2006/203/EC: Decision No 202 of  17 March 2005  on model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 001, E 101, E 102, E 103, E 104, E 106, E 107, E 108, E 109, E 112, E 115, E 116, E 117, E 118, E 120, E 121, E 123, E 124, E 125, E 126 and E 127)   (Text with EEA relevance)
Date: 2005-03-17
Institutions: Administrative Commission on Social Security for Migrant Workers, European Commission
Subjects: accession to the European Union, form, migrant worker, social security, social-security benefit

15.3.2006

EN

Official Journal of the European Union

L 77/1

II

(Acts whose publication is not obligatory)

COMMISSION

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

DECISION No 202

of 17 March 2005

on model forms necessary for the application of Council Regulations (EEC) No 1408/71 and (EEC)
No 574/72 (E 001, E 101, E 102, E 103, E 104, E 106, E 107, E 108, E 109, E 112, E 115, E 116, E 117,
E 118, E 120, E 121, E 123, E 124, E 125, E 126 and E 127)

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

(2006/203/EC)

THE ADMINISTRATIVE COMMISSION ON SOCIAL SECURITY FOR MIGRANT WORKERS,

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

Having regard to Article 2(1) of Council Regulation (EEC) No 574/72 of 21 March 1972 fixing the
procedure for implementing Regulation (EEC) No 1408/71 on the application of social security schemes
to employed persons and their families moving within the Community (2) under which it is the duty of the
Administrative Commission to draw up models of documents necessary for the application of the
regulations,

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

Having regard to Decision No 164 of 27 November 1996 on the model forms necessary for the
application of Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 101 and E 102) (4),

Having regard to Decision No 166 of 2 October 1997 on the amending of forms E 106 and E 109 (5),

(1) OJ L 149, 5.7.1971, p. 2. Regulation as last amended by Regulation (EC) No 647/2005 of the European

Parliament and of the Council (OJ L 17, 4.5.2005, p. 1).

(2) OJ L 74, 27.3.1972, p. 1. Regulation as last amended by Regulation (EC) No 647/2005 of the European

Parliament and of the Council.

(3) OJ L 244, 19.9.1994, p. 22.
(4) OJ L 216, 8.8.1997, p. 85.
(5) OJ L 195, 11.7.1998, p. 25.

L 77/2

EN

Official Journal of the European Union

15.3.2006

Having regard to Decision No 168 of 11 June 1998 on the amending of forms E 121 and E 127 and the
discontinuance of form E 122 (1),

Having regard to Decision No 179 of 18 April 2000 on the model forms necessary for the application of
Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 111, E 111 B, E 113 to E 118 and E 125 to
E 127) (2),

Having regard to Decision No 185 of 27 June 2002 amending Decision No 153 of 7 October 1993 (form
E 108) (3),

Having regard to Decision No 186 of 27 June 2002 on the model forms necessary for the application of
Council Regulations (EEC) No 1408/71 and (EEC) No 574/72 (E 101) (4),

Whereas:

(1) The enlargement of the European Union on 1 May 2004 requires forms E 001, E 101, E 102, E 103,
E 104, E 106, E 107, E 108, E 109, E 112, E 115, E 116, E 117, E 118, E 120, E 121, E 123, E 124, E
125, E 126 and E 127 to be amended.

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

(3) The European Community and its Member States, and the Swiss Confederation have concluded an
Agreement on the free movement of persons (Swiss Agreement) which entered into force on 1 June
2002. Annex II to the Agreement refers to Regulations (EEC) No 1408/71 and (EEC) No 574/72.

(4)

For practical reasons, the forms used in the European Union and under the EEA and Swiss
Agreements should be identical,

HAS DECIDED AS FOLLOWS:

1. Model form E 101 reproduced in Decision No 186 is replaced by the model appended hereto.

2. Model form E 102 reproduced in Decision No 164 is replaced by the model appended hereto.

3. Model form E 105 reproduced in Decision No 153 is repealed.

Model forms E 001, E 103, E 104, E 107, E 112, E 120, E 123 and E 124 reproduced in Decision
No 153 are replaced by the model forms appended hereto.

4. Model forms E 106 and 109 reproduced in Decision No 166 are replaced by the models appended

hereto.

5. Model form E 108 reproduced in Decision No 185 is replaced by the model appended hereto.

6. Model forms E 115, E 116, E 117, E 118, E 125, E 126 and E127 reproduced in Decision No 179 are

replaced by the models appended hereto.

(1) OJ L 195, 11.7.1998, p. 37
(2) OJ L 54, 25.2.2002, p. 1.
(3) OJ L 55, 1.3.2003, p. 74.
(4) OJ L 55, 1.3.2003, p. 80.

15.3.2006

EN

Official Journal of the European Union

L 77/3

7. Model form E 121 reproduced in Decision No 168 is replaced by the model appended hereto.

8.

The symbol of the State to which the institution completing the form belongs, is indicated in
accordance with the following:

‘BE = Belgium; CZ = Czech Republic; DK = Denmark; DE = Germany; EE = Estonia; EL = Greece;
ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia; LT = Lithuania;
LU = Luxembourg; HU = Hungary; MT = Malta; NL = The Netherlands; AT = Austria; PL = Poland;
PT = Portugal; SI = Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United Kingdom;
IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland.’

9.

The competent authorities of the Member States shall make available to the parties concerned the
forms according to the models appended hereto. These forms 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 all addressees to receive the form printed in their own
language.

10. This Decision, which replaces Decisions No 153, 164, 166, 168, 179, 185 and 186, shall be published
in the Official Journal of the European Union. It shall apply from the first day of the month following its
publication.

The Chairman of the Administrative Commission

Claude EWEN

ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY 
FOR MIGRANT WORKERS

□ Request for information
□ Communication of information
□ Request for forms
□ Reminder on

E 001

(1)

□ an employed person
□ a self-employed person
□ a frontier worker
□ a pensioner
□ a pension claimant
□ an unemployed person
□ a dependant

Regulation (EEC) No 1408/71: Article 84

The sending institution should complete part A and send two copies of the form to the institution to which it is addressed. The latter should complete 
part B and return one copy to the sending institution.
The form should be used to supplement other forms or as a basis for exchanges between institutions not yet provided for in the forms currently in 
use. It may not be used instead of another form.

Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out.

Part A

1.

Institution to which the form is addressed

1.1  Name: ............................................................................................................................................................................................................

1.2 

Identiﬁ cation number of the institution: ..........................................................................................................................................................

1.3  Address:  ........................................................................................................................................................................................................

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

2.

Information concerning the insured person (2)

2.1  Surname(s) (3):  ..............................................................................................................................................................................................

2.2  Forename(s) (4): .............................................................................................................................................................................................

2.3  Previous name(s):  .........................................................................................................................................................................................

2.4  Sex (5):  ..........................................................................................................................................................................................................

3.  Nationality (6):  ................................................................................................................................................................................................

4.

Details of birth

4.1  Date of birth (7): .............................................................................................................................................................................................

4.2  Place of birth (8): ............................................................................................................................................................................................

4.3  Province or department (9): ...........................................................................................................................................................................

4.4  Country (10): ...................................................................................................................................................................................................

5.

Personal identiﬁ cation number (11)

5.1  at the sending institution: ..............................................................................................................................................................................

5.2  at the institution to which the form is addressed: ..........................................................................................................................................

6. 

Address:  ........................................................................................................................................................................................................

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

7.

Information on the ﬁ le

7.1  Type of beneﬁ t:
          .....................................................................................................................................................................................................................
7.2  Reference number of the ﬁ le at the sending institution:

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

7.3  Reference number of the ﬁ le at the institution to which the form is addressed:
         ......................................................................................................................................................................................................................

1
1

 
 
 
E 001

8.

Dependant (12)

8.1

8.2

8.3

8.4

8.5

8.6

Surname(s) (3): ...............................................................................................................................................................................................

Forename(s) (4): .............................................................................................................................................................................................

Previous name (s): .........................................................................................................................................................................................

Place of birth (8):
.................................................................................................

 Date of birth: 

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

Sex: ................................................................ Nationality (6): ....................................................................................................................

Personal identiﬁ cation number (11):  ................................................................................................................................................................

at the sending institution: ...............................................................................................................................................................................

at the institution to which the form is addressed:  ..........................................................................................................................................

8.7

Address:  ........................................................................................................................................................................................................

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

9. □ Request

□ Reminder of request dated:  ...................................................................................................

With reference to the person named in section  □ 2 

□ 8  

please send

9.1 □  the following form(s):  .............................................................................................................................................................................
9.2 □  the following document(s):  ....................................................................................................................................................................
       ................................................................................................................................................................................................................

9.3 □  the following information: .......................................................................................................................................................................
       ................................................................................................................................................................................................................

9.4 Reason for request: ......................................................................................................................................................................................

10.

Change in circumstances: the following changes have taken place

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

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

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

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

11. Miscellaneous information

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

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

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

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

12.

Institution completing part A

12.1 Name: ..........................................................................................................................................................................................................

12.2

Identiﬁ cation number of the institution: ........................................................................................................................................................

12.3

Address:  ......................................................................................................................................................................................................

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

12.4

Stamp

2
2

12.5

Date:
..........................................................................................

12.6

Signature:

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

 
E 001

Part B

13.

In response to your request of  ................................................  we are enclosing:

13.1 □ the following form(s):  ............................................................................................................................................................................
13.2 □ the following document(s):  ...................................................................................................................................................................
  ...................................................................................................................................................................................................................

13.3 □ the following information:  .....................................................................................................................................................................
....................................................................................................................................................................................................................

14.

In response to your request of ....................................................................................................................................................................

we regret that we are unable to forward:

14.1 □ the following form(s):  ............................................................................................................................................................................
14.2 □ the following document(s):  ...................................................................................................................................................................
14.3 □ the following information:  .....................................................................................................................................................................
14.4 □ Reasons:  ..............................................................................................................................................................................................
....................................................................................................................................................................................................................

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

15.

Miscellaneous information

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

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

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

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

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

16.

□ With reference to your form transmitted on  ..........................................................................................................................................

we acknowledge receipt of the information contained in section 10

17.

Institution, completing part B

17.1

Name: .......................................................................................................................................................................................................

17.2

Identiﬁ cation number of the institution: .....................................................................................................................................................

17.3

Address:  ...................................................................................................................................................................................................

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

17.4

Stamp

17.5

Date:

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

17.6

Signature:

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

3

 
NOTES

E 001

(1) 

the 

the  country  of 

 Symbol  of 
form:  BE  =  Belgium;  CZ  =  Czech  Republic;  DK  =  Denmark;
DE  =  Germany;  EE  =  Estonia;  GR  =  Greece;  ES  =  Spain;  FR  =  France;  IE  =  Ireland;  IT  =  Italy;  CY  =  Cyprus;  LV  =  Latvia; 
LT  =  Lithuania;  LU  =  Luxembourg;  HU  =  Hungary;  MT  =  Malta;  NL  =  Netherlands;  AT  =  Austria;  PL  =  Poland;  PT  =  Portugal;
SI  =  Slovenia;  SK  =  Slovakia;  FI  =  Finland;  SE  =  Sweden;  UK  =  United  Kingdom;  IS  =  Iceland;  LI  =  Liechtenstein;  NO  =  Norway;
CH = Switzerland.

institution  completing 

the 

(2) 

Lines 2.1 to 2.4 identifying the insured person should be completed where appropriate.

(3)  Give all surnames in the order of civil status.  

(4)  Give all forenames in the order of civil status.

(5) 

Put ‘M’ for male or ‘F’ for female.

(6)  Where appropriate, give the date of naturalisation.

For the purpose of Spanish institutions in the case of Spanish nationals state the number appearing on the national identity card (DNI) or 
NIE in the case of foreign people, for both cases if it exists, even if the identity card is out of date. Failing this, state ‘None’.

(7) 

(8) 

(9) 

The day and month should each be expressed by two digits, and the year by four digits (e.g. 1 August 1921 = 01.08.1921).

For  French  cities  comprising  several  arrondissements,  please  give  the  number  of  the  arrondissement  (e.g.  Paris  14).  In  the  case  of 
Portuguese districts, please also state the parish and local authority.

This  information  is  obligatory  for  insured  persons  of  Spanish,  French  or  Italian  nationality.  Depending  on  the  country,  the  entry  should 
consist of the territorial division in which the place of birth is located (in the case of France, for example, if the commune of birth is Lille, the 
department of birth should be given as ‘Nord’ followed by the department code, if the insured person knows it, in this case ‘59’. The complete 
entry should therefore read ‘Nord 59’). In the case of persons born in Spain, state only the province.

(10)  Symbol of the insured person’s country of birth in accordance with note (1).

(11)  For the purpose of Italian institutions, give the ‘ﬁ scal code’.

For the purpose of Maltese institutions, give the Identity Card number in case of Maltese nationals, or the Maltese Social security number in 
case of a non-Maltese national.

For the purpose of Slovak institutions, give the Slovak birth number if applicable.

(12)  Complete where appropriate.

4

 
 
 
ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY
FOR MIGRANT WORKERS

E 101

(1)

CERTIFICATE CONCERNING THE LEGISLATION APPLICABLE

Regulation (EEC) No 1408/71: Article 13(2)(d); Article 14(1)(a), (2)(a) and (2)(b); Article 14a(1)(a), (2) and (4);
Article 14b(1), ( 2) and (4); Article 14c(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 12b

Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out.

1. □ Employed person

□ Self-employed person

1.1  Surname(s) (2):  .............................................................................................................................................................................................
1.2  Forename(s) (3):  ...........................................................................................................................................................................................
1.3  Previous name (s):  .......................................................................................................................................................................................

