichincludesanincreasefordependants of: net
andfromdate (date): ,
net,whichincludesanincreasefordependants of: net.
5Thepaymentofbenefitsmustbesuspendedinthefollowingcircumstances (Regulation574/72,Art.83.1andArt.83.3):
5.1—whentheunemployed personhastakenup'permanent 'gainfulemployment (4)orbecomesself-employed ;
5.2—whentheunemployed personisreceivingoccasionalearningsfromanactivityotherthanthoseshownat5.1above(in
thiscase,thepaymentofbenefitsmustbesuspendedforthenumberofdaysduringwhichthepersonconcernedisreceiving
theseoccasionalearnings);
5.3—whentheunemployed personrefusesanofferofemployment orrefusestoattendforaninterviewwiththeemployment services;
5.4—whentheunemployed personrefusesanofferofvocationalretrainingorfailstoparticipatetherein(5);
5.5—whentheunemployed persondoesnotsubmitornolongersubmitstocontrolproceduresandchecks;
5.6—whentheunemployed personissufferingfrompermanentincapacityforwork(6);
5.7—whentheunemployed personissufferingfromtemporaryincapacityforwork(inthiscase,thepaymentofbenefitsissuspended
untilre-registration );
5.8—whentheunemployed personisnotorisnolongeravailabletotheemployment services;
5.9—whenthenumberofthemembersofthefamilygivingentitlementtoincreasefordependants decreases ,orwhenoneofthese
membersreceivesanincomereferredtoonformE302(inthiscase,thebenefitistobepaidwithdeductionofthefamilyincrease).
6Institutioncompleting theform
6.1Name:
6.2Adress(7):
Tobecompletedbytheinstitutionofthecountrywheretheunemployed personisseekingemployment .
1Wecertify
7.1thattheunemployed personnamedaboveregisteredasbeinginsearchofemployment on
(date)
7.2andhasbeenreceivingunemployment benefitssince
(date).
8JInstitutionofthecountrywheretheunemployedpersonisseekingemployment
8.1Name:
8.2Address(7):
8.3Stamp
8.4Date:
8.5Signature

INSTRUCTIONS
Thecompetent institution ofthelastcountry ofemployment should complete therelevant sections oftheseries offorms E303/0toE303/4;itshould keep E303/0and
send therest oftheseries totheunemployed person ,including E303/5,or,ifappropriate ,send ittothecompetent unemployment institution oftheplace where theun­
employed person isseeking employment .
Please complete this form inblock letters ,writing onthe dotted lines only .
NOTES
(')Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;Irl=Ireland ;I=Italy ;L=Luxem­
bourg ;N=Netherlands ;UK =United Kingdom .
(2)InItaly and theNetherlands ,theunemployed person must inaddition submit aclaim forbenefits tothecompetent unemployment insurance institution through
the employment office .
(3)Putacross inthesquare preceding theappropriate subject .
(4)Under Italian legislation ,permanent employment ('occupazione non occasionale ')isany employment ofmore than five days ;under Belgian and Netherlands
legislation ,permanent employment ('volledige tewerkstelling ')isany employment ofatleast one normal working day .
(5)This situation does notentail suspension ofbenefits ifthecertificate was issued byaDanish institution .
(6)Orwhen theunemployed person isreceiving anold-age orinvalidity pension ,ifthecertificate isdrawn upbyaGerman orLuxembourg institution .
(7)Postal code ,town ,street ,number ,country .
<D

EUROPEAN COMMUNITIES See'Instructions'overleaf
SocialSecurityRegulations i jII
E303/3r
CERTIFICATE CONCERNING THERETENTION OFTHE
RIGHTTOUNEMPLOYMENT BENEFITS
Reg.1408/71:Art.69
Reg.574/72:Art.26.2;Art.83.1to3;Art.97
Thiscopyshouldbesenttothesicknessinsuranceinstitutionoftheplacewheretheunemployed personisseekingemployment(Reg.
574/72:Art.26.2).
1Unemployed person Insurancenumber:..
1.1Surname Forenames Maidenname
1.2Dateofbirth Placeofbirth Nationality
2UndertheprovisionsofArticle69ofRegulation1408/71,theunemployed personnamedaboveisentitledtounemployment benefits.
3Hecanreceivebenefitsfrom (date) ,providedthathehasregisteredasbeingin
searchofemployment atthelatestby withtheemployment services(2)ofthecountry
whereheislookingforwork.
4Theunemployed personisentitledtobenefitsforaperiodof days,
providedthattheperioddoesnotextendbeyond(date)
4.1Thebenefitsaregrantedforeverydayoftheweek,except
(3)□Monday□Tuesday□Wednesday□Thursday□Friday□Saturday□Sunday.
4.2Dailyamountofunemployment benefits:
net,whichincludesanincreasefordependants of: net
andfrom (date) ,
net,whichincludesanincreasefordependants of: net.
5Thepaymentofbenefitsmustbesuspendedinthefollowingcircumstances (Regulation574/72,Art.83.1andArt.83.3):
5.1—whentheunemployed personhastakenup'permanent 'gainfulemployment (4)orbecomesself-employed ;
5.2—whentheunemployed personisreceivingoccasionalearningsfromanactivityotherthanthoseshownat5.1above(in
thiscase,thepaymentofbenefitsmustbesuspendedforthenumberofdaysduringwhichthepersonconcernedisreceiving
theseoccasionalearnings);
5.3—whentheunemployed personrefusesanofferofemployment orrefusestoattendforaninterviewwiththeemployment services;
5.4—whentheunemployed personrefusesanofferofvocationalretrainingorfailstoparticipatetherein(5);
5.5—whentheunemployed persondoesnotsubmitornolongersubmitstocontrolproceduresandchecks;
5.6—whentheunemployed personissufferingfrompermanentincapacityforwork(6);
5.7—whentheunemployed personissufferingfromtemporaryincapacityforwork(inthiscase,thepaymentofbenefitsissuspended
untilre-registration );
5.8—whentheunemployed personisnotorisnolongeravailabletotheemployment services;
5.9—whenthenumberofthemembersofthefamilygivingentitlementtoincreasefordependants decreases,orwhenoneofthese
membersreceivesanincomereferredtoonformE302(inthiscase,benefitistobepaidwithdeductionofthefamilyincrease).
6|Institutioncompletingtheform
6.1Name:
6.2Address(7):
Tobecompletedbytheinstitutionofthecountrywheretheunemployed personisseekingemployment andtobeattachedtoformE119
7Wecertify
7.1thattheunemployed personnamedaboveregisteredasbeinginsearchofemployment on
(date)
7.2andhasbeenreceivingunemployment benefitssince
(date)
8IInstitutionofthecountrywheretheunemployedpersonisseekingemployment
8.1Name:
8.2Address(7):
8.3Stamp
8.4Date:
8.5Signature

