1999/371/EC: Administrative Commission of the European Communities on social security for migrant workers - Decision No 172 of 9 December 1998 on the model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 101)
Date: 1998-12-09
Institutions: Administrative Commission on Social Security for Migrant Workers, European Commission
Subjects: family benefit, form, migrant worker, self-employed person, wage earner

8. 6. 1999

EN

Official Journal of the European Communities

L 143/13

DECISION No 172

of 9 December 1998

on the model forms necessary for the application of Council Regulations (EEC) No
1408/71 and (EEC) No 574/72 (E 101)

(1999/371/EC)

THE ADMINISTRATIVE COMMISSION OF THE EUROPEAN COMMUNITIES ON SOCIAL SECURITY
FOR MIGRANT WORKERS,

Having regard to Article 81(a) of Council Regulation (EEC) No 1408/71 of 14 June 1971 on the
application of social security schemes to employed persons, to self-employed persons and to
members of their families moving within the Community (1), under which it is the duty of the
Administrative Commission to deal with all administrative questions arising from Regulation
(EEC) No 1408/71 and subsequent Regulations,

Having regard to Article 2(1) of Council Regulation (EEC) No 574/72 of 21 March 1972 laying
down the procedure for implementing Regulation (EEC) No 1408/71 on the application of social
security schemes to employed persons, to self-employed persons and to members of their families
moving within the Community (2), under which it is the duty of the Administrative Commission
to draw up models of certificates, certified statements, declarations, applications and other
documents necessary for the application of the Regulations,

Having regard to Council Regulation (EC) No 1606/98 of 29 June 1998 amending Regulation
(EEC) No 1408/71 on the application of social security schemes to employed persons, to
self-employed persons and to members of their families moving within the Community and
Regulation (EEC) No 574/72 laying down the procedure for implementing Regulation (EEC) No
1408/71, with a view to extending them to cover special schemes for civil servants (3),

Whereas this model form should be adapted to take account of Decision No 164;

Whereas the Agreement on the European Economic Area of 2 May 1992, amended by the
Protocol of 17 March 1993, Annex VI, implements Regulations (EEC) No 1408/71 and (EEC) No
574/72 within the European Economic Area;

Whereas, by Decision of the EEA Joint Committee, the model forms necessary to implement
Regulations (EEC) No 1408/71 and (EEC) No 574/72 are to be adapted and used within the
European Economic Area;

Whereas, for practical reasons, identical forms should be used within the Community and within
the European Economic Area;

Whereas the language in which the forms should be drawn up is dealt with by Recommendation
No 15 of the Administrative Commission,

HAS DECIDED AS FOLLOWS:

1. The model form E 101 reproduced in Decision No 164 of 27 November 1996 shall be

replaced by the model appended hereto.

2. The competent authorities of the Member States shall make available to those involved
(rightful claimants, institutions, employers, etc.) the form according to the attached model.

(1) OJ L 149, 5.7.1971, p. 2.
(2) OJ L 74, 27.3.1972, p. 1.
(3) OJ L 209, 25.7.1998, p. 1.

L 143/14

EN

Official Journal of the European Communities

8. 6. 1999

3. The form shall be available in the official languages of the Community and laid out in such
manner that the different versions are perfectly superposable, thereby making it possible for
each person or body to which a form is addressed (rightful claimant, institution, employer, etc.)
to receive the form printed in their own language.

4. This Decision shall be applicable from the first day of the month following its publication in

the Official Journal of the European Communities.

The Chairman of the
Administrative Commission

Helmut SIEDL

EUROPEAN COMMUNITIES
Social Security Regulations
EEA (*)

See ‘Instructions' on page 3

E 101

(1)

CERTIFICATE CONCERNING THE LEGISLATION APPLICABLE

Regulation (EEC) No 1408/71: Article 13.2.d; Article 14.1.a; Article 14.2.b; Article 14 a.1.(a), 2 and 4; Article 14b.1, 2 and 4; Article
14 c (a); Article 14e; Article 17
Regulation (EEC) No 574/72: Article 11.1; Article 11a.1; Article 12a.2(a), 5.(c) and 7(a); Article 12 b

1.

Employed person

1.1. Surname (2)

Self-employed person

......................................................................................................................................................................

1.2.

Forename(s)

Previous names (2)

...................................................

....................................................

...................................................

1.3. Date of birth (3)

Nationality

DNI (4)

...................................................

....................................................

...................................................

1.4. Permanent address

Street

......................................................................

No

...................

PO box

...................

Town

.................................................................

Postal code

...........

Country .............................

1.5.

Insurance No (5)

......................................................................................................................................

2.

Employer

Activity as a self-employed person

2.1. Name of employer or firm

......................................................................................................................................................................

2.2.

Identification No (6)

......................................................................................................................................................................

2.3.

The employer is a recruitment agency

2.4. Address

Telephone ................................................................

Street

......................................................................

Yes

Fax

No

No

...............

E-mail

...............................

...................

PO box

...................

Town

.................................................................

Postal code

...........

Country .............................