1.4  Date of birth: 

Nationality: 

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

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

1.5  Permanent address

Street:  ............................................................................... 

No: ...................................  

PO Box:  ............................................

Town: ................................................................................. 

Country: ............................................
1.6  Personal identiﬁ cation number (4):  ...............................................................................................................................................................

Postal code: .....................  

2. □ Employer 

2.1  Name or business name:

□ Activity as a self-employed person

......................................................................................................................................................................................................................
Identiﬁ cation number (5): ...............................................................................................................................................................................

Yes □ 

No □

2.2 
2.3  The employer is a recruitment agency 
2.4  Permanent address

Telephone:  .....................................  

Fax:  ........................................................  

E-mail:  ..................................................................

Street:  .......................................................... 

No: .............................................. 

PO Box: .............................................

Town: ...........................................................  

Postal code: ................................ 

Country:  .............................................

3.

The aforementioned insured person

3.1  □ 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  □ in the ﬁ rm(s) mentioned below 
3.4  Name(s) or business name(s) of the ﬁ rm or ship:

□ on the ship mentioned below

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

3.5  Address(es)

Street:  .......................................................................................   No:  .........................................   PO Box: .............................................

Town:  ........................................................................................  Postal code:  ..........................   Country:  ............................................

Street:  .......................................................................................  No:  .........................................  PO Box:  .............................................

Town:  .......................................................................................   Postal code:  ...........................  Country:  ............................................

3.6 

Identiﬁ cation number (5):  ..............................................................................................................................................................................

1
1

 
 
 
 
 
 
E 101

4. 

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

4.1 

The employer referred to in point 2 

4.2 

The ﬁ rm referred to in point 3.4 

4.3 

Other 

□
□
□ if so, give the name

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

Address

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)(a) 
□ 14b(2) 

of Regulation (EEC) No 1408/71

□ 14(2)(b) 
□ 14b(4) 

□ 14a(1)(a) 
□ 14c(a) 

□ 14a(2) 
□ 14e 

□ 14a(4)
□ 17

5.2  □ from  .................................................................................  

5.3 

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 is applicable

6.1  Name:  ...........................................................................................................................................................................................................

6.2 

Identiﬁ cation number of the institution: .........................................................................................................................................................

6.3  Address

Telephone: .............................................. 

Fax:  ........................................................  E-mail:  .............................................................

Street:  .....................................................................................   No:  ..............................................  PO Box:  ............................................

Town: .................................................................................  

Postal code:  ................................  Country: ............................................

6.4  Stamp

6.5  Date:

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

6.6 

Signature:

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

2
2

 
 
 
 
 
 
 
 
 
 
 
 
 
 
E 101

INSTRUCTIONS

The designated institution of the Member State to whose legislation the worker is subject should ﬁ ll in the form at the request of the worker or 
his employer and return it to the applicant. If the worker is posted to Belgium, Denmark, Germany, France, the Netherlands, Austria, Finland, 
Sweden, or Iceland, the institution should also send a copy to: in Belgium, in the case of employed persons to the ‘Ofﬁ ce national de sécurité 
sociale/Rijksdienst voor Sociale Zekerheid’ (National Social Security Ofﬁ ce), Brussels; in the case of self-employed persons to the ‘Institut national 
d’assurances sociales pour travailleurs indépendants/ Rijksinstituut voor sociale verzekering der zelfstandigen’ (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: de 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 S.P.F. Sécurité sociale’ (International Relations Department, Social Affairs Ministry); in Denmark, to ‘Den Sociale Sikringsstyrelse’ (The National 
Social  Security Agency);  in  Germany,  to  the  Deutsche  Rentenversicherung-Bund  (German  Federal  Pension  Insurance),  97041  Würzburg;  in 
France, to the ‘Centre des liaisons européennes et internationales de sécurité sociale (Cleiss)’ (Centre for European and International Liaison on 
Social Security), Paris; in the Netherlands, to the ‘Sociale Verzekeringsbank’ (Social Insurance Bank), Amstelveen; in Austria, to the ‘Hauptverband 
der österreichischen Sozialversicherungsträger’ (Main Association of Austrian Social Insurance Institutions); in Finland, to the ‘Elaketurvakeskus’ 
(Finnish  centre  for  Pensions),  Helsinki;  in  Sweden,  to  Försäkringskassan,  Huvudkontoret  (Swedish  Social  Insurance  Agency,  Head  Ofﬁ ce), 
Stockholm; in Iceland, to the ‘Tryggingastofnun rikisins’ (The State 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, make sure you have the document which entitles you 
to receive the necessary beneﬁ ts in kind (e.g. medical care, medication, treatment in hospital, etc.) in the country where you are working. If you 
are going to be living in the country in which you are working, ask your sickness insurance institution for an E 106 form and submit it as soon as 
possible to the competent sickness insurance institution of the place where you are going to work. If you are staying temporarily in the country in 
which you are going to work, ask your sickness insurance institution for the European health insurance card. You must show this card to your care 
provider if you need beneﬁ ts in kind during your stay.

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 Regulation (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 ﬁ rst 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 document (European health insurance card or form E 106), the insurance institution in the country of stay will 
also provide him provisionally with beneﬁ ts in the event of an accident at work or an occupational disease. If in such a case the institution requires form 
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 the Czech Republic, to the sickness insurance fund with which the person concerned is insured;
in Denmark, to ‘Arbejdsskadestyrelsen’ (National Board of Industrial Injuries), Copenhagen;
in Germany, to the competent ‘Berufsgenossenschaft’ (Accident Insurance Institution); 
in Estonia, to the ‘Sotsiaalkindlustusamet’ (Social Insurance Board), Tallinn;
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, Planning Unit, Dublin 2;
in Italy, to the competent provincial ofﬁ ce of the ‘Istituto nazionale per I’assicurazione contro gli infortuni sul lavoro’ (INAIL) )National Institute for 
Insurance against Accidents at Work); 
in Latvia, to the ‘Valsts sociālās apdrošināšanas aģentūra’ (State Social Insurance Agency), Riga;
in Lithuania, to the ‘Teritorinė ligoniu kasa’ (Regional Sickness Insurance Fund);
in Luxembourg, to the ‘Association d’assurance contre les accidents’ (Accident Insurance Association);
in Malta, to the ‘Diviżjoni tas-Sa ħa', Triq il-Merkanti, Valletta CMR 01;
in the Netherlands, to the competent sickness insurance institution;
in Austria, to the competent accident insurance institution;
in Poland, to the regional branch of the ‘Narodowy Fundusz Zdrowia’ (National Health Fund);
in Portugal, to the ‘Centro Nacional de Proteccao contra os Riscos Proﬁ ssionais’ (National Centre for Protection against Occupational Risks), Lisbon;
in Slovakia, to the health insurance company of the insured person or the Social Insurance agency, Bratislava;
in Finland, to the ‘Tapaturmavakuutuslaitosten Liitto’ (Federation of Accident Insurance Institutions), Bulevardi 28, 00120 Helsinki;
in Sweden, to the ‘Forsakringskassan’ (Local Social Insurance Ofﬁ ce);
in all other Member States, to the competent sickness insurance institution;
in Iceland, to the ‘Tryggingastofnun rikisins’ (The State Social Security Institute), Reykjavik;
in Liechtenstein, to the ‘Amt fur Volkswirtschaft’ (Ofﬁ ce of National Economy), Vaduz;
in Norway, to the ‘Folketrygdkontoret for Utenlandssaker’ (National Ofﬁ ce for Social Insurance Abroad), Oslo;

3

E 101

in  Switzerland,  for  employed  persons,  to  the  employer’s  accident  insurance  institution;  for  self-employed  persons,  to  the  accident  insurance 
institution of the person concerned.

Where  the  worker  is  covered  by  the  French  social  security  scheme,  the  fund  which  is  competent  to  recognise  entitlement  to  beneﬁ ts  is  his 
insurance fund, which may not be the one appearing on form E 101. It will be necessary, where appropriate, to request the European health 
insurance card or form 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.

NOTES

(1) 

Symbol  of  the  country  to  which  the  institution  completing  the  form  belongs:  BE  =  Belgium;  CZ  =  Czech  Republic;  DK  =  Denmark;
DE  =  Germany;  EE  =  Estonia;  GR  =  Greece;  ES  =  Spain;  FR  =  France;  IE  =  Ireland;  IT  =  Italy;  CY  =  Cyprus;  LV  =  Latvia; 
LT  =  Lithuania;  LU  =  Luxembourg;  HU  =  Hungary;  MT  =  Malta;  NL  =  Netherlands;  AT  =  Austria;  PL  =  Poland;  PT  =  Portugal;
SI  =  Slovenia;  SK  =  Slovakia;  FI  =  Finland;  SE  =  Sweden;  UK  =  United  Kingdom;  IS  =  Iceland;  LI  =  Liechtenstein;  NO  =  Norway;
CH = Switzerland.

(2)  Give all surnames in the order of civil status.

(3)  Give all forenames in the order of civil status.

For workers subject to Spanish law, indicate the social security number.For the purpose of Maltese institutions, give the Identity Card number 
in case of Maltese nationals, or the Maltese Social security number in case of a non-Maltese national. in the case of persons being subject 
to Polish legislation, please indicate the PESEL and NIP numbers or, failing that, the series and the number of the identity card or passport. 
For the purpose of Slovak institutions, give the Slovak birth number if applicable.

in 

indicate, 

the  business  number 

the  case  of  employed  persons, 

(numéro  d’entreprise/ondernemingsnummer/ 

Please give as much information as possible to facilitate identiﬁ cation of the employer or the ﬁ rm of the self-employed person. In the case 
of a ship, indicate its name and its registration number.
 Belgium: 
Unternehmensnummer) and, in the case of self-employed persons, the VAT number.
 Czech Republic: indicate the identiﬁ cation number (IČ).
Denmark: indicate the CVR number.
Germany: indicate the ‘Betriebsnummer des Arbeitgebers’.
Spain: indicate the ‘Código de Cuenta de Cotización del Empresario CCC’ (employer’s contribution account number).
France: indicate the SIRET number.
Italy: indicate the company’s registration number where possible.
 Luxembourg:  indicate  the  employer’s  social  security  registration  number  and,  for  self-employed  persons,  the  social  security  number 
(CCSS).
 Hungary: indicate the employer’s social security registration number or, for self-employed persons, the identiﬁ cation number of the private 
company.
Poland: indicate the NUSP number, where there is one, or the NIP and REGON numbers. 
Slovakia: indicate the identiﬁ cation number (IČO).
 Slovenia: indicate the registration number of the employer or self-employed person.
 For  workers  subject  to  Finnish  legislation  on  occupational  accidents,  please  indicate  the  name  of  the  competent  accident  insurance 
institution.
Norway: indicate the organisation number.

(4) 

(5) 

4

 
 
 
 
 
 
 
 
 
 
 
 
 
 
ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY
FOR MIGRANT WORKERS

E 102

(1)

EXTENSION OF TERM OF POSTING OR OF ACTIVITY AS SELF-EMPLOYED PERSON

Regulation (EEC) No 1408/71: Article 14(1)(b); Article 14a(1)(b); Article 14b(1) and (2)
Regulation (EEC) No 574/72: Article 11(2) and 11a(2)

Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out out.

A.  To be completed by the employer or the self-employed person

1.

Institution to which the form is addressed (2)

1.1 

Name:

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

Identiﬁ cation number of the institution:  ......................................................................................................................................................

Address:  .....................................................................................................................................................................................................

1.2 

1.3 

  Tel.: ....................................................................................     

Fax: ................................................................................................

  Street: ................................................................................      No: ..............................................    PO Box:  ..........................................

  Town:  .................................................................................      Postcode:  ...................................    Country: ..........................................

2. □ Employed person

□ Self-employed person

2.1 

2.2 

2.3 

2.4 

Surname(s) (3): ............................................................................................................................................................................................

Forename(s) (4): ..........................................................................................................................................................................................

Previous name(s):  ......................................................................................................................................................................................

Date of birth:  

Nationality:

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

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

2.5 

Permanent address:

  Street: ................................................................................      No: ..............................................    PO Box:  ..........................................

  Town:  .................................................................................      Postcode:  ...................................    Country: ..........................................

2.6 

Personal identiﬁ cation number (5):  ..............................................................................................................................................................

3. 

The abovementioned insured person
□ has been posted
□ is carrying out an activity as a self-employed person in accordance with Article:

3.1  □ 14(1)(a)  
3.2 

 □ 14b(2) of Regulation (EEC) No 1408/71
□ 14b(1) 
for the period from …………………………………………………………….    to  .........................................................................................

□ 14a(1)(a) 

3.3  □ to/in the undertaking(s) speciﬁ ed below 

□ to/on the ship speciﬁ ed below

3.4 

Name of ﬁ rm or ship

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

3.5 

Address:  .....................................................................................................................................................................................................

  Tel.: ....................................................................................     

Fax: ................................................................................................

  Street: ................................................................................      No: ..............................................    PO Box:  ..........................................

  Town:  .................................................................................      Postcode:  ...................................    Country: ..........................................

3.6 

Identiﬁ cation number (6):  .............................................................................................................................................................................

1
1

 
 
 
 
 
E 102

4.

The insured person was in possession of a certiﬁ cate concerning the legislation applicable (an E 101 form)

4.1

issued by the following institution:

Name: ..............................................................................

Street: .............................................................................. 

No: .............................................   PO Box: ...........................................

Town: 

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

Postcode:  ..................................   Country: ............................................

4.2

on …………………………………………………………………..… 

and expiring on   ………………………………………………..............

5.