INSTRUCTIONS
Thecompetent institution ofthelastcountry ofemployment should complete therelevant sections oftheseries offorms E303/0toE303/4;itshould keep E303/0and
send therestoftheseries totheunemployed person ,including E303/5,or,ifappropriate ,send ittothecompetent unemployment institution oftheplace where theun­
employed person isseeking employment .
Please complete this form inblock letters ,writing onthe dotted lines only .
NOTES
(n)Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;Irl=Ireland ;I=Italy ;L—Luxem­
bourg ;N=Netherlands ;UK =United Kingdom .
(2)InItaly and theNetherlands ,theunemployed person must inaddition submit aclaim forbenefits tothecompetent unemployment insurance institution through
the employment office .
(3)Putacross inthesquare preceding theappropriate subject ,
(4)Under Italian legislation ,permanent employment ('occupazione non occasionale ')isany employment ofmore than five days ;under Belgian and Netherlands
legislation ,permanent employment ('volledige tewerkstelling ')isany employment ofatleast one normal working day .
(5)This situation does notentail suspension ofbenefits ifthecertificate was issued byaDanish institution .
(6)Orwhen theunemployed person isreceiving anold-age orinvalidity pension ,ifthecertificate isdrawn upbyaGerman orLuxembourg institution .
(7)Postal code ,town ,street ,number ,country .
©

See'Instructions overleaf EUROPEAN COMMUNITIES
SocialSecurityRegulations
E303/4 C)
CERTIFICATE CONCERNING THERETENTION OFTHE
RIGHTTOUNEMPLOYMENT BENEFITS
Reg.1408/71:Art.69
Reg.574/72:Art.26.2;Art.83.1to3;Art.97
Thiscopymustbereturnedtothecompetentinstitution,toserveasthebasisforrefundofunemployment benefitspaidonbehalf
ofthatinstitution(Reg.574/72:Art.97).
1jUnemployedpersonInsurancenumber:..
1.1Surname Forenames Maidenname
2.1Dateofbirth Placeofbirth Nationality
2UndertheprovisionsofArticle69ofRegulation 1408/71,theunemployed personnamedaboveisentitledtounemployment benefits.
3Hecanreceivebenefitsfrom (date) ,providedthathehasregisteredasbeingin
searchofemployment atthelatestby withtheemployment services(2)ofthecountry
whereheislookingforwork.
4Theunemployed personisentitledtobenefitsforaperiodof days,
providedthattheperioddoesnotextendbeyond(date)
4.1Thebenefitsaregrantedforeverydayoftheweek,except
(3)□Monday□Tuesday □Wednesday□Thursday□Friday□Saturday□Sunday.
4.2Dailyamountofunemployment benefits :
net,ofwhichthereisanincreasefordependants of: net
and,from (date): ,
net,ofwhichthereisanincreasefordependants of: net.
5Thepaymentofbenefitsmustbesuspendedinthefollowingcircumstances (Regulation574/72,Art.83.1andArt.83.3):
5.1—whentheunemployed personhastakenup'permanent'gainfulemployment (4)orbecomesself-employed ;
5.2—whentheunemployed personisreceivingoccasionalearningsfromanactivityotherthanthoseshownat5.1above(in
thiscase,thepaymentofbenefitsmustbesuspendedforthenumberofdaysduringwhichthepersonconcernedisreceiving
theseoccasionalearnings);
5.3—whentheunemployed personrefusesanofferofemployment orrefusestoattendforaninterviewwiththeemployment services;
5.4—whentheunemployed personrefusesanofferofvocationalretrainingorfailstoparticipatetherein(5);
5.5—whentheunemployed persondoesnotsubmitornolongersubmitstocontrolproceduresandchecks;
5.6—whentheunemployed personissufferingfrompermanentincapacityforwork(6);
5.7—whentheunemployed personissufferingfromtemporaryincapacityforwork(inthiscase,thepaymentofbenefitsissuspended
untilre-registration );
5.8—whentheunemployed personisnotorisnolongeravailabletotheemployment services;
5.9—whenthenumberofthemembersofthefamilygivingentitlementtoincreasefordependantsdecreases ,orwhenoneofthese
membersreceivesanincomereferredtoonformE302(inthiscase,thebenefitistobepaidwithdeductionofthefamilyincrease).
6|Institutioncompletingtheform
6.1Name:
6.2Address(7):
Tobecompletedbytheinstitutionofthecountrywheretheunemployed personisseekingemployment .
7Thefollowingsumshavebeenpaidtotheunemployed personinaccordancewiththeabovecertificate :
from to AmountReasonforsuspension or
cessationofpayments
8Institutionofthecountrywheretheunemployed personisseekingemployment
8.1Name:
8.2Address(7):
8.3Stamp
8.4Date:
8.5Signature