3.

3.1.

The abovementioned insured person

has been employed by the employer mentioned above since

...........................................................................

has been pursuing an activity as a self-employed person since ............................................................................

in

..........................................................................................................................................................

3.2.

is being posted or will pursue an activity as a self-employed person for a period probably

lasting from ..................................................................

to

.................................................................

3.3.

to the firm(s) mentioned below

on the ship mentioned below

3.4. Name(s) of firm or ship

......................................................................................................................................................................

3.5. Address(es)

Street

......................................................................

No

...................

PO box

...................

Town

.................................................................

Postal code

...........

Country .............................

Street

......................................................................

No

...................

PO box

...................

Town

.................................................................

Code postal

...........

Country .............................

3.6.

Identification No (6)

................................................................................................................................

➀

4.

4.1.

4.2.

4.3.

Who pays the wage of the employed posted person? Who pays the social security contributions of the posted employee?

E 101

The employer referred to in point 2

The firm referred to in point 3.4

Other

Name

Address:

....................................................................................................................................... and

if so, give the

Street

...........................................................

No

...................

PO box

.....................

Town

...........................................................

Postal code

...................

Country

.....................

5.

The insured person remains subject to the legislation of the country

(1)

5.1.

in accordance with Article

13.2.d

14.1.a

14b.1

14.2.b

14b.2

14a.1(a)

14b.4

14a.2

14c(a)

14a.4

14e

5.2.

5.3.

of Regulation (EEC) No 1408/71

from

.............................

to

.............................

for the duration of the activity (see the letter from the competent authority or designated body in the country of employment
which entitles the insured person to remain subject to the legislation of the sending State

of

.............................

reference ...................... )

6.

Competent institution whose legislation will be applicable

6.1. Name

........................................................................

Code number (7)

...................................

6.2. Address

Phone

................................................................

Street

......................................................................

Fax

No

...............

E-mail

...............................

...................

PO box

...................

Town

.................................................................

Postal code

...........

Country .............................

6.3. Stamp

6.4. Date

............................................

6.5. Signature

............................................

➁

INSTRUCTIONS

E 101

Please complete this form in block letters, writing on the dotted lines only. It consists of 4 pages, none of which may be left out
even if they do not contain any relevant information.

The designated institution of the Member State to whose legislation the worker is subject should fill in the form at the request of the
worker or his employer and return it to the person involved. Where the worker is posted to Belgium, the Netherlands, Finland, Sweden or
Iceland, the institution should also send a copy to, in Belgium: in the case of employed persons to the ‘Office national de sécurité sociale/
Rijksdienst voor Sociale Zekerheid' (National Social Security Office), Brussels; in the case of self-employed persons to the ‘Institut
national d’assurances sociales pour travailleurs indépendants/Rijksinstituut voor de Sociale Verzekering der Selfstandigen' (National
Social Insurance Institute for the Self-Employed), Brussels; in the case of seamen to the ‘Caisse de secours et de prévoyance en faveur
des marins/Hulp- en Voorzorgskas voor Zeevarenden' (Relief and Welfare Fund for Mariners), Antwerp; or in the case of civil servants to
the ‘Service des Relations internationales du Ministère des Affaires sociales/Dienst Internationale Betrekkingen van het Ministerie van
Sociale Zaken' (International Relations Department, Social Affairs Ministry); in the Netherlands, to the ‘Sociale Verzekeringsbank' (Social
Security Bank), Amstelveen; in Finland, to the ‘Eläketurvakeskus' (Central Pension Security Institute), Helsinki; in Sweden, to the
‘Riksförsäkringsverket' (National Social Insurance Board), Stockholm; in Iceland, to the ‘Tryggingastofnun Rikisins' (National Social
Security Institute), Reykjavik.

Information for the insured person

Before you leave the country where you are insured to go to another Member State to work, you should ask your sickness and maternity
insurance institution for an E 128 form or E 106 form, as appropriate. If you or a member of your family require benefits in kind (e.g.
medical treatment, medicines, hospital treatment, etc.) in the country where you are working, your should follow the instructions given on
the appropriate form. If you have an E 106 form you should submit it as soon as possible to the sickness and maternity insurance institu-
tion of the place where you go in order to work. If you have an E 128 form, you should keep it until you require medical treatment. If you
are not in possession of the said form, the latter institution should request it from the institution with which you are insured.

Information for employers

A Member State which receives a request for the application of the aforementioned Article 14(1), Article 14b(1) or Article 17 of Regula-
tion (EEC) No 1408/71 shall duly inform the employer and the worker concerned of the conditions under which the posted worker may
continue to be subject to its legislation.

The employer shall be informed of the possibility of checks throughout the period of posting so as to ascertain that this period has not
come to an end. Such checks may relate, in particular, to the payment of contributions and the maintenance of the direct relationship.
Moreover, the employer of the posted worker shall inform the competent institution of the sending State of any change that has occurred
during the period of posting, in particular:

— if the posting applied for has not taken place or if the extension of the posting applied for has not taken place,
— if the posting has been interrupted, unless this interruption of the worker’s activities on behalf of the undertaking in the country of

employment is of a purely temporary nature,

— if the posted worker has been assigned by his employer to another undertaking in the State of employment.