We request that you continue to apply the legislation of the country

(1)     

5.1

for the period from  ................................................................. 

to  ………………………………………………….. (7)

6. □ Employer  

6.1

Name of employer or ﬁ rm:

□ Activity as self-employed person

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

6.2

Identiﬁ cation number (6):

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

6.3

Address:  .......................................................................... 

Tel.: 

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

Fax:  ................................................................................................

Street:  ............................................................................. 

No: .............................................   PO Box: ...........................................

Town:   ............................................................................. 

Postcode:  ..................................   Country: ...........................................

6.4

Stamp 

6.5 

Date:

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

6.6 

Signature:

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

B.   To be completed by the competent authority or the designated body of the country of employment (8)

7. 
We declare that:
7.1  □ it is agreed 

□ it is not agreed

that the social security legislation of the country still applies to the insured person mentioned in box 2

(1)

7.2 

for the period from  ............................................................................ 

to  ......................... ………………………………………………….

8.

Competent authority or designated body in the country of employment

8.1

Name:

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

8.2

Identiﬁ cation number of the institution:.........................................................................................................................................................

8.3

Address:  ..........................................................................

Tel.: 

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

Fax:  ................................................................................................

Street:  ............................................................................. 

No: .............................................   PO Box: ..........................................

Town:   ............................................................................. 

Postcode:  ..................................   Country: ..........................................

8.4

Stamp 

8.5 

Date:

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

8.6 

Signature:

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

2
2

 
 
 
 
 
 
 
 
 
 
 
 
 
 
E 102

Information for the employer or the self-employed person

INSTRUCTIONS

(a)  The employer or the self-employed person should complete part A of the form, providing 4 copies, which he should send to the competent 
authority or to the designated body in the country to which the worker has been posted or is carrying out an activity as a self-employed 
person, i.e.:

in Belgium, in the case of employed persons the ‘Ofﬁ ce national de sécurité sociale/Rijksdienst voor sociale zekerheid’ (national ofﬁ ce 
of  social  security);  in  the  case  of  self-employed  persons  the  ‘Institut  national  d’assurances  sociales  pour  les  travailleurs  indépendants/
Rijksinstituut voor sociale verzekering der selfstandigen’ in Brussels; in the case of seamen the ‘Caisse de Secours et de Prévoyance des 
marins/Hulp-en Voorzorgskas voor Zeevarenden’ in Antwerp;

in the Czech Republic, the ‘Česká správa sociálního zabezpečení’ (Czech social security administration) in Prague;

in Denmark, ‘Den Sociale Sikringsstyrelse’ (National Social Security Agency) in Copenhagen;

in Germany, the ‘Deutsche Verbindungsstelle Krankenversicherung – Ausland’ (German Liaison Agency Health Insurance – International) 
in Bonn;

in Estonia, the ‘Sotsiaalkindlustusamet’ (Social Insurance Board) in Tallinn;

in Greece, for employed persons, the regional or local branch of the Social Insurance Institute (IKA-ETAM); for mariners, the Seamen’s 
Pension Fund (NAT); for self-employed persons, the institution designated for each professional category under Annex 10 - F. GREECE of 
Regulation (EEC) No 574/72;

in Spain, the ‘Tesorería General de la Seguridad Social - Ministerio de Trabajo y Asuntos Sociales’ (central treasury for social security - 
Ministry of Labour and Social Affairs) in Madrid;

in France, the ‘Centre des liaisons européennes et internationales de sécurité sociale (Cleiss)’ (centre for European and international social 
security liaison);

in Ireland, the Department of Social and Family Affairs, PRSI Special Collections Section, Government Buildings, Cork Rd, Waterford;

in Italy, the ‘Ministerio del Lavoro e delle Politiche Sociali’ (Ministry of Labour and Social Policy) in Rome;

in Latvia, the ‘Valsts sociālās apdrošināšanas aģentūra’ (State Social Insurance Agency);

in Lithuania, the ‘Valstybinio socialinio draudimo fondo valdyba’ (national social insurance fund board);

in Luxembourg, the ‘Centre commun de la sécurité sociale’ (common social security centre) in Luxembourg;

in Hungary, the ‘Országos Egészségbiztosítási Pénztár’ (national sickness insurance fund) in Budapest;

in Malta, the ‘Dipartiment tas-Sigurta’ Soċjali’ (social security department), 38, Triq l-Ordinanza, Valletta, CMR 01

in the Netherlands, the ‘Sociale Verzekeringsbank’ (social insurance bank) in Amstelveen;

in  Austria,  the  ‘Bundesministerium  für  soziale  Sicherheit,  Generationen-  und  Konsumentenschutz’  (Federal  Ministry  of  Social  Security, 
Generations and Consumer Protection) in Vienna;

in Poland, the ‘Zakład Ubezpieczeń Społecznych (ZUS)’ (Social Insurance Institution) in Warsaw;

in Portugal, for metropolitan Portugal: the ‘Departamento de Relações Internacionais de Segurança Social’ (Department of International 
Relations and Social Security) in Lisbon; for Madeira: the ‘Secretario Regional dos Assuntos Sociais’ (regional secretary for social affairs) in 
Funchal; for the Azores: the ‘Direcção Regional de Segurança Social’ (regional social security directorate) in Angra do Heroismo;

in Slovenia, the ‘Ministrstvo za delo, družino in socialne zadeve’ (Ministry of Labour, Family and Social Affairs) in Ljubljana;

in Slovakia, the ‘Sociálna poist’ovňa’ (Social Insurance Agency) in Bratislava;

in Finland, the ‘Eläketurvakeskus’ (Finnish Centre for Pensions) in Helsinki;

in Sweden, the Försäkringskassan, Huvudkontoret (Swedish Social Insurance Agency, Head Ofﬁ ce) in Stockholm;

in the United Kingdom, the Inland Revenue, Centre for Non-Residents, Benton Park View, Newcastle upon Tyne, NE98 1ZZ;

in Iceland, the ‘Tryggingastofnun rikisins’ (The State Social Security Institute) in Reykjavik;

in Liechtenstein, the ‘Amt für VoIkswirtschaft’ (ofﬁ ce of national economy) in Vaduz;

in Norway, the ‘Folketrygdkontoret for utenlandssaker’ (national insurance ofﬁ ce for social insurance abroad) in Oslo;

in Switzerland, to whichever ‘Caisse de Compensation AVS’ (old-age and survivors’ insurance fund) would be competent for the employed 
or self-employed worker if Swiss legislation were applicable.

(b)  Two copies of the form, with part B completed, will be sent to the employer or the self-employed person. The employer will send one of these 

copies to the employed person.

(c)  A Member State which receives a request for an application of the aforementioned Articles 14(1) or 14b(1) of Regulation (EEC) No 1408/
71 shall duly inform the employer and the worker concerned of the conditions under which the worker may continue to be subject to its 
legislation.

The employer shall thus 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.

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E 102

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 posting applied for has not taken place,

–   if this posting has been interrupted, unless this interruption of the worker’s acitivities for the undertaking in the State 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 ﬁ rst two cases, the employer shall return this form to the competent institution of the sending State.

NOTES

(1) 

the 

the  country  of 

Symbol  of 
form:  BE  =  Belgium;  CZ  =  Czech  Republic;  DK  =  Denmark;
DE  =  Germany;  EE  =  Estonia;  GR  =  Greece;  ES  =  Spain;  FR  =  France;  IE  =  Ireland;  IT  =  Italy;  CY  =  Cyprus;  LV  =  Latvia; 
LT  =  Lithuania;  LU  =  Luxembourg;  HU  =  Hungary;  MT  =  Malta;  NL  =  the  Netherlands;  AT  =  Austria;  PL  =  Poland;  PT  =  Portugal;
SI  =  Slovenia;  SK  =  Slovakia;  FI  =  Finland;  SE  =  Sweden;  UK  =  United  Kingdom;  IS  =  Iceland;  LI  =  Liechtenstein;  NO  =  Norway;
CH = Switzerland.

institution  completing 

the 

(2) 

See the information given at point (a) under ‘Information for the employer or the self-employed person’.

(3)  Give all surnames in the order of civil status.

(4)  Give all forenames in the order of civil status.

For workers subject to Belgian law, indicate the national social security number (NISS).
For workers subject to Czech law, indicate the Czech birth number.
For workers subject to Danish law, indicate the CPR number.
For workers subject to Spanish law, indicate the social security number.
For workers subject to Italian law, indicate the Italian ﬁ scal code number.
For workers subject to Lithuanian law, indicate the national registration number and the national social security certiﬁ cate number.
For workers subject to Luxembourg law, indicate the worker’s social security number (CCSS).
For workers subject to Maltese law, indicate the Maltese social security number.
For workers subject to Netherlands’ law, indicate the SOFI number.
For workers subject to Polish law, indicate the PESEL and NIP numbers or, failing that, the series and the number of the identity card or 
passport.
For workers subject to Slovenian law, indicate the ZZZS number.
For workers subject to Slovak law, indicate the Slovak birth number.

Please state as much information as possible which may be used in order to identify the employer or the ﬁ rm of the self-employed person.
In the case of a ship indicate the name of the ship and the ship registration number.
For  Belgium,  indicate  in  the  case  of  employed  persons,  the  business  number  (numéro  d’entreprise/ondernemingsnummer/ 
Unternehmensnummer) and, in the case of self-employed persons, the VAT registration number.
For the Czech Republic, indicate the identiﬁ cation number (IČ).
For Denmark, indicate the CVR number.
For Germany, indicate the ‘Betriebsnummer des Arbeitgebers’.
For Spain, indicate the ‘Código de Cuenta de Cotización del Empresario CCC’ (employer’s contribution account number).
For France, indicate the SIRET number.
For Luxembourg, indicate the employer’s social security registration number and, for self-employed workers, the social security number 
(CCSS).
For Hungary, indicate the employer’s social security registration number and, for self-employed workers, the private-company identiﬁ cation 
number.
For Malta, in the case of Maltese nationals indicate the identity card number and in the case of non-Maltese nationals indicate the Maltese 
social security number.
For Poland, indicate the NUSP number if there is one, or the NIP and REGON numbers, at point 3.6 and the PESEL and NIP numbers or, 
failing that, the series and the number of the identity card or passport, at point 6.2.
For Slovenia, indicate the registration number of the employer or self-employed person.
For Slovakia, indicate the company identiﬁ cation number (IČO).
For workers subject to Finnish occupational accident law, indicate the name of the competent accident insurance institution.
For Norway, indicate the number of the organisation.

This period must not be more than 24 months from the date of the commencement of posting or of the self-employed activity.

Two copies should be returned to the claimant and one copy sent to the designated institution in the country in which the undertaking has 
its registered ofﬁ ce.

(5) 

(6) 

(7) 

(8) 

4

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ADMINISTRATIVE COMMISSION ON 
SOCIAL SECURITY FOR MIGRANT 
WORKERS

E 103

(1)

EXERCISING THE RIGHT OF OPTION

Regulation (EEC) No  1408/71:  Article 16(2) and (3)

Regulation (EEC) No 574/72: Article 13(2) and (3); Article 14(1) and (2)

After completing part A of the form in accordance with points a) and b) of the instructions, the insured person should hand the form in or forward it 
in accordance with points a) and c) of the instructions. The institution receiving the form should complete part B and return one copy to the insured 
person.

Please complete this form in block letters (in triplicate), writing on the dotted lines only. It consists of three pages, none of which may be left out.

A.  Option

1.

The undersigned

1.1  Surname(s) (2):  .............................................................................................................................................................................................

1.2  Forename(s) (3): ............................................................................................................................................................................................

1.3  Previous name(s): .........................................................................................................................................................................................

1.4  Date of birth: ............................................................................ 

1.5 Nationality:

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

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

1.6  Personal identiﬁ cation number (4):.............................................

Employed since:  ...........................................................................................................................................................................................

2. 
2.1 (4) □ as: .....................................................................................  

by the diplomatic mission or consulate post

named hereafter: 

......................................................................................................................................................................................................................
2.2 (4) □ as: ...........................................................................................................................................................................................................
in the private staff of the following employer (5): ...........................................................................................................................................

agent of the diplomatic mission or consular post named hereafter: .............................................................................................................

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

2.3  □ as a member of the auxiliary staff of the European Communities 

3.

3.1 

3.2 

Hereby opts to be subject to the social security legislation 
(6) □ of the State of which he is a national 
(6) □ of the State to whose legislation he was last subject, i.e. the legislation of 
□ Belgium 
□ Greece  
□ Cyprus 
□ Malta  
□ Portugal  
□ Iceland 

□ Czech Republic 
□ Spain 
□ Latvia 
□ Netherlands  
□ Slovakia  
□ Liechtenstein 

□ Denmark 
□ France 
□ Lithuania  
□ Austria  
□ Finland  
□ Norway 

□ Germany 
□ Ireland 
□ Luxembourg 
□ Poland  
□ Sweden  
□ Switzerland 

□ Estonia
□ Italy
□ Hungary 
□ Slovenia
□ United Kingdom

4. 

Place and date:

 .………………………………….……………….…….……………………….........

5. 

Signature:

 .………………………………….……………….…….……………………….........

6.

Authority of the European Communities which has concluded the contract with the member of the auxiliary staff

6.1  Name: ...........................................................................................................................................................................................................

6.2  Address: .......................................................................................................................................................................................................

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

6.3  Stamp 

6.4 

6.5 

Date:  .............................................................

Signature:

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

1
1

 
 
 
 
 
 
 
 
 
 
B. 