INSTRUCTIONS
The competent institution ofthelastcountry ofemployment should complete therelevant sections oftheseries offorms E303/0toE303/4;itshould keep E303/0and
send therestoftheseries totheunemployed person ,including E303/5,or,ifappropriate ,send ittothecompetent unemployment institution oftheplace where theun­
employed person isseeking employment .
Please complete this form inblock letters ,writing onthe dotted lines only .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;Irl=Ireland ;I=Italy ;L=Luxem­
bourg ;N=Netherlands ;UK =United Kingdom .
(2)InItaly and theNetherlands ,theunemployed person must inaddition submit aclaim forbenefits tothecompetent unemployment insurance institution through
the employment office .
(3)Putacross inthesquare preceding theappropriate subject .
(4)Under Italian legislation ,permanent employment ('occupazione non occasionale ')isany employment ofmore than five days ;under Belgian and Netherlands
legislation ,permanent employment ('volledige tewerkstelling ')isany employment ofatleast one normal working day .
(5)This situation does notentail suspension ofbenefits ifthecertificate was issued byaDanish institution .
(6)Orwhen theunemployed person isreceiving anold-age orinvalidity pension ,ifthecertificate isdrawn upbyaGerman orLuxembourg institution .
(7)Postal code ,town ,street ,number ,country .
©

EUROPEAN COMMUNITIES
Social Security Regulations E303/5
Information forthe unemployed person
who intends togotoanother Member State toseek employment
Before leaving ,
you must dowhatever isrequired tobesure ofreceiving ,ifneed be,sickness andmaternity insurance benefits for
yourself andforthemembers ofyour family ,even while you arelooking forwork .
Accordingly ,youshould gotothesickness fund with which you areorwere lastinsured .Onpresentation ofform
E303which hasbeen issued toyou bytheunemployment insurance institution ,thesickness fund willgive you a
certificate 'E119'.Inthecase ofsickness ormaternity ,you should present this certificate tothesickness fund of
thecountry where you areseeking employment .
Assoon asyou arrive
intheplace where you aregoing tolook foremployment ,youshould gototheemployment office (1);inItaly and
theNetherlands ,you must also gototheunemployment insurance office (1).You should hand inallthecopies of
form E303that areinyour possession .
Please note theultimate date ,indicated onform E303 ,bywhich youmust attend ifyoustillwish toreceive unem­
ployment benefits from themoment when you ceased toberegistered asseeking employment inthecountry you
areleaving .
While you arelooking forwork ,
youaresubject tothesupervision oftheemployment services andunemployment insurance bodies justliketheother
unemployed persons inthearea .You must inform theinstitution towhich you gave form E303ofanychange of
circumstances that may affect your entitlement tounemployment benefits ;thesame applies ifyou become unfit for
work .
Ifthischange incircumstances could entitle youtoincreased benefits (e.g.when yougetmarried orincase ofthe
birth ofachild ),you may alsodirectly inform theinstitution which issued youwith form E303 ,attaching theappro­
priate documents asproof .
Ifyour search forajoboutside your lastcountry ofemployment lasts formore than three months ,youwilllose ,at
theendofthisperiod ,anyremaining rights tounemployment benefits inthis lastcountry ofemployment .However ,
theoffice which issued youwith form E303 may authorize exceptions .
(1)These offices arethefollowing :
inBelgium :thelocal offices ofthe 'Office national del'emploi '(national employment office );
inDenmark :thelocal 'Arbejdsformidlingskontor '(labour exchange office );
inGermany :the'Arbeitsamt '(employment office );
inFrance :the'Agence del'emploi '(local employment office );
inIreland :thenearest local office oftheDepartment ofSocial Welfare ;
inItaly :the'Ufficio provinciale dellavoro '(provincial employment office )andtheprovincial office ofthe'Istituto nazionale della previ­
denza sociale '(INPS ,national social welfare institute );
inLuxembourg :the'Office national dutravail '(national labour office );
intheNetherlands :the 'Gewestelijk Arbeidsbureau '(regional employment office )and the 'Nieuwe Algemene Bedrijfsvereniging '
(new general professional and trade association );
intheUnited Kingdom :thelocal employment exchange .
©

SeeInstructions'onpage3 EUROPEAN COMMUNITIES
SocialSecurityRegulations
E401(1)
CERTIFICATE CONCERNING THECOMPOSITION OFTHEFAMILYFORTHE
PURPOSE OFTHEGRANTING OFFAMILYBENEFITS
Reg.1408/71:Art.73.1;Art.74.1
Reg.574/72:Art.86.2;Art.88
Tobeattachedtoaclaimsenttotheinstitutioncompetentforthegrantoffamilybenefits.
1Worker
1.1Surname Forenames Maidenname
1.2Placeofbirth Dateofbirth Sex Nationality
1.3Civilstatus:(2)Qsingle married Qwidow/widower
(2)QdivorcedQseparated
1.4Address(3):
2Spouse
2.1Surname Forenames Maidenname
2.2Placeofbirth Dateofbirth Sex Nationality
2.3Occupation :
2.4Address(3):
3Membersofthefamilyotherthanthespouse
Surname ForenamesDateof
birthRelation­
ship(4)Placeof
residenceOccupation
1.
2
3
4
5.
6.
7
8
9
10.
3.1Remarks :

E401
4InformationtobesuppliedonlyiftheformistobesenttoaDanishinstitution
4.1Personexercisingtheauthorityoffather:
4.2Themaintenanceofthechildren(2)QisQisnotpaidforfrompublicfunds
4.3Themotherofthechildren (2)Qis EH'snotdead.
Ifsheis,pleaseindicatedateofdeath:
4.4Themotherorfatherofthechildren (2)QdrawsQdoesnotdraw
anold-ageorinvaliditypension.
InformationtobesuppliedonlyiftheformistobesenttoaUnitedKingdominstitutioniftheworkeris0neitherthefathernorthemotherofthechildren
Number
inbox3PlaceofbirthNumber
inbox3Placeofbirth
®Certificateofthepopulationregistryortheauthorityoradministrationcompetentinmattersofcivilstatus(5)
Theaccuracyoftheinformationgivenabovehasbeenverifiedfromtheofficialdocumentsinourpossession .
6.1Nameandaddressoftheregistry ,authorityoradministration (3):
6.2Stamp
6.3Date:
6.4Signature
7JNameandaddressoftheinstitutioncompetentforthegrantingoffamilybenefits
7.1Name:
7.2Address(3):
7.3Filereferencenumber:

E401
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .Itconsists ofthree pages ,
none ofwhich may beleftout even ifitdoes notcontain any relevant information .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing theform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;F=France ;
Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Put across inthesquare preceding theappropriate subject .
(3)Postal code ,town ,street ,number ,country .
(4)Show therelationship ofeach member ofthefamily totheworker ,using thefollowing symbols :
A=legitimate child
B=legitimized child
C=adopted child
D=natural child (iftheform iscompleted foramale worker ,thenatural children must bementioned only ifthepaternity orthe worker 's
obligation tomaintain them hasbeen officially recognized )
E=child ofaspouse belonging totheworker 'shousehold
F=grandchildren ,brothers and sisters whom theperson concerned hastaken into hishousehold
G=other children belonging permanently tothehousehold onthesame footing astheworker 'schildren (foster children ).
Other relationships (e.g.grandfather )must bewritten infull .Ifachild ismarried ,show this atpoint 3.1.
C5)InFrance ,the 'mairie '(registrar 'soffice )orthe 'caisse d'allocations familiales '(fund forfamily allowances );
inIreland ,theDepartment ofSocial Welfare ,Dublin ;
intheUnited Kingdom ,theDepartment ofHealth and Social Security ,Overseas Group ,Newcastle-upon-Tyne ,orthe Ministry of
Health and Social Services ,Overseas Branch ,Belfast ,asappropriate .

See'Instructions'overleaf EUROPEAN COMMUNITIES
SocialSecurityRegulations
E402 1
CERTIFICATE OFCONTINUATION OFSTUDIESFORTHEPURPOSE
OFTHEGRANTING OFFAMILYBENEFITS
Reg.1408/71:Art.73.1andArt.74.1
Reg.574/72:Art.86andArt.88
A.Requestforcertificate
Tobecompletedbytheinstitutioncompetentforthegrantingoffamilybenefits.IftheformisaddressedtoaBelgian
institution,aform'E402Annex'shouldbeattached .
Workerapplyingforfamilybenefitsorpersonclaimingthemonothergrounds
1
1.1Surname Forenames Maidenname
1.2Placeofbirth Dateofbirth Sex Nationality
1.3Address(2):
2jPupilorstudent
2.1Surname Forenames Maidenname
2.2Placeofbirth Dateofbirth Sex
2.3Address(2):
3JInstitutioncompetentforthegrantingoffamilybenefits
3.1Name:
3.2Address(2):
3.3Filereferencenumber:
3.4Stamp
3.5Date:
3.6Signature

E402
B.Certificate
Tobecompleted bytheestablishment (school,university orestablishment ofhighereducation)andsenttothe
institution namedinbox3.
4
4.1Thepupilnamedinbox2isattending theschoolshowninbox5
since
4.2His/hereducation willprobably lastuntil
4.3Thenumberofhoursofthecourseis aweek.
Thesehoursarespreadover half-days .
4.4Typeofschool(3):
4.5Thestudentnamedinbox2hasbeenregistered atthe
(4)Qestablishment ofhighereducation Q]universityshowninbox5
since
4.6His/herstudiesatthisestablishment oruniversity willprobably last
until
5JSchool,universityorestablishment ofhighereducation
5.1Name:
5.2Address (2):
5.3Stamp
5.4Date:
5.5Signature
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.
NOTES
(1)Symbolofthecountrytowhichtheinstitution completing partAoftheformbelongs :B=Belgium ;Dk=Denmark ;D=Germany ;
F=France;Irl=Ireland;I=Italy;L=Luxembourg ;N=Netherlands ;UK=UnitedKingdom .
(2)Postalcode,town,street,number,country .
(3)Pleaseindicatewhetheritisapubliclymaintained school,'publicschool',orstate-controlled school.Tobecompleted onlyifthe
institution showninbox3isaUnitedKingdom institution .
(4)Putacrossinthesquarepreceding theappropriate subject .

(1)E402Annex
TobecompletediftheclaimforfamilybenefitshastobemadetoaBelgianinstitution .
1Educationgivenattheestablishment (otherthanestablishments ofhigheroruniversityeducation)
1.1Overhowmanyhalf-daysandhowmanyhoursaweekarethelessonsspread?
half-days hours.
1.2Thelessons (4)Qare Qarenotgivenbefore6p.m.
1.3Thepupil (4)Q]does Qdoesnotattendlessonsregularly.
Ifhedoesnot,showthenumberofdaysofabsenceandthereason:
1.4Thelessonsmentioned at1above
a)(4)Q]include Qdonotinclude
hoursofpracticaltrainingoutsidetheestablishment ,requiredforobtaininganofficialdiploma
b)(4)Qinclude Qdonotinclude
hoursofpracticallessonswhichtakeplaceintheestablishment
c)(4)Q]include Qdonotinclude
hoursdevotedtostudyintheestablishment .
Iftheydo,showthenumberofhoursaweek:
1.5Typeofeducationprovided :
(4)Ogeneraleducation Q]technicalorvocationaltrainingQ]arteducation
(4)Qcoursestreatedasequivalenttouniversityeducation .
1.6Thecurriculum
(4)□'s □isnotapprovedbytheState
(4)Q]corresponds QdoesnotcorrespondtoacurriculumapprovedbytheState.
1.7Showtheperiodsofholidays :
—Christmasholiday:from to
—Easterholiday:from to
—Summerholiday:from to