In the first two cases, he/she shall return this form to the competent institution of the sending State.

Information for the institution of the place of stay

If the person involved produces the proper certificate (E 128 or E 106), the insurance institution in the country of stay will also provide
him provisionally with benefits in the event of an accident at work or an occupational disease. If in such a case the institution requires
certificate E 123, it should apply as soon as possible:

in Belgium, for employed persons and as regards an occupational disease, to the ‘Fonds des maladies professionnelles/Fonds voor
Beroepsziekten' (Occupational Diseases Fund), Brussels, and as regards accidents at work to the insurance company designated by the
employer
in Denmark, to the ‘Arbejdsskadestyrelsen' (National Office for Accidents at Work and Occupational Diseases), Copenhagen
in Germany, to the competent ‘Berufsgenossenschaft' (institution for accident insurance)
in Spain, to the ‘Dirección Provincial del Instituto Nacional de Seguridad Social' (Provincial Directorate of the National Social Security
Institution)
in Ireland, to the Department of Health and Children, Planning Unit, Hawkins House, Dublin 2
in Italy, to the competent provincial office of the ‘Istituto nazionale per l’assicurazione contro gli infortuni sul lavoro' (INAIL, National
Institute for Insurance against Accidents at Work)
in Luxembourg, to the ‘Association d’assurance contre les accidents' (Accident Insurance Association)
in the Netherlands, to the ‘Sociale Verzekeringsbank' (Social Security Bank), Amstelveen
in Austria, to the competent institution for accident insurance
in Portugal, to the ‘Centro Nacional de Protecção contra os Riscos Profissionais' (National Centre for Protection against Occupational
Risks), Lisbon
in Finland, to the ‘Tapaturmavakuutuslaitosten Liitto' (Federation of Accident Insurance Institutions), Bulevardi 28, 00120 Helsinki
in Sweden, to the ‘Försäkringskassan' (Social Insurance Office)
in all other Member States, to the competent sickness insurance institution
in Iceland, to the ‘Tryggingastofnun Rikisins' (State Social Security Institute), Reykjavik
iu Liechtenstein, to the ‘Amt für Volkswirtschaft' (Office of National Economy), Vaduz
in Norway, to the ‘Folketrygdkontoret for Utenlandssaker' (National Office for Social Insurance Abroad), Oslo.

Where the worker is covered by the French social security scheme, the fund which is competent to recognise entitlement to benefits is
his insurance fund, which may not be the one appearing on form E 101. It will be necessary, where appropriate, to request forms E 128
or E 123 from the fund of the worker’s place of habitual residence.

Where a self-employed person is covered by a Finnish or Icelandic social security scheme it will always be necessary to request form
E 123.

Where a worker covered by an Icelandic social security scheme suffers an accident at work or contracts an occupational disease, the
employer must always duly notify the competent institution.

➂

NOTES

E 101

(*) EEA = Agreement on the European Economic Area, Annex VI, Social Security. For the purpose of this agreement, this form shall

also apply to Iceland, Liechtenstein and Norway.

(1) Symbol of the Member State to whose legislation the worker is subject: B = Belgium; DK = Denmark; D = Germany; GR = Greece;
E = Spain; F = France; IRL = Ireland; I = Italy; L = Luxembourg; NL = the Netherlands; A = Austria; P = Portugal; FIN = Finland;
S = Sweden; GB = United Kingdom; IS = Iceland; FL = Liechtenstein; N = Norway.

(2) In the case of Spanish nationals, state both names at birth.

In the case of Portuguese nationals, state all names (forenames, surname, maiden name) in the order of civil status in which they
appear on the identity card or passport.

(3) The day and the month should be shown by two digits each and the year by four digits (for example: 1 August 1921 = 01.08.1921).
(4) In the case of Spanish nationals, state the number appearing on the national identity card (DNI), if it exists, even if the identity card is

out of date. Failing this, indicate ‘None'.

(5) For workers subject to Belgian law, indicate the national social security number (NISS).

For workers subject to Danish law, indicate the CPR-number.
For workers subject to Dutch law, indicate the SOFI-number.

(6) Please give as much information as possible to facilitate identification of the employer or the firm of the self-employed person:

In the case of a ship, indicate its name and its registration number.
For Belgium, indicate in the case of employed persons the employer’s ONSS/RSZ registration number and in the case of self-
employed persons the TVA/BTW-number.
For Denmark, indicate the SE-number.
For Germany, indicate the ‘Betriebsnummer des Arbeitgebers'.
For France, indicate the SIRET-number.
For Spain, indicate the ‘Código de Cuenta De Cotización Del Empresario CCC' (Employer’s Contribution Account Number).
For workers subject to Finnish work accident legislation, please indicate the name of the competent accident insurance institution.
For Norway, indicate the organisation number.

(7) To be filled in where available.

➃