Declaration

7.  We have taken note of the fact that the person mentioned in box 1 is subject to the legislation of (6) 
□ Germany 
□ Ireland 
□ Luxembourg 
□ Poland  
□ Sweden  
□ Switzerland 

□ Czech Republic 
□ Spain 
□ Latvia 
□ Netherlands  
□ Slovakia  
□ Liechtenstein 

□ Denmark 
□ France 
□ Lithuania  
□ Austria  
□ Finland  
□ Norway 

□ Belgium 
□ Greece  
□ Cyprus 
□ Malta  
□ Slovenia 
□ Iceland 

E 103

□ Estonia
□ Italy
□ Hungary 
□ Portugal
□ United Kingdom

7.1  As from:   ……………………………………. 

7.2  For the period during which he is engaged in the employment indicated in part A of this form (7) 

8.

Institution designated by the competent authority

8.1  Name:   .........................................................................................................................................................................................................

8.2 

Identiﬁ cation number of the institution: .........................................................................................................................................................

8.3  Address:  .......................................................................................................................................................................................................   

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

8.4  Stamp 

8.5 

8.6 

Date: ...............................................................

Signature:

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

For staff of diplomatic missions or consular posts and their private domestic staff

(a)  After completing part A of the form, excluding section 6, you should give one copy of the form to your employer and send two copies to the 

institution designated by the competent authority of the State for whose legislation you have opted, i.e.:

in Belgium, the ‘Ofﬁ ce national de sécurité sociale’ (National Ofﬁ ce for Social Security), Brussels;

in the Czech Republic, the ‘Česká správa sociálního zabezpečení’ (Czech Social Security Administration), Prague;

in Denmark, the ‘Den Sociale Sikringsstyrelse’ (National Social Security Agency),  Copenhagen;

in Germany, the Bonn ofﬁ ce of the ‘Krankenkasse’ (sickness insurance fund) chosen by the insured person;

in Estonia, the ‘Sotsiaalkindlustusamet’ (Social InsuranceBoard), Tallinn;

in  Greece, the regional or local branch of the Social Insurance Institute (IKA);

in Spain, the ‘Tesoreria General de la Seguridad Social - Ministerio de Trabajo y Seguridad Social’ (Central Treasury for Social Security 
– Ministry of Labour and Social Security), Madrid;

in France, the ‘Caisse primaire d’assurance maladie’ (Sickness Insurance Fund), Paris;

in Ireland, the ‘Department of Social and Family Affairs’, Dublin;

in Italy, the competent local ofﬁ ce of the ‘Istituto nazionale della previdenza sociale INPS’ (National Social Welfare Institution);

in  Cyprus,  the  ‘Τµήµα  Κοινωνικών  Ασφαλίσεων,  Υπουργείο  Εργασίας  και  Κοινωνικών  Ασφαλίσεων’  (Department  of  Social  Insurance, 
Ministry of Labour and Social Insurance), 1465 Lefkosia;

in  Latvia, the ‘Valsts sociālās apdrošināšanas aģentūra’  (State Social Insurance Agency);

in Lithuania, the ‘Valstybinio socilinio draudime fondo valdyba’ (Council of the National Social Security Fund), Vilnius;

in Luxembourg, the ‘Centre commun de la sécurité sociale’ ( Common Social Security Centre), Luxembourg;

in  Hungary,  the  ‘Fővárosi  és  Pest  Megyei  Egészségbiztosítási  Pénztár’  (Regional  Sickness  Insurance  Fund  for  Pest  and  the  Capital), 
Budapest;

in  Malta, the ‘Dipartiment tas-Sigurta’Soċjali’ (Department of Social Security), Valletta;

in the Netherlands,  the ‘Sociale Verzekeringsbank’ (Social Insurance Bank), Amstelveen;

in Austria, the competent institution for sickness insurance;

in  Poland, the ‘Zakład Ubezpieczeń Społecznych – ZUS’ (Social Insurance Institution), Warsaw;

in Portugal, the ‘Departamento de Relações Internacionais e Convenções de Segurança Social’ (Department of International Relations and 
Social Security Conventions), Lisbon; 

in Slovenia, to the competent regional unit of the the ‘Zavod za zdravstveno zavarovanje Slovenije (ZZZS)’ (Health Insurance Institution of 
Slovenia);

in  Slovakia, the ‘Sociálna poisťovňa’ (Social InsuranceAgency), Bratislava;

in Finland, the ‘Eläketurvakeskus’ (Finnish Center for Pensions), Helsinki;

in Sweden, the ‘Försäkringskassan, Huvudkontoret’ (Swedish Social Insurance Agency Head Ofﬁ ce) Stockholm;

in the United Kingdom, the Inland Revenue Centre for Non-Residents, Benton Park View, Newcastle upon Tyne, NE98 1ZZ;

in Iceland, the ‘Tryggingastofnun rikisins’ the State Social Security Institute),  Reykjavik; 

2
2

 
 
 
 
 
E 103

in Liechtenstein, the ‘Amt für VoIkswirtschaf’ (Ofﬁ ce of National Economy), Vaduz;

in Norway, the ‘Folketrygdkontoret for utenlandssaker’ (National Insurance Ofﬁ ce for Social Insurance Abroad), Oslo;

in Switzerland, the ‘Caisse fédérale de compensation’ (Federal Compensation Fund), Bern.

For the authority of the European Communities empowered to conclude contracts of employment with auxiliary staff

(b) 

 When a person engaged as a member of the auxiliary staff expresses a wish to exercise the right of option, the empowered authority of the 
European Communities must ensure that the person completes part A of the form, with the exception of box 6, which must be completed by 
the authority.

(c) 

 Two copies of the form should be sent to the institution designated by the competent authority of the Member State for whose legislation the 
person concerned has opted (see a) above).

NOTES

(1)  Symbol  of 

the 

the  country  of 

form:  BE  =  Belgium;  CZ  =  Czech  Republic;  DK  =  Denmark;
DE  =  Germany;  EE  =  Estonia;  GR  =  Greece;  ES  =  Spain;  FR  =  France;  IE  =  Ireland;  IT  =  Italy;  CY  =  Cyprus;  LV  =  Latvia; 
LT  =  Lithuania;  LU  =  Luxembourg;  HU  =  Hungary;  MT  =  Malta;  NL  =  Netherlands;  AT  =  Austria;  PL  =  Poland;  PT  =  Portugal;
SI  =  Slovenia;  SK  =  Slovakia;  FI  =  Finland;  SE  =  Sweden;  UK  =  United  Kingdom;  IS  =  Iceland;  LI  =  Liechtenstein;  NO  =  Norway;
CH = Switzerland.

institution  completing 

the 

(2)  Give the surnames in the order of civil status.
(3)  Give the forenames in the order of civil status.
(4)  For workers subject to Belgian legislation, please indicate the national registration number.

For workers subject to Spanish legislation, please indicate the social security number.

For workers subject to Maltese legislation, please indicate the identity card number in the case of a Maltese national, or the Maltese social 
security number in the case of non-Maltese citizen.

For workers subject to Slovak legislation, please indicate the Slovak birth number if applicable.

For workers subject to Polish legislation, please indicate the PESEL and NIP numbers or, in case you do not have such a number,  the series 
and the number of the Identity card or passport.
(5)   Give the surnames and forenames of the employer.
(6)  Put a cross in the box preceding the appropriate country. Please note that persons employed by diplomatic missions or consular posts and 
members of the private domestic staff of agents of such missions or posts may opt only for the social security legislation of the State of which 
they are a national.

(7)   The right of option of workers employed by diplomatic missions or consular posts and members of the private domestic staff of agents of 

such missions or posts may be exercised at the end of each calendar year.

3

 
 
 
 
ADMINISTRATIVE COMMISSION 
ON SOCIAL SECURITY FOR
MIGRANT WORKERS

E 104

(1)

CERTIFICATE CONCERNING THE AGGREGATION OF PERIODS OF INSURANCE, EMPLOYMENT OR RESIDENCE

Sickness – maternity – death (grant) – invalidity

Regulation (EEC) No 1408/71: Article 9(2); Article 18(1); Article 38(1); Article 64
Regulation (EEC) No 574/72: Article 6(2); Article 16; Article 39(1) and (2); Article 79

The competent institution should complete Part A of the form and send two copies to the institution of the Member State to whose legislation the 

person concerned was last subject. The latter institution should complete Part B and return the form to the institution from which it received the 

form. If the form is drawn up at the request of the person concerned, the institution issuing the form should complete parts A.2 and B and give or 

send the form to the person concerned.

Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out.

Part A

1.

Institution to which the form is addressed

1.1

1.2

1.3

Name:  ........................................................................................................................................................................................................

Identiﬁ cation number of the institution: .......................................................................................................................................................

Address:  .....................................................................................................................................................................................................

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

2.

Insured person

2.1

Surname(s) (2):

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

2.2

Forename(s) (3):

Date of birth:

2.3

2.4

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

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

Previous name(s):  .......................................................................

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

Personal identiﬁ cation number:

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

2.5

From the date stated at 3.1, the insured person has been pursuing an occupation as:
□ an employed person 
2.6 □ Name of last employer

 □ a self-employed person in (4) 

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

□ Last occupation as a self-employed person
....................................................................................................................................................................................................................

Address:  .....................................................................................................................................................................................................

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

2.7 □ Previous employers: 
(name and address)

□ Previous occupations as a self-employed person:
........................................................................................................

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

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

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

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

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

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

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

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

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

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

3.

3.1

3.2

In order to act on a claim submitted by the insured person mentioned above, please indicate the periods of insurance, employment or 
residence completed by him

from   ...........................................................................................................................................................................................................

under the legislation of your country, for the following risk:
□ sickness and maternity (5)

 □ death (grant)

 □ invalidity (6)

1
1

4.

Competent institution

4.1

4.2

4.3

Name: .........................................................................................................................................................................................................

Identiﬁ cation number of the institution: .......................................................................................................................................................

Address:  .....................................................................................................................................................................................................

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

E 104

4.4

Stamp

Part B

4.5

4.6

Date: ....................................................................................

Signature:

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

The person indicated in box 2

5.
5.1 □ has been insured for the risk of sickness-maternity since the date stated at 3.1 (7)
5.2 □ has completed 

since   .......................................................

6.

the following periods of insurance or employment for the following beneﬁ ts:

(5)

6.1

6.2

6.3

6.4

6.5

6.6

6.7

6.8

6.9

from  ....................................  to  ........................................ (8)  

from  ....................................  to  ........................................ (8)  

from  ....................................  to  ........................................ (8)  

from  ....................................  to  ........................................ (8)  

from  ....................................  to  ........................................ (8)  

from  ....................................  to  ........................................ (8)  

from  ....................................  to  ........................................ (8)  

from  ....................................  to  ........................................ (8)  

from  ....................................  to  ........................................ (8)  

6.10

from  ....................................  to  ........................................ (8)  

for (9) the risk of  .......................................................................□ (10)
for (9) the risk of  .......................................................................□ (10)
for (9) the risk of  .......................................................................□ (10)
for (9) the risk of  .......................................................................□ (10)
for (9) the risk of  .......................................................................□ (10)
for (9) the risk of  .......................................................................□ (10)
for (9) the risk of  .......................................................................□ (10)
for (9) the risk of  .......................................................................□ (10)
for (9) the risk of  .......................................................................□ (10)
for (9) the risk of  .......................................................................□ (10)

7.

7.1

7.2

7.3

7.4

7.5

7.6

7.7

7.8

7.9

the following periods of residence:

from  ....................................  to  ........................................ (8)  

from  ....................................  to  ........................................ (8)  

from  ....................................  to  ........................................ (8)  

from  ....................................  to  ........................................ (8)  

from  ....................................  to  ........................................ (8)  

from  ....................................  to  ........................................ (8)  

from  ....................................  to  ........................................ (8)  

from  ....................................  to  ........................................ (8)  

from  ....................................  to  ........................................ (8)  

7.10

from  ....................................  to  ........................................ (8)  

for (9) the risk of  .......................................................................□ (10)
for (9) the risk of  .......................................................................□ (10)
for (9) the risk of  .......................................................................□ (10)
for (9) the risk of  .......................................................................□ (10)
for (9) the risk of  .......................................................................□ (10)
for (9) the risk of  .......................................................................□ (10)
for (9) the risk of  .......................................................................□ (10)
for (9) the risk of  .......................................................................□ (10)
for (9) the risk of  .......................................................................□ (10)
for (9) the risk of  .......................................................................□ (10)

8.

8.1

8.2

Institution completing part B

Name: .........................................................................................................................................................................................................

Identiﬁ cation number of the institution: 

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

8.3

Address:  .....................................................................................................................................................................................................

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

8.4

Stamp

2
2

8.5

8.6

Date: ..................................................................................

Signature:

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

NOTES

E 104

(1) 

(2) 

(3) 

(4) 

(5) 

(6) 

(7) 

(8) 

Symbol  of  the  country  to  which  the  institution  which  ﬁ rst  completes  the  form  belongs:  BE  =  Belgium;  CZ  =  Czech  Republic;  DK  = 
Denmark;  DE  =  Germany;  EE  =  Estonia;  GR  =  Greece;  ES  =  Spain;  FR  =  France;  IE  =  Ireland;  IT  =  Italy;  CY  =  Cyprus;  LV  =  Latvia; 
LT  =  Lithuania;  LU  =  Luxembourg;  HU  =  Hungary;  MT  =  Malta;  NL  =  Netherlands;  AT  =  Austria;  PL  =  Poland;  PT  =  Portugal;
SI  =  Slovenia;  SK  =  Slovakia;  FI  =  Finland;  SE  =  Sweden;  UK  =  United  Kingdom;  IS  =  Iceland;  LI  =  Liechtenstein;  NO  =  Norway;
CH = Switzerland.

Indicate the surnames in the order of civil status.

Indicate the forenames in the order of civil status

Indicate the State.

Only if the form is addressed to a Belgian, French, Greek, Liechtenstein or Swiss institution, indicate the risk covered by using the following 
codes: N = beneﬁ ts in kind, E = beneﬁ ts in cash.