(1)E402Annex
2JEducationgivenintheestablishmentofhigheroruniversityeducation
21(4)QItinvolves QItdoesnotinvolveafull-timecurriculum .
2.2Thecoursefollowed (4)Qleads Qdoesnotleadtoauniversity
degreeoradiploma .
2.3Thestudent (4)[Jhasbeanpreparing\_jhasnotbeenpreparingathesis.
Ifhe/shehas,indicate:
—sincewhen?
—whenmusthe/shesubmitthethesis?
2.4Showtheperiodsofholidays:
—Christmasholiday:from to
—Easterholiday:from to
—Summerholiday:from to
3School,universityorestablishment ofhighereducation
3.1Name:
3.2Address(2):
3.3Stamp
3.4Date:
3.5Signature
FORINSTRUCTIONS ANDNOTES
seepage2offormE402

See'Instructions'onpage3 EUROPEAN COMMUNITIES
SocialSecurityRegulations
E403r
CERTIFICATE OFAPPRENTICESHIP FORTHEPURPOSE OFTHE
GRANTING OFFAMILYBENEFITS
Reg.1408/71:Art.73.1andArt.74.1
Reg.574/72:Art.86andArt.88
A.Requestforcertificate
Tobecompletedbytheinstitutioncompetentforthegrantingoffamilybenefits.
1|Workerapplyingforfamilybenefitsorpersonclaimingthemonothergrounds
1.1Surname Forenames Maidenname
1.2Placeofbirth Dateofbirth Sex Nationality
1.3Address(2):
2IApprentice
2.1Surname Forenames Maidenname
2.2Placeofbirth Dateofbirth Sex
2.3Address(2):
3Institutioncompetentforthegrantingoffamilybenefits
3.1Name:
3.2Address(2):
3.3Stamp
3.4Date:
3.5Signature

E403
B.Certificate
Tobecompletedbytheperson,undertaking orinstitutionresponsiblefortheapprenticeship andtobesenttothe
bodyresponsibleforsupervisionoftheapprenticeship ,whichmustforwardthecompletedformtotheinstitution
mentioned inbox3.
4Informationconcerningtheapprenticeship
4.1Thepersonnamedinbox2hasbeenapprenticedtous
from
toreceivetrainingforthetradeof
4.2Theapprenticeship willprobablylastuntil
4.3Theapprentice
(3)Qisreceiving:
(3)Q]anapprenticeship allowanceorwage
(3)Qweekly Qmonthly amountingto
(3)Qotherbenefits(4),namely:
(3)Q]accommodation Q]fullboard Qpartialboard
(3)Qtips Qmealsaday Q]other(5)
from to amountingto
(3)Qisnotreceiving
(3)Qanapprenticeship allowanceorwage Qotherbenefits.
4.4Work-place :
4.5Nameoftheperson,undertaking orinstitutionresponsiblefortheapprenticeship :
4.6Address(2):
4.7Stamp
4.8Date:
4.9Signature
5Endorsement ofthebodyresponsibleforsupervisionoftheapprenticeship (6)
5.1Name:
5.2Address(2):
5.3Stamp
5.4Date:
5.5Signature

E403
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .Itconsists ofthree pages ,
none ofwhich may beleftouteven ifitdoes notcontain any relevant information .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing part Aoftheform belongs :B=Belgium ;Dk=Denmark ;D=Germany ;
F=France ;Irl=Ireland ;I=Italy ;L=Luxembourg ;N=Netherlands ;UK=United Kingdom .
(2)Postal code ,town ,street ,number ,country .
(3)Putacross inthesquare preceding theappropriate subject .
(4)When theform isbeing sent toaUnited Kingdom institution ,give details oftheamount ofthese benefits inthebox below :
accommodation : other benefits :
full board :
partial board :
tips :
meals :
(5)Ifapplicable ,give details ofthese other benefits inthebox below :
(6)This boxshould becompleted bythefollowing :
inIreland ,theDepartment ofSocial Welfare ,Dublin ,inthecase ofapprenticeships that arenotsupervised bytheIndustrial Training
Authority ;
intheUnited Kingdom ,theDepartment ofHealth and Social Security ,Overseas Group ,Newcastle-upon-Tyne ,ortheMinistry of
Health and Social Services ,Overseas Branch ,Belfast ,asappropriate .

See'Instructions overleaf EUROPEAN COMMUNITIES
SocialSecurityRegulations
E4041)
MEDICAL CERTIFICATE FORTHEPURPOSE OFTHEGRANTING
OFFAMILYBENEFITS
Reg.1408/71:Art.73.1and3;Art.74.1
Reg.574/72:Art.86;Art.88
A.Requestforcertificate
Tobecompletedbytheinstitutioncompetentforthegrantingoffamilybenefits.
1Workerapplyingforfamilybenefitsorpersonclaimingthemonothergrounds
1.1Surname Forenames Maidenname
1.2Placeofbirth Dateofbirth Sex Nationality
1.3Address(2):
2Persontowhomthemedicalcertificaterelates
2.1Surname Forenames Maidenname
2.2Placeofbirth Dateofbirth Sex
2.3Address(2):
3Institutioncompetentforthegrantingoffamilybenefits
3.1Name:
3.2Address(2):
3.3Stamp
3.4Date:
3.5Signature

E404
B.Certificate
Tobecompleted bythedoctordesignated bytheliaisonbody(3)ofthecountryofresidenceofthepersonexamined
andtobesenttotheinstitution mentioned inbox3.
4
4.1a)Thephysicalormentalfacultiesofthepersonexamined
(4)Qarediminished Qarenotdiminished .
Iftheyare,indicatepercentage ofdiminishment : %
b)Thepersonexamined (4)Qiscapableofearninghis/herliving
(4)Qisincapableofearninghis/herlivingduetophysicalormental
deficiency .
c)Thepersonexamined (4)QisQisnotahousewife .
Ifsheis,indicatewhether (4)Q]sheisQ]sheisnotinafitconditiontolookafterher
home .
d)Observations :
e)Description oftheconditionofthepersonexamined :
4.2Dateofcommencement ©fdisablement orillness(beaspreciseaspossible):
4.3Probable duration :
4.4a)Afurtherexamination (4)Qisnecessary Q]isnotnecessary .
b)Ifitis,indicatedateoftheexamination :
5
5.1Surname andforenames ofthedoctor :
5.2Address (2):
5.3Date:
5.4Signature
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.
NOTES
(1)Symbolofthecountrytowhichtheinstitution completing partAoftheformbelongs :B=Belgium ;Dk=Denmark ;D=Germany ;
F=France;Irl=Ireland;I=Italy;L=Luxembourg ;N=Netherlands ;UK=UnitedKingdom .
(2)Postalcode,town,street,number,country .
(3)Orthedoctorofthefunddesignated bytheliaisonbody.
(4)Putacrossinthesquarepreceding theappropriate subject .