For the purposes of French and Latvian institutions.

Complete only if the competent institution is a Belgian institution.

If the certiﬁ cate is intended for a Belgian, Czech, Greek, Latvian, Lithuanian, Polish or Liechtenstein institution, indicate whether the periods 
of activity were as an employed person or as a self-employed person by using the following code: D = employed person; I = self-employed 
person.

If the certiﬁ cate is intended for a German, Lithuanian, Luxembourgish or Polish institution, indicate the insurance periods in section 7 using 
the following codes: P = compulsory insurance; F = voluntary insurance.

(9) 

Indicate the risk covered by using the following code:

A = sickness and maternity; B = death (grant); O = invalidity.

(10) 

If the competent institution is a Cypriot, German, Irish, Hungarian, Austrian or UK institution, put a cross in this box if the period of insurance 
or the period of residence corresponds to a period of actual employment and indicate the type of employment or self-employment.

3

 
 
ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY
FOR MIGRANT WORKERS

E 106

(1)

CERTIFICATE OF ENTITLEMENT TO SICKNESS AND MATERNITY INSURANCE BENEFITS IN KIND FOR PERSONS RESIDING IN A 
COUNTRY OTHER THAN THE COMPETENT COUNTRY

Employed and self-employed persons and members of their families residing with them; members of the family of 
unemployed persons 

Regulation (EEC) No 1408/71: Article 19(1)(a); Article 19(2) and Article 25(3)(i)
Regulation (EEC) No  574/72: Article 17(1) and (4) and  Article 27 (ﬁ rst sentence)

The competent institution should complete Part A of the form and send two copies to the insured person, or send them - where necessary through 
the liaison body - to the institution in the place of residence if the form is drawn up at that institution’s request. As soon as it has received the two 
copies, the latter institution should complete Part B and return one copy to the competent institution.

Please complete this form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out.

A. 

Notiﬁ cation of entitlement

1.

1.1 
1.2 
1.3 

1.4 

2.

Institution of the place of residence (2)

Name:  .........................................................................................................................................................................................................
Identiﬁ cation number of the institution:  .......................................................................................................................................................
Address:  .....................................................................................................................................................................................................
....................................................................................................................................................................................................................
Reference: your E 107 form of  ...................................................................................................................................................................

The insured person

2.1 

Surname(s) (3):

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

2.2 

Forename(s) (4): 

Date of birth:

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

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

2.3 

2.4 

Previous name(s):  .......................................................................................................................................................................................

Address in the country of residence:  ...........................................................................................................................................................

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

2.5 

Personal identiﬁ cation number:

2.6 

2.7 

2.8 

2.9 

2.10 

3.

3.1 

.....................................................................................................................................................................................................................
The insured person   □ is an employed person
The insured person  □ is a self-employed person
The insured person   □ is a frontier worker (employed)
The insured person  □ is a frontier worker (self employed)
The insured person  □ is an unemployed worker

Member of the family (5)

Surname(s) (3):
.....................................................................................................................................................................................................................

3.2 

Forename(s) (4): 

Date of birth:

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

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

3.3 

3.4 

Previous name(s):  .......................................................................................................................................................................................

Address in the country of residence:  ...........................................................................................................................................................

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

3.5 

Personal identiﬁ cation number: .................................................................................................................................................................

4.1  □ The abovementioned insured person and the members of his family (6) residing with him
4.2  □ The members of the family (6) of the above unemployed person

5. 

are entitled to sickness and maternity insurance beneﬁ ts in kind

as from ........................................................................................................................................................................................................

1
1

 
 
 
 
 
 
 
 
E 106

The persons concerned will retain their entitlement

6.
6.1  □ until this certiﬁ cate is cancelled
6.2  □ for a period of one year from the date speciﬁ ed in point 5 (7)
6.3  □ until .....................................................................................................................................................    inclusive (8)

7.

7.1

7.2

7.3

Competent institution for sickness and maternity insurance

Name: ........................................................................................................................................................................................................

Identiﬁ cation number of the institution: ......................................................................................................................................................

Address:  ....................................................................................................................................................................................................

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

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

7.4

Stamp

B.  Notiﬁ cation of registration (9)

7.5

7.6

Date:  ............................................................................

Signature:

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

8.
8.1 □ The insured person named in box 2 and the members of his family
8.2 □ The members named in box 3 of the family of the unemployed person
8.3 □ were registered with us on   ................................................................................................................................................................
8.4 □ cannot be registered with us because  ...............................................................................................................................................
..................................................................................................................................................................................................................

9.

9.1

Surname(s) (3) 

Forename(s) (4)

Previous name(s) Date of birth

Personal identiﬁ cation number

9.2 ………………………… ……………………….. …………………… …………………. ……………………………………………………

9.3 ………………………… ……………………….. …………………… …………………. ……………………………………………………

9.4 ………………………… ……………………….. …………………… …………………. ……………………………………………………

9.5 ………………………… ……………………….. …………………… …………………. ……………………………………………………

9.6 ………………………… ……………………….. …………………… …………………. ……………………………………………………

9.7 ………………………… ……………………….. …………………… …………………. ……………………………………………………

9.8 ………………………… ……………………….. …………………… …………………. ……………………………………………………

9.9 ………………………… ……………………….. …………………… …………………. ……………………………………………………

10.

Institution of the place of residence

10.1

10.2

10.3

Name: ........................................................................................................................................................................................................

Identiﬁ cation number of the institution: ......................................................................................................................................................

Address:  ....................................................................................................................................................................................................

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

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

10.4

Stamp

2
2

10.5

10.6

Date: .............................................................................

Signature:

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

E 106

Information for the insured person

(a)  This form entitles you to receive sickness and maternity insurance beneﬁ ts in kind for yourself and the members of your family. If you are 
unemployed, this form is not intended for you; it is intended solely for members of your family who reside in a Member State other than the 
one where you are insured.

(b)  The two copies of the form which are in your possession must be submitted as soon as possible to the sickness and maternity insurance 
institution in your place of residence. If you are unemployed, the form must be submitted by the members of your family to the sickness and 
maternity insurance institution in their place of residence.

(c)  The sickness and maternity insurance institutions are:

in Belgium, the ‘mutualité’ (local sickness insurance fund) chosen

in the Czech Republic, ‘Zdravotní pojišťovna’, the health insurance fund in  the place of residence

in Denmark, the municipal authority in the place of residence

in Germany, the ‘Krankenkasse’ (sickness insurance  fund) chosen by the person concerned 

in Estonia, ‘Eesti Haigekassa’ (Estonian Health Insurance Fund)

in Greece, normally the regional or local branch of the Social Insurance Institute (IKA). The branch ofﬁ ce should issue the person concerned 
with a ‘health book’ without which no beneﬁ ts in kind can be provided

in  Spain,  the  ‘Dirección  Provincial  del  Instituto  Nacional  de  la  Seguridad  Social’  (Provincial  Directorate  of  the  National  Social  Security 
Institution) in the place of residence. If you require beneﬁ ts you may apply to the medical and hospital service of the Spanish social security 
health system. You must submit the form together with a photocopy

in France, the ‘Caisse primaire d’assurance-maladie’ (local sickness insurance fund)

in Ireland, the local health ofﬁ ce of the  Health  Service Executive 

in Italy, normally the ‘Unità sanitaria locale’ (ASL, the local health administration unit) responsible for the area concerned. For mariners and 
for civilian aircrews, the ‘Ministero della Sanità - Ufﬁ cio di sanità marittima o aerea’ (Ministry of Health, area health ofﬁ ce for the merchant 
navy or civil aviation)

in Cyprus, ‘Υπουργείο Υγείας’ (Ministry of Health,1448 Lefkosia),  Upon application, the person concerned will be provided with a Cyprus 
medical card, without which no beneﬁ ts in kind can be provided at the Government Medical institutions

in Latvia, ‘Veselības obligātās apdrošināšanas valsts aģentūra’ ( Health Compulsary Insurance State Agency)

in Lithuania, the ‘Teritoriné ligoniu kasa’ (Territorial Patient Fund)’, sickness and maternity institutions

in Luxembourg, the ‘Caisse de maladie des ouvriers’ (sickness fund for manual workers)

in Hungary, the competent  ‘Megyei Egészségbiztosítási Pénztár’ (local health insurance ofﬁ ce)

in Malta, the Entitlement Unit, Ministry of Health, 23, John Street, Valletta

in the Netherlands, any sickness fund competent for the place of residence

in Austria, the ‘Gebietskrankenkasse’ (Regional Fund for Sickness Insurance) competent for the place of residence

in Poland, the regional branch of the ‘Narodowy Funsdusz Zdrowia’ ( National Health Fund) competent for the place of residence 

in Portugal, for metropolitan Portugal: the ‘Centro Distrital de Solidariedade e Segurança Social’ (District Solidarity and Social Security 
Centre) in the place of residence; for Madeira: the ‘Centro de Segurança Social da Madeira’ (Social Security Centre of Madeira) in Funchal; 
for the Azores: the ‘Centro de Prestações Pecuniárias’ (Centre for Cash Beneﬁ ts) in the place of residence

in Slovenia, the ‘Zavod za zdravstveno zavarovanje Slovenije (ZZZS)’ (Health Insurance Institute of Slovenia)

in Slovakia, the ‘zdravotná poisťovňa’ (health insurance company)  of the insured person’s choice 

in Finland, the local ofﬁ ce of the ‘Kansaneläkelaitos’ (Social Insurance Institution)

in Sweden, ‘Försäkringskassan (Local Social Insurance Ofﬁ ce) in the place of residence

in  the  United  Kingdom,  the  Department  for  Work  and  Pensions,  the  Pension  Service,  International  Pension  Centre,  Tyneview  Park, 
Newcastle-upon-Tyne, or for Northern Ireland the Department for Social Development,  Overseas Beneﬁ ts Branch,  Block 2, Castle Buildings, 
Belfast, as appropriate

in Iceland, ‘Tryggingastofnun rikisins’ (The State Social Security Institute), Reykjavik

in Liechtenstein, the ‘Amt für Volkswirtschaft’ (Ofﬁ ce of National Economy), Vaduz

in Norway, the ‘lokale trygdekontor’ (the local Insurance ofﬁ ce) in the place of residence

in Switzerland, the ‘Institution commune LAMal — Instituzione commune LAMal — Gemeinsame Einrichtung KVG’ (Joint Institution under 
the Federal Sickness Insurance Act), Solothurn.

(d)  This form is valid from the date indicated in item 5 and for the period indicated in box 6 by the square marked with a cross.

(e)  You or the members of your family must inform the insurance institution to which the form has been submitted of any change of circumstances 
which might affect the right to beneﬁ ts in kind, such as termination or change of employment, change of your place of residence or stay or of 
that of a member of your family.

3

NOTES

E 106

Symbol  of  the  country  to  which  the  institution  completing  the  form  belongs:  B  =  Belgium;  CZ  =  Czech  Republic;  DK  =  Denmark;
DE  =  Germany;  EE  =  Estonia;  GR  =  Greece;  ES  =  Spain;  FR  =  France;  IE  =  Ireland;  IT  =  Italy;  CY  =  Cyprus;  LV  =  Latvia; 
LT  =  Lithuania;  LU  =  Luxembourg;  HU  =  Hungary;  MT  =  Malta;  NL  =  Netherlands;  AT  =  Austria;  PL  =  Poland;  PT  =  Portugal;
SI  =  Slovenia;  SK  =  Slovakia;  FI  =  Finland;  SE  =  Sweden;  UK  =  United  Kingdom;  IS  =  Iceland;  LI  =  Liechtenstein;  NO  =  Norway;
CH = Switzerland.

Complete only if the form is drawn up at the request of the institution in the place of residence.

State surnames in civil status order.

State the forenames in civil status order.

Complete  only  if  the  form  relates  to  members  of  the  family  of  an  unemployed  person.  Mention  one  member  of  the  family  only  for 
registration, since the legislation of the country of residence determines which members of the family are entitled to beneﬁ t.

The legislation of the country of residence determines which members of the family are entitled to beneﬁ t.

If the form is issued by a German, French, Italian or Portuguese institution.

If the form is issued by a Greek, Hungarian or United Kingdom institution for employed persons or self-employed persons.
If this form is issued in renewal of a certiﬁ cate previously provided, part B need not be completed.

(1) 

(2) 

(3) 

(4) 

(5) 

(6) 

(7) 

(8) 
(9) 

4

ADMINISTRATIVE COMMISSION 
ON SOCIAL SECURITY FOR
 MIGRANT WORKERS

E 107

     (1)

APPLICATION FOR A CERTIFICATE OF ENTITLEMENT TO BENEFITS IN KIND

Regulation (EEC) No 1408/71: Article 19(1)(a); Article 19(2); Article 22(1)(a)(i), (b)(i) and (c)(i); Article 22(3); Article 25(1)(a)  and (3)(i); Article 26(1); 
Article 28(1)(a); Article 29(1)(a); Article 31(a); Article 52(a); Article 55(1)(a)(i), (b)(i) and (c)(i)
Regulation (EEC) No 574/72: Article 17(1); Article 21(1); Article 22(1) and (3); Article 23; Article 27 ﬁ rst sentence; Article 28; Article 29(1) and (2); 
Article 30(1); Article 31(1) and (3); Article 60(1); Article 62(3), (4) and (7); Article 63(1) and (3)

The institution of the place of residence or stay should complete part A and send two copies of the form to the competent institution, taking into 
account the provisions of the abovementioned articles of Regulation (EEC) No 574/72. If that institution considers it is unable to send the requested 
form, it should complete part B and return one of the two copies to the institution from which it received them. If Belgium is the competent country, the 
form  should  be  sent  to  the  sickness  insurance  institution,  except  when  it  concerns  an  accident  at  work  which  has  been  veriﬁ ed  or  a  disease 
recognised as an occupational disease.

Please complete the form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out.

A.  To be completed by the institution in the place of residence or stay

1.

Institution to which this form is addressed

1.1 

1.2 

1.3 

Name:  .......................................................................................................................................................................................................

Identiﬁ cation number of the institution:  .....................................................................................................................................................

Address: ....................................................................................................................................................................................................

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

2.

□ the insured person

2.1 

Surname(s) (2):

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

2.2 

Forename(s) (3): 

Date of birth:

2.3 

2.4 

2.5 

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

Previous name(s):  ....................................................................................................................................................................................

Address:  ...................................................................................................................................................................................................

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

Personal identiﬁ cation number (4): 
...................................................................................................................................................................................................................

2.6  □ Person entitled to 

□ Claimant of

pension in respect of
□ old age 
□ accident at work 

□ invalidity 
□ occupational disease

□ survivor

2.7 

Institution responsible for payment of pension:

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

3. □ Last employer (5) 

□ Last activity as a self-employed person (5)

3.1 

3.2 

3.3 

3.4 

Name:  ......................................................................................................................................................................................................

Address:  ...................................................................................................................................................................................................

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

Field of activity (6):  ....................................................................................................................................................................................

Work accident insurance institution with which the employer is insured (7):   ...........................................................................................

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

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

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

1
1

 
 
 
 
 
 
 
 
 
 
 
 
 
E 107

4.

Members of the family (8)

4.1

Surname(s) (2)

Forename(s) (3)

Date of birth

Personal identiﬁ cation number (4)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

......................................................... ………………………………… .....................................

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

4.2

Address in the country of residence (9):   ……….……………………………………………………………….……………………………

………………………………………………………………………………………………………………………………………………….....

5.

On  ..............................................................................  we received a claim from the person mentioned
□ in box 2 
for

□ in box 4

5.1 □ the granting of beneﬁ ts in kind
5.2 □ the retention of the right to beneﬁ ts in kind

5.3

6.

6.1

6.2

7.

 □ registration with us as a person entitled to beneﬁ ts in kind

The beneﬁ ts in kind 
in accordance with Article  □ 29(2) 

□ have been awarded 

□ 60(1) 

□ have not been awarded
□ 62(3) of Regulation (EEC) No 574/72.

The claimant 

□ has not worked again up to now
□ has exercised the following activity: 
..........................................................................................................................................................

Please send us the certiﬁ cate of entitlement to beneﬁ ts on
□ form     E  .....................................................................................................................................................................................
□ a certiﬁ cate provisionally replacing the European Health Insurance Card or  a European Health Insurance Card (if this can be 
issued under the legislation of the competent State)

Valid from    ...........................................................     to   .................................................................................................................

8. □ Medical report attached (10)

9.

9.1

9.2

9.3

Institution of the place of residence or stay

Name:........................................................................................................................................................................................................

Identiﬁ cation number of the institution: .....................................................................................................................................................

Address: ....................................................................................................................................................................................................

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

9.4

Stamp 

9.5           Date: .............................................................................

9.6          Signature:

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

2
2

 
 
 
 
E 107

B.  To be completed by the competent institution

10.
10.1 □ The abovementioned form is attached. Please return to us a copy duly completed and signed (11).
10.2 □ We are unable to issue the document requested in part A, because:

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

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

11.

Competent institution

11.1

Name:   .................................................................................................................................................................................................

11.2

11.3

Identiﬁ cation number of the institution:

Address:    .............................................................................................................................................................................................

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

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

11.4

Stamp 

11.5         Date:

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

11.6         Signature:

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

3

 
 
 
 
 
NOTES

E 107

(1)  Symbol  of  the  country  to  which  the  institution  completing  the  form  belongs:  BE  =  Belgium;  CZ  =  Czech  Republic;  DK  =  Denmark; 
DE  =  Germany;  EE  =  Estonia;  GR  =  Greece;  ES  =  Spain;  FR  =  France;  IE  =  Ireland;  IT  =  Italy;  CY  =  Cyprus;  LV  =  Latvia; 
LT  =  Lithuania;  LU  =  Luxembourg;  HU  =  Hungary;  MT  =  Malta;  NL  =  Netherlands;  AT  =  Austria;  PL  =  Poland;  PT  =  Portugal;
SI  =  Slovenia;  SK  =  Slovakia;  FI  =  Finland;  SE  =  Sweden;  UK  =  United  Kingdom;  IS  =  Iceland;  LI  =  Liechtenstein;  NO  =  Norway;
CH = Switzerland.

(2)  Give the full surname in the order of civil status.

(3)  Give the forenames in the order of civil status.

(4)  For the purpose of Italian institutions, give the ‘ﬁ scal code’.

For the purpose of Maltese institutions, give the Identity Card number in case of Maltese nationals, or the Maltese Social security number in 
case of a non-Maltese national.

For the purpose of Slovak institutions, give the Slovak birth number if applicable.

For the purpose of Spanish institutions, give the number indicated on the DNI in the case of Spanish nationals, the number indicated on the 
NIE in the case of non-Spanish national. If the validity period of the DNI or NIE is expired, complete with ‘none’.

(5)  Complete only if the form concerns an employed or self-employed person who is working or an unemployed person.

(6)  Complete only if the form concerns an employed person assumed to have sustained an accident at work.

(7)  For  Spain:  the  ‘Dirección  Provincial  del  Instituto  Nacional  de  la  Seguridad  Social’  (provincial  directorate  of  the  national  social  security 
institution) or the ‘Dirección Provincial del Instituto Nacional de la Marina’ (provincial directorate of the social institution for seafarers) for the 
special scheme for seafarers.

(8)  Complete only for members of the family for whom a claim for beneﬁ ts or a request for registration has been made. For registration, indicate 

one member of the family only.

(9)  Complete only if the address of the members of the family is different from that of the head of household.

(10)  To be attached only if necessary. In that case, put a cross in the box.

(11)  For the purposes of Netherlands and Swiss institutions and where the nature of the form to be returned permits.

4

 
 
 
ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY FOR
MIGRANT WORKERS

E 108

(1)

NOTIFICATION OF SUSPENSION OR WITHDRAWAL OF THE RIGHT TO
 SICKNESS AND MATERNITY INSURANCE BENEFITS IN KIND

Persons residing in a country other than the competent country

Regulation (EEC) No 1408/71: Article 19(1)(a) and (2); Article 25(3)(i); Article 26(1); Article 28(1)(a) and Article 29(1)(a)
Regulation (EEC) No 574/72: Article 17(2) and (3); Article 27; Article 28; Article 29(5); Article 30; Article 94(4) and Article 95(4)

The competent institution or the institution in the place of residence should complete part A of the form and send two copies to the institution in the 
place of residence or to the competent institution (where appropriate through the liaison body). The receiving institution should complete part B of 
the form and return one copy to the sending institution.

Please complete this form in block letters, writing on the dotted lines only. It consists of three pages, none of which may be left out.

A.  Notiﬁ cation

1.

Institution to which the form is addressed

1.1

1.2

1.3

Name: .........................................................................................................................................................................................................

Identiﬁ cation number of the institution: .......................................................................................................................................................

Address:  ....................................................................................................................................................................................................

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

□ Frontier worker (employed)
□ Frontier worker (self-employed)

2. □ Employed person 

□ Self-employed person 
□ Unemployed person
□ Pensioner (scheme for employed persons)
□ Pensioner (scheme for self-employed person)
□ Pension Claimant 

2.1

Surname(s) (2):

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

2.2

Forename(s) (3):

Date of birth:

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

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

2.3

2.4

Previous name(s):  ......................................................................................................................................................................................

Address in the country of residence: ..........................................................................................................................................................

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

2.5

Personal identiﬁ cation number (4):

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

3.

Member of the family (5)

3.1

Surname(s) (2):

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

3.2

Forename(s) (3):

Date of birth:

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

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

Previous names:  .......................................................................................................................................................................................

Address in the country of residence: ...........................................

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

Personal identiﬁ cation number:

3.3

3.4

3.5

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

1
1

E 108

4.

Entitlement to beneﬁ ts certiﬁ ed on our □   your □   form ...........................................  of           .............................................................
has been suspended or withdrawn for the following reason:

4.1 □ The insurance of the above-mentioned insured person ended on  .......................................................................................................

4.2

4.3

4.4

None of the registered family members of the  insured person has resided in our □   your □   country since: 
.....................................................................................................................................................................................................................

The pension of the above-mentioned pensioner has been suspended or withdrawn since ........................................................................

The person entitled to beneﬁ ts named in box 2

or
□ The family member named in box 3

□ has not resided in our □   your □   country since  .............................................................................................................   (date)
□ died on  ..................................................................................................................................................................................   (date)

4.5 □ The family member named in 3 has not met the requirements of the legislation of the country of residence since

....................................................................................................................................................................................................................
4.6 □ (6)...........................................................................................................................................................................................................

5. □ Competent institution

□ Institution in the place of residence

5.1

5.2

5.3

Name: .........................................................................................................................................................................................................

Identiﬁ cation number of the institution: .......................................................................................................................................................

Address:  .....................................................................................................................................................................................................

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

5.4

Stamp

B. 

Acknowledgement of receipt

5.5

5.6

Date: ..............................................................................

Signature:

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

6.
We received the above notiﬁ cation (Part A) on  ..........................................................................................................................................
7. □ The registration of the person(s) indicated in Part A ended on  ............................................................................................................

□ We conﬁ rm the suspension or withdrawal of entitlement to beneﬁ ts as notiﬁ ed in section 4 which will take effect on
....................................................................................................................................................................................................................

8. □ Competent institution

□ Institution in the place of residence

8.1

8.2

8.3

Name: .........................................................................................................................................................................................................

Identiﬁ cation number of the institution: ........................................................................................................................................................

Address:  ......................................................................................................................................................................................................

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

8.5

8.6

Date: ...............................................................................

Signature:

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

8.4

Stamp

2
2

NOTES

E 108

(1) 

(2) 

(3) 

(4) 

(5) 

(6) 

Symbol of the country to which the institution which ﬁ rst completes the form belongs: BE = Belgium; CZ = Czech Republic; DK = Denmark; 
DE = Germany; EE = Estonia; GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia; LT = Lithuania; 
LU = Luxembourg; HU = Hungary; MT = Malta; NL = Netherlands; AT = Austria; PL = Poland; PT = Portugal; SI = Slovenia; SK = Slovakia; 
FI = Finland; SE = Sweden; UK = United Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland.

Indicate the full surname in the order of civil status.

Indicate the forenames in the order of civil status.

For the purpose of  the competent institution if Italian, give the ‘ﬁ scal code’.

For the purpose of the competent institution if Maltese, give the Identity Card number in case of Maltese nationals, or the Maltese Social 
security number in case of a non-Maltese national.

For the purpose of the competent institution if Slovak, give the Slovak birth number if applicable.

For the purpose of the institution if Spanish, give the number indicated on the DNI in the case of Spanish nationals, the number indicated 
on the NIE in the case of non-Spanish national. If the validity period of the DNI or NIE is expired, complete with ‘none’.

Complete if the end of entitlement to beneﬁ ts affects family members.

The reason for suspension/withdrawal must be speciﬁ ed using one of the letters below:
(a) the pension holder has taken up an occupation in the country of residence;
(b) a family member has taken up an occupation in the country of residence;
(c) non-payment of contributions;
(d) other.

3

ADMINISTRATIVE COMMISSION 
ON SOCIAL SECURITY FOR
MIGRANT WORKERS     

E 109

(1)

CERTIFICATE FOR THE REGISTRATION OF MEMBERS OF AN INSURED PERSON’S FAMILY AND THE UPDATING OF LISTS

Regulation (EEC) No 1408/71: Article 19(2)
Regulation (EEC) No 574/74: Article 17(1), (2), (3) and (4) and Article 94(4)

The competent institution should complete part A of the form and issue two copies to the insured person or send them, where necessary through 
the liaison body, to the institution in the place of residence if the form has been drawn up at that institution’s request. Where the members of the 
insured person’s family are resident in the United Kingdom, the competent institution should send the two copies to the Department for Work and 
Pensions, Pension Service, International Pension Centre, Tyneview Park, Newcastle upon-Tyne. On receipt of the txo copies, the institution of 
the place of resistence should complete part B and return one copy to the competent institution. Where the members of the family are resident in 
different contries, a separate certiﬁ cate should be drawn up for each of these countries.

Please complete the form in block letters, writing on the dotted lines only. It consists of four pages, none of which may be left out.

A.  Notiﬁ cation of entitlement 

1.

Institution in the place of residence (2) 

1.1

1.2

1.3

Name: .........................................................................................................................................................................................................

Identiﬁ cation number of the institution: .......................................................................................................................................................

Address:  .....................................................................................................................................................................................................

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

1.4

Reference: your E 107 form of  ...................................................................................................................................................................

2.

The insured person

2.1

Surname(s) (3):

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

2.2

Forename(s) (4):

Date of birth:

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

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

2.3

2.4

Previous name(s):  ......................................................................................................................................................................................

Address:   ....................................................................................................................................................................................................

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

2.5

Personal identiﬁ cation number:

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

2.6

The insured person

 □ is

a self-employed worker

3.

Member of the family

3.1

Surname(s) (3):  ...........................................................................................................................................................................................

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

3.2

Forename(s) (4):

Date of birth:

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

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

3.3

3.4

Previous name(s):  ......................................................................................................................................................................................

Address:  .....................................................................................................................................................................................................