SeeInstructions overleaf EUROPEAN COMMUNITIES
SocialSecurityRegulations
E405 (1)
PAYMENT OFFAMILYBENEFITS ORFAMILYALLOWANCES INTHECASEOFSUCCESSIVE
EMPLOYMENT INSEVERALMEMBER STATES,BETWEEN THEDATESONWHICHPAYMENT
ISDUEACCORDING TOTHELEGISLATION OFTHESESTATES
Reg.1408/71:Art.12;Art.72
Reg.574172:Art.10.2;Art.85.2and3
Thiscertificateshouldbeissuedtothepersonconcernedathisrequest.Ifappropriate ,thecompetentinstitution
shouldrequestitfromtheinstitutionwithwhichtheworkerwaspreviouslyregistered .
A.Tobecompletedbytheinstitutioncompetentforthegrantingoffamilybenefitsorfamilyallowanceswith
whichtheworkerisreaistered .
1Worker
1.1Surname Forenames Maidenname
1.2Placeofbirth Dateofbirth Sex Nationality
1.3Civilstatus (2)QsingleQmarried Qwidow/widower
(2)Qdivorced Qseparated .
1.4Address(3):
2JPersonwhoshouldreceivethefamilybenefitsorfamilyallowances
2.1Surname Forenames Maidenname
2.2Placeofbirth Dateofbirth Sex Nationality
2.3Address(3):
3Institutionwithwhichtheworkerwaspreviouslyregistered
3.1Name:
3.2Address(3):
4Institutionoftheplaceofresidenceofthemembersofthefamily
4.1Name:
4.2Address(3):

E405
j5Institutionwithwhichtheworkeriscurrentlyregistered
5.1Name:
5.2Address (3):
5.3Filereference number :
5.4Stamp
5.5Date:
5.6Signature
B.Tobecompleted bytheinstitution competent forthegrantingoffamilybenefitsorfamilyallowances withwhichthe
workerwaspreviously registered .
6
6.1Wecertifythattheworkernamedinbox1
6.2completed daysofwork, from to
6.3in(4)
6.4(2)QHeisentitled QHeisnotentitledtofamilybenefitsorfamilyallowances .
6.5Familybenefitsorfamilyallowances werepaidtohim
i
from to
7Institution withwhichtheworkerwaspreviously registered
7.1Name:
7.2Address (3):
7.3Stamp
7.4Date:
75Signature
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.
NOTES
(1)Symbolofthecountrytowhichtheinstitution completing partAoftheformbelongs :B=Belgium ;Dk=Denmark ;D=Germany ;
F=France;Irl=Ireland;I=Italy;L=Luxembourg ;N=Netherlands ;UK=UnitedKingdom .
(2)Putacrossinthesquarepreceding theappropriate subject .
(3)Postalcode,town,street,number,country .
(4)Countryinwhichtheemployment underconsideration wascarriedout.

See'Instructions'page3 EUROPEAN COMMUNITIES
SocialSecurityRegulations
E406 F(1)
CLAIMFORFAMILYALLOWANCES TOBESUBMITTED BYAWORKERWHOISSUBJECT TO
FRENCHLEGISLATION ANDWHOSEFAMILYRESIDESINAMEMBER STATEOTHERTHAN
FRANCE
Reg.1408171:Art.73.2;Art.75.2.b;Art.76
Reg.574172:Art.87.1
Thisclaimform,drawnupinduplicate(intriplicateifthemembersofthefamilyresideinItaly)(2),shouldbesent
bytheworkerdirecttotheFrenchfamilyallowancesinstitutionwithwhichheisregisteredbyvirtueofhisemploy­
ment.
1Worker
1.1Surname Forenames Maidenname
1.2Placeofbirth Dateofbirth Sex Nationality
1.3AddressinFrance(3):
1.4Occupation (4):
1.5DateofentryintoFrance:
2Personwhoshouldreceivethefamilyallowances
IdeclarethatthepersonnamedbelowmaintainsthemembersofmyfamilyandIrequestthatthefamilyallowances
bepaidtohim/her.
2.1Surname Forenames Maidenname
2.2Placeofbirth Dateofbirth Sex Nationality
2.3Relationship totheworker:
2.4Nameifitisalegalperson:
2.5Address(3):
2.6Date:
2.7Signature
2.8Nameandaddressoftheinstitutionwhichhastopaythefamilyallowancestothemembersofthefamily
intheirplaceofresidence(3):

E406F
mDependentmembersofthefamily
3.1Surname 3.2Forenames 3.3Dateofbirth
1)
2)
3)
4)
5)
6)
7)
8)
9)
3.4Relationship 3.5Placeofresidence 3.6Remarks
1)(5)--
2)
3)
4)
5)
6)
7)
8)
9)
3.7Ideclarethatthereisnoentitlementtofamilyallowancesonaccountofaprofessional ortradeactivityunder
thelegislationofthecountryofresidenceofthemembersofmyfamily.
3.8Date:
3.9Signature
4(6)Incomeofmembersofthefamily,ifany(natureandmonthlyamount,includingsocialbenefits)
Number
(5)Membersofthefamily Natureofincome Amount