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

3.5

Personal identiﬁ cation number: ..................................................................................................................................................................

4.

The members of the family of the abovementioned insured person are entitled to sickness and maternity insurance beneﬁ ts in kind 
unless
□ they are already entitled to such beneﬁ ts under the legislation of the country in which they reside (5)
□ they are pursuing a professional activity or trade (5)

5.

This entitlement begins on  .........................................................................................................................................................................

1

 
E 109

and continues

6.
6.1 □ until this certiﬁ cate is cancelled
6.2 □ for one year from the date speciﬁ ed in point 5 (6)
6.3 □ until the date on which the seasonal work is due to end, i.e. 
6.4 □ until (7) ………………………………………………………………………………………………………………………………..   inclusive.

7.

8.

8.1

8.2

8.3

□ Please return the European Health Insurance Card of the in section 3 mentioned member of the family with number 
................................................................................................   and valid till   .........................................................................................

Competent institution 

Name:
..................................................................................................................................................................................................................

Identiﬁ cation number of the institution: .....................................................................................................................................................

Address:  ...................................................................................................................................................................................................

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

8.4

Stamp

B.  Notiﬁ cation of registration (8)

9. □ 
(9)

8.5

8.6

Date: .............................................................................

Signature:

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

The following family members have not been registered:

Surnames (3)

Forenames (4)

Date of birth

Personal identiﬁ cation number

9.1

9.2

9.3

9.4
9.5

9.6

9.7

9.8

9.9

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

9.10

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

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

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

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

Because

□ They are not entitled to beneﬁ ts
□ 
□ Other reasons

They are already entitled to beneﬁ ts in kind

10. □ 
(9)

The following members of the family of the insured person named in box 2 have been registered:

Surnames (3)

Forenames (4)

Date of birth

Personal identiﬁ cation number

10.1
10.2
10.3
10.4
10.5
10.6
10.7
10.8
10.9

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

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

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

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

10.10

The cost of these beneﬁ ts is payable by you. The date from which the lump sum referred to in Article 94 of Regulation (EEC) 
No 574/72 should be calculated is ..........................................................................................................................................................

2
2

European Health Insurance Card

11.
11.1 □ Please ﬁ nd attached the European Health Insurance Card with number: …….. as requested in section 7

11.2

□  Please indicate the measures to be applied concerning the European Health Insurance card issued to the in section 3 mentioned 
member of the family with number: .........................................................................  and valid till: ....................................................

E 109

12.

Institution in the place of residence

12.1

12.2

12.3

12.4

Name:   ....................................................................................................................................................................................................

Identiﬁ cation number of the institution: ....................................................................................................................................................

Address:    ................................................................................................................................................................................................
.................................................................................................................................................................................................................
Date:   ..........................................................................
Stamp

12.5

12.6

Signature:

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

Instructions for the insured person

(a)  This  form  enables  the  members  of  your  family  to  receive  beneﬁ ts  in  kind  in  case  of  sickness  or  maternity  in  the  country  where  they  are 

resident and under the legislation of that country, unless they are already entitled to such beneﬁ ts under that legislation.

(b)  As soon as you have received the two copies of the form, you should send them to the members of your family, who should submit them 

immediately to the sickness and maternity insurance institution in their place of residence, i.e.:

in Belgium, the ‘mutualité’ (local sickness insurance fund) of your choice;
in the Czech Republic, ‘Zdravotní pojišťovna’ ( the health  insurance fund) of your place of residence;
in Denmark, the municipal authority of the place of residence;
in Germany, the ‘Krankenkasse’  (sickness insurance fund) of your choice;
in Estonia, the ‘Eesti Haigekassa’ (Estonian Health Insurance Fund);
in Greece, normally the regional or local branch of the Social Insurance Institute (IKA), which will issue the person concerned with a ‘health 
book’ without which no beneﬁ ts in kind can be provided;
in  Spain,  the  ‘Dirección  Provincial  del  Instituto  Nacional  de  la  Seguridad  Social’  (Provincial  Directorate  of  the  National  Social  Security 
Institution);
in France, the ‘Caisse primaire d’assurance-maladie’ (local sickness insurance fund);
in  Ireland, the local health ofﬁ ce of the Health Service Executive;  
in Italy, normally the ‘Unità sanitaria locale’ (local health administration unit) responsible for the area concerned;
in Cyprus, the ‘Υπουργείο Υγείας’ (Ministry of Health, 1448 Lefkosia), the sickness and maternity institutions; Upon application, the person 
concerned  will  be  provided  with  a  Cyprus  Medical  Card,  without  which  no  beneﬁ ts  in  kind  can  be  provided  at  the  Government  Medical 
Institutions;
in Latvia, the ‘Veselības obligātās apdrošināšanas valsts aģentūra’ (Health Compulsory Insurance State Agency);
in Lithuania, the ‘Teritoriné ligoniu kasa’ (Territorial Patient Fund), sickness and maternity institutions;
in Luxembourg, the ‘Caisse de maladie des ouvriers’ (sickness fund for manual workers);
in Hungary, the competent ‘Megyei Egészségbiztosítási Pénztár’ (regional sickness insurance fund);
in Malta, the Entitlement Unit, Ministry of Health, 23 John Street, Valletta;
in the Netherlands, any sickness fund competent for the place of residence;
in Austria, the ‘Gebietskrankenkasse’ (regional sickness insurance fund) competent for the place of residence;
in Poland, the regional  branch  of the ‘Narodowy Fundusz Zdrowia’ (National Health Fund) competent for the place of residence; 
in Portugal, for metropolitan Portugal: the ‘Centro Distrital de Solidariedade e Segurança Social’ (Regional Centre for Solidarity and Social 
Security) of the place of residence; for Madera: the ‘Centro de Segurança Social da Madeira’ (Madeira Social Security Centre), Funchal; for 
the Azores: the ‘Centro de Prestações Pecuniárias’ ( Centre for Cash Beneﬁ ts) of the place of residence;
in Slovenia, to the regional unit of the the ‘Zavod za zdravstveno zavarovanje Slovenije (ZZZS)’ (Health Insurance Institution of Slovenia) 
competent for the place of residence;
in Slovakia, the ‘zdravotná poisťovňa’ (health insurance icompany) of the insured person’s choice;
in Finland, the local ofﬁ ce of the ‘Kansaneläkelaitos’ (Social Insurance Institution);
in Sweden, ‘Försäkringskassan’ (Local Social Insurance Ofﬁ ce) at the place of residence;
in the United Kingdom, the Department for Work and Pensions, Pension Service, International Pension Centre, Tyneview Park, Newcastle 
upon Tyne  or, for Northern Ireland, the Department for Social Development,  Overseas Beneﬁ ts Branch,  Block 2, Castle Buildings, Belfast;
in  Iceland, the ‘Tryggingastofnun rikisins’ (the State Social Security Institute), Reykjavik;
in Liechtenstein,  the ‘Amt für Volkswirtschaft’ (Ofﬁ ce of National Economy), Vaduz;
in Norway, the ‘lokale trygdekontor’ (local Insurance ofﬁ ce) at the place of residence;
in Switzerland, the ‘Institution commune LAMal — Instituzione commune LAMal — Gemeinsame Einrichtung KVG’  (Joint institution under 
the Federal Sickness Insurance Act), Solothurn.

(c)  This form is valid from the date indicated in section 5 and for the period indicated in section 6 by the box marked with a cross.
(d)  Both you and the members of your family are required to inform the institution of any change of circumstances which might affect the right to 

beneﬁ ts in kind, such as termination or change of employment, or change in your or a family member’s place of residence or stay.

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E 109

NOTES

(1) 

(2) 
(3) 
(4) 
(5) 
(6) 
(7) 
(8) 

(9) 

Symbol  of  the  country  to  which  the  institution  completing  the  form  belongs:  BE  =  Belgium;  CZ  =  Czech  Republic;  DK  =  Denmark;
DE  =  Germany;  EE  =  Estonia;  GR  =  Greece;  ES  =  Spain;  FR  =  France;  IE  =  Ireland;  IT  =  Italy;  CY  =  Cyprus;  LV  =  Latvia; 
LT  =  Lithuania;  LU  =  Luxembourg;  HU  =  Hungary;  MT  =  Malta;  NL  =  Netherlands;  AT  =  Austria;  PL  =  Poland;  PT  =  Portugal;
SI  =  Slovenia;  SK  =  Slovakia;  FI  =  Finland;  SE  =  Sweden;  UK=  United  Kingdom;  IS  =  Iceland;  LI  =  Liechtenstein;  NO  =  Norway;
CH = Switzerland.
Complete only if the form is being drawn up at the request of the institution of the place of residence.
Give the full surname in the order of civil status.
Give the forenames in the order of civil status.
Put a cross in the box if the form is addressed to an Irish or United Kingdom institution.
If the form is issued by a German, French, Italian or Portuguese institution.
If the form is issued by a Greek, Hungarian or United Kingdom institution for employed or self-employed persons.
 If this certiﬁ cate is issued in renewal of a previously issued certiﬁ cate which has expired, the institution of the place of residence need not 
complete part B.
Complete section 9 or 10 as applicable and put a cross in the corresponding box.

4

ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY FOR
MIGRANT WORKERS

E 112

(1)

CERTIFICATE CONCERNING THE RETENTION OF THE RIGHT TO SICKNESS OR MATERNITY BENEFITS 
CURRENTLY BEING PROVIDED

Regulation (EEC) No 1408/71: Article 22(1)(b)(i); Article 22(1)(c)(i); Article 22(3); Article 22(a) and Article 31
Regulation (EEC) No 574/72: Article 22(1) and (3); Article 23 and Article 31(1) and (3)

The competent institution or the institution of the place of residence of the insured person, pensioner or family member should issue the form to the 
insured person, pensioner or family member. If the insured person or the pensioner is going to the United Kingdom, one copy of the form should 
also be sent to the Department for Work and Pensions, Pension Service, International Pension Centre, Tyneview Park, Newcastle upon Tyne.

Please complete this form in block letters, writing on the dotted lines only. It consists of two pages, none of which may be left out.

1. □ Insured person

□ Self-employed worker
□ Pensioner (employed worker)
□ Pensioner (self-employed worker)

1.1

Surname(s) (2):

□ Family member of the insured person
□ Family member of a self-employed worker
□ Family member of a pensioner (employed worker)
□ Family member of  pensioner (self-employed worker)

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

Forename(s) (3):
Date of birth:
.......................................................................................................
.........................................................................................................
Previous name(s):  .........................................................................................................................................................................................
Address in the competent country: 
.......................................................................................................................................................................................................................
Address in the country to which the person concerned is going:  

.......................................................................................................................................................................................................................
.......................................................................................................................................................................................................................
Personal identiﬁ cation number (4):

The person referred to above is authorised to retain the right to beneﬁ ts in kind
□ from sickness and maternity insurance
in  ...................................................................................................................................................   (country), where he/she is going

 □ from non-occupational accident insurance (5)

1.2

1.3
1.4

1.5

1.6

2.

2.1 □ to take up residence
2.2 □ to receive treatment from (6)

.......................................................................................................................................................................................................................
.......................................................................................................................................................................................................................
or from any other establishment of a similar nature in case of a transfer which is medically necessary in respect of this treatment.

2.3 □ to send biological samples for the purposes of analysis without the need for the person concerned to be present.
3.

These beneﬁ ts may be provided, on production of this certiﬁ cate,

from  .................................................................................................   to  ...................................................................................    inclusive.

4.
The report from our examining doctor
4.1 □ is attached to this form in a sealed envelope
4.2 □ was sent on ...............................................................................   to (7)  .................................................................................................
4.3 □ will be sent by us on request
4.4 □ has not been drawn up

5.

Competent institution

5.1

5.2

5.3

Name: ...........................................................................................................................................................................................................

Identiﬁ cation number of the institution: .........................................................................................................................................................

Address:  .......................................................................................................................................................................................................

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

5.4

Stamp

5.5 

5.6 

Date:  ................................................................................