E406 F
5
5.1Ifyouwereingainfulemployment inanotherMemberStateduringthemonthinwhichyouarrivedinFrance
andifaformE405hasnotyetbeendrawnup,indicate :
5.2theperiodofemployment :
5.3thenameandaddress(3)oftheinstitution competent forfamilyallowances withwhichyouareregistered :
5.4yourinsurance numberwiththisinstitution :
5.5Date:
5.6Signature
6IStatementofemployer
6.1Nameofemployer orfirm:
6.2Branchofactivity(7):
6.3Address (3):
6.4Datewhenemployment commenced :
6.5Theworker (8)Qdoes Qdoesnotholdacontractforseasonalwork.
6.6Ifhedoes,stateduration ofthecontract :
6.7Date:
6.8Signature
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.Itconsistsofthreepages,
noneofwhichmaybeleftoutevenifitdoesnotcontainanyrelevantinformation .
Information fortheinsuredperson
TheworkersubjecttoFrenchlegislation andtheunemployed personwhoisreceiving unemployment benefitsfromFranceareentitled,
forthemembers oftheirfamilywhoresideinaMemberStateotherthanFrance,tofamilyallowances underthelegislation ofthecountry
ofresidence ofthemembersofthefamily.Theallowances arepaidbytheinstitution oftheplaceofresidence ofthemembersofthefamily
onpresentation ofacertificate E407issuedbytheFrenchfamilyallowances institution .
NOTES
(1)Symbolofthecountrytowhoselegislation theworkerissubject :(F=France.)
(2)Tomêettherequirements ofItalianinstitutions ,acopyofformE406mustbeattachedtoformE407.
(3)Postalcode,town,street,number ,country .
(4)Tomeettherequirements ofItalianinstitutions ,specifywhethermanualorclericalworker .
(5)Indicateateachnumbertheinformation concerning thepersonnamedatthesamenumberinthethreecolumnsatpoint3.
(6)Tobecompleted onlyifthemembers ofthefamilyresideinItaly.
(7)Personsemployed intradeandindustry ,theprofessions (supervisory staff,clericalstaff,manualworkers),professional journalists ,
personsemployed byinsurance companies orcreditinstitutions ,inthecraftsorinagriculture .-
(8)Putacrossinthesquarepreceding theappropriate subject .

SeeInstructions 'overleaf EUROPEAN COMMUNITIES
SocialSecurityRegulations
E407 F1
CERTIFICATE OFPERIODSOFEMPLOYMENT INFRANCE,ORPERIODSOFUNEMPLOYMENT INFRANCEFOR
WHICHBENEFITS WEREPAID,FORTHEPURPOSE OFGRANTING FAMILYALLOWANCES TOMEMBERS OFTHE
FAMILYOFAWORKER ORUNEMPLOYED PERSONWHORESIDEINAMEMBER STATEOTHERTHANFRANCE
Reg.1408/71:Art.73.2;Art.74.2—Reg.574172:Art.87.1to5;Art.89.1
Thiscertificateisissuedtotheworker,theunemployed personor,whereappropriate ,theinstitutionoftheplaceofresidencebythe.Frenchinstitutioncompetentfor
familyallowances .Theworkerorunemployed personshouldforwardittothemembersofhisfamily,whoshouldsendittotheinstitutionoftheirplaceofresidence .If
themembersofthefamilyareresidentinIrelandorintheUnitedKingdom,thiscertificateshouldbesentdirecttotheinstitutionofthesecountriescompetentfortheplace
ofresidenceofthemembersofthefamily.Subjecttotheconditionssetoutbelowandunlessitissubsequently cancelled,thecertificateisvalidforthreemonthsinthe
caseofpersonsinpermanentemployment andforthedurationofthecontractinthecaseofseasonalworkers.
11(2)QWorker □Seasonalworker□Unemployed person Insurancenumber:
1.1Surname Forenames Maidenname
1.2Placeofbirth Dateofbirth Sex Nationality
1.3Address(3):
2INaturalorlegalpersonwhoistoreceivethefamilyallowances
2.1Surnameandforenamesornameofbody Sex Maidenname
2.2Address(3):
3IInstitutionoftheplaceofresidenceofthemembersofthefamily Insurancenumber:
3.1Name:
3.2Address(3):
4ICertificateofentitlement
Thepersonshowninbox1
4.1(2)□hassatisfiedtheconditionsofemploymentinFranceentitlinghim/hertoreceivethefullamountofmonthlyfamilyallowances ,exceptincaseof
subsequent cancellation ,forthefollowingmonths:
4-2(2)□hascarriedoutanoccupationin Franceentitlinghim/her,exceptincaseofsubsequentcancellation ,to (fraction)
ofthemonthlyfamilyallowancesforthemonthsof and
andtothefullamountforthemonthsfrom to
inclusive,andentitlinghim/hertopaymentoffamilyallowancesonthisbasis
4.3(2)□holdsacontractofseasonalworkinFrance,validfrom to
whichentitleshim/hertoreceivethefullamountoffamilyallowancesforthemonthsfrom to
inclusive,andonaproratabasisforthemonthsof and
4.4(2)Qreceivedunemployment benefitsunderFrenchlegislationintheperiodfrom to
for days
5j-Frenchinstitutioncompetentforfamilyallowances
5.1Name:
5.2Address(3):
5.3Stamp
5.4Date:
5.5Signature

INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .Tomeet therequirements ofItalian institutions acopy ofform E406must beattached .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing theform belongs :(F=France ).
(2)Put across inthesquare preceding theappropriate subject .
(3)Postal code ,town ,street ,number ,country .
©

EUROPEAN COMMUNITIES
SocialSecurityRegulationsSeeinstructions overleaf
E408 (1)
REQUEST FORINFORMATION
Reg.1408/71:Art.73.2
Reg.574/72:Art.87.1;Art.87.7,secondsubparagraph ;Art.89.2
Thisrequestforinformation maybesentatanytimebytheinstitutionoftheplaceofresidenceofthemembersof
thefamilytotheFrenchinstitutionwithwhichtheworkerisregistered .
A.Tobecompletedbytheinstitutionoftheplaceofresidenceofthemembersofthefamily.
1(2)EHWorker QSeasonalworker Q]Unemployed person
1.1Surname Forenames Maidenname
1.2Placeofbirth Dateofbirth Sex Nationality
1.3Address(3):
2Employer
2.1Nameofemployerorfirm:
2.2Address(3):
3jPersonwhoistoreceivethefamilyallowancesinthecountryofresidence
3.1Surname Forenames Sex
3.2Address(3):
4Requestforinformation
4.1Certificateofperiodsofemployment (Art.87.1ofRegulation574/72)completed
between and
4.2Otherinformationrelatingtotheworker'sentitlementtoallowances (Art.87.7ofRegulation574/72):

E408
5JInstitutionoftheplaceofresidenceofthemembersofthefamily
5.1Name :
5.2Address (3):
5.3Stamp
5.4Date:
5.5Signature
B.Tobecompleted bythecompetent Frenchinstitution .
6jInformation requested
6.1(2)QReplytopoint4.1:seeformE407attached .
6.2(2)QReplytopoint4.2:
6.3Stamp
6.4Date:
6.5Signature
7jCompetentFrenchinstitution
7.1Name:
7.2Address (3):
7.3Stamp
7.4Date:
7.5Signature
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.
NOTES
(1)Symbolofthecountrytowhichtheinstitution completing partAoftheformbelongs :B=Belgium ;Dk=Denmark ;D=Germany ;
Irl=Ireland;I=Italy;L=Luxembourg ;N=Netherlands ;UK=UnitedKingdom .
(2)Putacrossinthesquarepreceding theappropriate subject .
(3)Postalcode,town,street,number,country .

SeeInstructions overleaf EUROPEAN COMMUNITIES
SocialSecurityRegulations
E409 F1)
VERIFICATION OFTHEDECLARATION OFABSENCE OFENTITLEMENT TOFAMILY
ALLOWANCES BYVIRTUEOFAPROFESSIONAL ORTRADEACTIVITY INTHECOUNTRY OF
RESIDENCE OFTHEFAMILY
Reg.1408/71:Art.73.2
Reg.574/72:Art.87.1;Art.87.7,thirdsubparagraph
ThisrequestforinformationshouldbeusedbytheFrenchcompetentinstitutiontoverify,ifnecessary,thedeclara­
tionoftheheadofthehouseholdthatthereisnoentitlementtofamilyallowancesbyvirtueofthepursuitofaprofes­
sionalortradeactivityinthecountryofresidenceof themembersofthefamily.AcopyofformE406shouldbeattached .
A.TobecompletedbytheFrenchinstitutioncompetentforfamilyallowances .
1I(2)Q]Worker QSeasonalworkerQUnemployedperson
1.1Surname Forenames Maidenname
1.2Dateofbirth Placeofbirth Sex Nationality
1.3AddressinFrance(3):
1.4Reference E406of(date):
2Requestforinformation
2.1(2)Q]Pleaseverifythedeclarationatpoint3.7offormE406concerningtheperson
namedatNo inbox3ofthatform.
2.2(2)QPleaseverifyformE406of(date):
concerning
3Frenchinstitution
3.1Name:
3.2Address(3):
3.3Stamp
3.4Date:
3.5Signature

E409 F
B.Tobecompleted bythefamilyallowances institution oftheplaceofresidence ofthemembers ofthe
family.
4!Information requested
4.1(2)QThereisentitlement \^\Thereisnoentitlement
asaresultofthepursuitofaprofessional ortradeactivityinthecountryofresidenceofthemembersofthefamily.
4.2Thefollowing membersofthefamilyareentitledtofamilyallowances :
5Institution oftheplaceofresidence ofthemembersofthefamily
5.1Name:
5.2Address (3):
5.3Stamp
5.4Date:
5.5Signature
INSTRUCTIONS
Pleasecomplete thisforminblockletters,writingonthedottedlinesonly.
NOTES
(1)Symbolofthecountrytowhichtheinstitution completing partAoftheformbelongs :(F=France).
(2)Putacrossinthesquarepreceding theappropriate subject .
(3)Postalcode,town,street,number ,country .

See'Instructions 'overleaf EUROPEAN COMMUNITIES
SocialSecurityRegulations
E410nF
NOTIFICATION OFCANCELLATION OFENTITLEMENT TOFAMILYALLOWANCES
Reg.1408/71:Art.73.2;Art.74.2
Reg.574/72:Art.87.3and7;Art.98.2
TheFrenchinstitutioncompetentforfamilyallowancesshouldcompletethisformandsendittotheinstitutionof
theplaceofresidenceofthemembersofthefamily.
1Familyallowancesinstitutiontowhichformisaddressed
1.1Name:
1.2Address(2):
1.3Reference :E407of(date):.
2(3)QWorker Q]Seasonalworker Q]Unemployedperson
2.1Surname Forenames Maidenname
2.2Placeofbirth Dateofbirth Sex Nationality
2.3AddressinFrance(2):
3
3.1Thepersonnamedabove
3.2(3)Qhasnotsatisfiedtheconditionofpursuingaprofessionalortradeactivityrequiredinordertoreceive
familyallowances
duringthemonthof (Art.87.7ofRegulation574/72)
3.3(3)Qceasedtopursueaprofessionalortradeactivityon (4);
3-4(3)Q]interruptedhiscontractofseasonalwork
from(date): (Art.87.3ofRegulation574/72)
3.5(3)\_jtransferredhisresidenceto(5)
from(date): (Art.87.7ofRegulation574/72).
4Frenchcompetentinstitution
4.1Name:
4.2Address(2):
4.3Stamp
4.4Date:
4.5Signature

[E410||F
INSTRUCTIONS
Please complete this form inblock letters ,writing onthedotted lines only .
NOTES
(1)Symbol ofthecountry towhich theinstitution completing theform belongs :(F=France ).
(2)Postal code ,town ,street ,number ,country .
(s)Put across inthesquare preceding theappropriate square .
(4)Complete only iftheform istobesent toaUnited Kingdom institution .
(5)Indicate thecountry .
©