Signature:

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

1
1

E 112

Instructions for the person concerned

You should submit this form as soon as possible to the sickness and maternity insurance institution of the place to which you are going, i.e.:

in Belgium, the ‘mutualité’ (local sickness insurance fund) of your choice;
in the Czech Republic, the ‘Zdravotní pojišťovna’ (health  insurance fund of your choice;
in Denmark, the treatment provider, normally the general practitioner, who will refer you to a specialist;
in Germany, the ‘Krankenkasse’  (sickness insurance fund) of your choice;
in  Estonia, the ‘Eesti Haigekassa’ (Sickness Insurance Agency);
in Greece, normally the regional or local branch of the Social Insurance Institute (IKA), which issues the person concerned with a ‘health book’, 
without which no beneﬁ ts in kind can be provided;
in Spain, the medical / hospital services of the health system covered by Spanish social insurance. You must submit the form and a photocopy;
in France, the ‘Caisse primaire d'assurance maladie’ (local sickness insurance fund); 
in Ireland, the local health Ofﬁ ce of the Health Service Executive; 
in  Italy, normally the ‘Unità sanitaria locale’ (local health administration unit) responsible for the area concerned;
in Cyprus, the ‘Υπουργείο Υγείας’ (Ministry of Health, 1448 Lefkosia);
in Latvia, the ‘Veselības obligātās apdrošināšanas valsts aģentūra’ (Health Compulsroy Insurance State Agency);
in Lithuania, the ‘Territorial Patient Fund’, the sickness and maternity institutions;
in Luxembourg, the ‘Caisse de maladie des ouvriers’ (sickness fund for manual workers);
in Hungary, the treatment provider;
in Malta, the National Health Service establishment (doctor, dentist, hospital, health centre) providing treatment;
in the Netherlands, any sickness fund competent for the place of residence or, in case of temporary stay, the ‘Agis zorgverzekeringen’, Utrecht;
in Austria, the ‘Gebietskrankenkasse’ (regional sickness insurance fund) competent for the place of residence or stay;
in Poland, the regional branch of the ‘Narodowy Fundusz Zdrowia’ (National Health Fund) competent for the place of residence or stay;
in Portugal, for metropolitan Portugal: the ‘Administração Regional de Saúde’ (Regional Health Administration) of the place of residence or 
stay; for Madeira: the ‘Centro de Saúde’ (Health Centre) of the place of stay; for the Azores: the ‘Centro de Saúde’ (Health Centre) of the place 
of stay;
in Slovenia, the regional unit of the  ‘Zavod za zdravstveno zavarovanje Slovenije (ZZZS)’ (Health Insurance Institute of Slovenia) at the place of 
residence or stay;
in Slovakia, the ‘zdravotná poisťovňa’ (health insurancecompany) of the insured person’s choice. For cash beneﬁ ts, the ‘Sociálna poisťovňa’ 
(Social InsuranceAgency), Bratislava;
in Finland, the local ofﬁ ce of the ‘Kansaneläkelaitos’ (Social Insurance Institution). The form must be presented to the municipal health centre or 
the public hospital providing treatment;
in  Sweden, the ‘Försäkringskassan’ (Local Social Insurance Ofﬁ ce. The form must e presented to the institution providing treatment;
in the United Kingdom, the medical service (doctor, dentist, hospital, etc.) providing treatment;
in Iceland, the ‘Tryggingastofnun rikisins’ (the State Social Security Institute), Reykjavik; 
in Liechtenstein, the ‘Amt für Volkswirtschatf’ (Ofﬁ ce of National Economy), Vaduz;
in Norway, the ‘Iokale Trygdekontor’ (local insurance ofﬁ ce);
in Switzerland, the ‘Institution commune LAMal — Instituzione commune LAMal — Gemeinsame Einrichtung KVG’ (Joint institution under the 
Federal Sickness Insurance Act), Solothurn. The form must be presented to the doctor or the hospital providing the treatment.

NOTES

(1) 

 Symbol  of  the  country  to  which  the  institution  completing  the  form  belongs:  BE  =  Belgium;  CZ  =  Czech  Republic;  DK  =  Denmark;
DE  =  Germany;  EE  =  Estonia;  GR  =  Greece;  ES  =  Spain;  FR  =  France;  IE  =  Ireland;  IT  =  Italy;  CY  =  Cyprus;  LV  =  Latvia; 
LT  =  Lithuania;  LU  =  Luxembourg;  HU  =  Hungary;  MT  =  Malta;  NL  =  Netherlands;  AT  =  Austria;  PL  =  Poland;  PT  =  Portugal;
SI  =  Slovenia;  SK  =  Slovakia;  FI  =  Finland;  SE  =  Sweden;  UK=  United  Kingdom;  IS  =  Iceland;  LI  =  Liechtenstein;  NO  =  Norway;
CH = Switzerland.

(2)  Give the full surname in the order of civil status.
(3)  Give the forenames in the order of civil status.
(4) 
(5) 
(6) 
(7)  Name and address of the institution to which the medical report has been sent.

Please indicate the number of the insured person if the member of family does not have a personal identiﬁ cation number.
To be completed by French institutions for self-employed agricultural workers.
To be completed if possible.

2

ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY FOR
MIGRANT WORKERS

E 115

(1)

CLAIM FOR CASH BENEFITS FOR INCAPACITY FOR WORK

Regulation (EEC) No  1408/71: Article (19)(1)(b); Article 22(1)(a)(ii); Article 25(1)(b); Article 52(b) and Article 55(1)(a)(ii)
Regulation (EEC) No  574/72: Article 18(2) and (3); Article 24; Article 26(5) and (7); Article 61(2) and (3) and Article 64

If the form is drawn up for an insured person in active employment, one copy only should be completed and sent to the institution competent as 
regards sickness and maternity insurance or as regards an insurance against accidents at work and occupational diseases. However, if it concerns 
an unemployed person, two additional copies should be drawn up, one of which should be sent to the institution competent in unemployment 
insurance, the other to the corresponding institution in the country to which the unemployed person has gone to seek employment.

Please complete this form in block letters, writing on the dotted lines only. The form consists of three pages.

1.

Competent institution

1.1

1.2

Name: ......................................................................................................................................................................................................... 

Address:  .....................................................................................................................................................................................................

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

1.3

Identiﬁ cation number of the institution:

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

2. □ Employed person

2.1

Surname(s) (2):

□ Self-employed person

□ Unemployed person

Surname(s) at birth (if different):

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

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

2.2

Forenames:

Date of birth:

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

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

2.3

Personal identiﬁ cation number: 

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

2.4

Holds an E 119 form issued on  ...................................................................................................................................  (3)

and an E 303 form issued on  ......................................................................................................................................  (3)

3.

Employer (4)

3.1

3.2

Name of employer or ﬁ rm: ..........................................................................................................................................................................

Address:  .....................................................................................................................................................................................................

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

A.   □ (5) Claim for beneﬁ ts

4.

The person mentioned in box 2 applied on  .................................................................................................................................... (date) 
for cash beneﬁ ts for
□ in-patient treatment from  .............................   to  .........................(dates) in a hospital or in a prevention or rehabilitation centre (6)
□ incapacity for work
due to
4.1 □ sickness

□ maternity   (expected date of conﬁ nement:  .......................................................................... )
□ accident sustained on  ................................................................................................... (date)
□ adoption

□ reduced compensation in case of maternity and adoption

□ accident at work
□ occupational disease

1
1

5.

The certiﬁ cate of the doctor treating him/her
□ is attached

□ could not be supplied

E 115

6.

In the opinion of our examining doctor

□ whose report is attached
□ whose report will be sent to you as soon as possible

6.1 □ the incapacity for work began on   ........................................................................................................................................................
      and will probably continue until    ..........................................................................................................................................................

6.2 □ there is no incapacity for work (7)

7. □ The person concerned is deemed not to have complied with the provisions of our legislation for the following reasons:

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

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

8. □ The incapacity for work was presumably caused by an accident for which a third party was responsible.
8.1 □ The incapacity for work  was due to other speciﬁ c circumstances as set out in the attached documentation.
8.2 □ A report on this accident with the address of the third party involved is attached to this form.
8.3 □ Other documentation on the cause of the incapacity for work is attached to this form.

9. □ We are willing to provide cash beneﬁ ts to the person concerned on your behalf. Will you please let us know if you agree to this 

      procedure and, if so, give us all information necessary for the payment of the beneﬁ ts. (8)

10. □ We are not willing to provide cash beneﬁ ts to the person concerned on your behalf.

B.  □ (5) Extension of the incapacity for work

With reference to

11.
11.1 □ our E 115 form of  ..................................................................................... (date)
11.2 □ your E 117 form of  ................................................................................... (date)
11.3

we wish to inform you that, in the opinion of our examining doctor
□ whose report is attached
□ whose report will be sent to you as soon as possible
the person mentioned in box 2 will probably remain incapable of work until ...........................................................................  inclusive.

12.

Institution of the place of residence or stay

12.1

12.2

12.3

Name: ...................................................................................................................................................................................................

Identiﬁ cation number of the institution: .................................................................................................................................................

Address:  ...............................................................................................................................................................................................

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

12.4

Stamp

2
2

12.5

12.6

Date: .........................................................................

Signature:

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

E 115

Instructions for the persons concerned

In  Italy  you  should  submit  this  form,  in  case  of  sickness  or  maternity  to  the  local  ofﬁ ce  of  the  ‘Istituto  nazionale  della  previdenza  sociale’ 
(INPS, National Social Welfare Institute), in case of an accident at work or occupational disease to the ‘Istituto nazionale assicurazione contro gli 
infortuni sul lavoro’ (INAIL). 

For  the  Netherlands,  if  the  competent  sickness  insurance  institution  is  not  known,  send  the  form  to  the  UWV,  Postbus  57002,  1040  CC 
Amsterdam. 

In Slovenia you should submit this form, in case of maternity cash beneﬁ ts to the competent ‘Center za socialno delo Ljubljana Bežigrad, Centralna 
enota za starševsko varstvo in družinske prejemke’ (Centre for Social Work Ljubljana Bežigrad, Central Unit for Parental Protection and Family 
Beneﬁ ts) and in case of incapacity for work to the competent regional unit of the ‘Zavod za zdravstveno zavarovanje Slovenije (ZZZS)’ (Health 
Insurance Institute of Slovenia).

NOTES

(1) 

the 

the  country  of 

Symbol  of 
form:  BE  =  Belgium;  CZ  =  Czech  Republic;  DK  =  Denmark;
DE  =  Germany;  EE  =  Estonia;  GR  =  Greece;  ES  =  Spain;  FR  =  France;  IE  =  Ireland;  IT  =  Italy;  CY  =  Cyprus;  LV  =  Latvia; 
LT  =  Lithuania;  LU  =  Luxembourg;  HU  =  Hungary;  MT  =  Malta;  NL  =  Netherlands;  AT  =  Austria;  PL  =  Poland;  PT  =  Portugal;
SI  =  Slovenia;  SK  =  Slovakia;  FI  =  Finland;  SE  =  Sweden;  UK  =  United  Kingdom;  IS  =  Iceland;  LI  =  Liechtenstein;  NO  =  Norway;
CH = Switzerland.

institution  completing 

the 

(2)  Give the full surname in the order of civil status.

(3)  Complete only if the form concerns an unemployed person.

(4) 

For unemployed persons, indicate the last employer.

(5)  Complete either part A or part B and put a cross in the square corresponding to the part completed. 

(6)  Concerning persons insured at a German health insurance fund or at an Austrian or Belgian Institution: if the social insurance institution of 
the place of residence does not know the exact date of leaving the hospital when issuing this form, it is to complete this information as soon 
as possible at a later date.

(7) 

(8) 

Please attach a copy of an E 118 form sent to the person concerned.

If the form is being sent to a German, an Italian, a Hungarian or a Polish institution, this box need not be ticked.

3

ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY FOR
MIGRANT WORKERS

E 116

(1)

MEDICAL REPORT RELATING TO INCAPACITY FOR WORK
(SICKNESS, MATERNITY, ACCIDENT AT WORK, OCCUPATIONAL DISEASE)

Regulation (EEC) No 1408/71: Article (19)(1)(b); Article 22(1)(a)(ii); (1)(b)(ii); (1)(c)(ii); Article 25(1)(b); Article 52(b); Article 55(1)(a)(ii); (1)(b)(ii) 

and (1)(c)(ii)
Regulation (EEC) No 574/72: Article 18(2) and (3); Article 24; Article 26(5) and (7); Article 61(2) and (3); Article 64; Article 65(2) and (4)

To be completed by the doctor of the institution which draws up an E 115 form to be attached to that form and sent under sealed cover in the 
case of sickness or maternity (2). 

Please complete this form in block letters, writing on the dotted lines only.  The form consists of three pages.

1.

Competent institution to which the form is addressed

1.1

1.2

1.3

Name: .........................................................................................................................................................................................................

Identiﬁ cation number of the institution: .......................................................................................................................................................

Address:  .....................................................................................................................................................................................................

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

1.4

Reference: our E 116 form of  ..........................................................................................................................................................  (date)

2.

Attached to an E 115 form of ............................................................................................................................................................ (date)

3.

The person concerned

3.1 Surname(s) (3):  ........................................................................................................................................................................................... 

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

3.2 Surname(s) at birth (if different): 

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

3.3 Forenames:

Date of birth:

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

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

3.4 Address in the country of residence or stay: . .............................................................................................................................................

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

3.5 Personal identiﬁ cation number:

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

4.

I, the undersigned,  ...................................................................................................................................................... doctor of medicine,

having examined the person mentioned above

on ................................................................................................................................................................................................................

4.2

4.1

consider that it is
□ case of sickness
that it is probably
□ an accident at work
4.3 □ a relapse or aggravation

□ case of maternity (expected date of conﬁ nement:  ............................................................... )

□ an occupational disease

 □ an accident

1

E 116

A.  General report

5.

To be completed in every case

5.1 Medical history and present symptoms:  ...................................................................................................................................................

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

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

5.2

Clinical examination: .................................................................................................................................................................................

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

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

5.3

Other observations: ...................................................................................................................................................................................
....................................................................................................................................................................................................................

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

5.4

Special examinations (4): ...........................................................................................................................................................................

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

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

5.5

Diagnosis:  .................................................................................................................................................................................................

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

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

5.6

Conclusions: ..............................................................................................................................................................................................

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

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

5.7 □ The person concerned has not been found to be unﬁ t for work
5.8 □ The person concerned has been found to be unﬁ t for work

from ......................................................................................   to  ......................................................................................................

5.9 □ The person concerned has been found partly unﬁ t for work to a degree of

(............................ %)   from  ...............................................   to  .................................................................................................  (5)
5.10 □ The person concerned will be given a further medical examination on  ..............................................................................................
5.11 □ The person concerned should be ﬁ t for work on .................................................................................................................................

B.  Reports in the case of an accident at work

6.

First medical report

6.1

This accident has resulted in the following injuries (6): .............................................................................................................................

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

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

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

6.2

These injuries

□ have had

□ will have the following effects (7)

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

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

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

Incapacity for work began on ...................................................................................................................................................................

The injured person is being treated
□ at home
□ in hospital
Address (8):  

□ at the doctor’s surgery
□ elsewhere

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

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

6.3

6.4

2
2

  
 
E 116

7.

Latest medical report

7.1

Treatment ended on:  ..................................................................................................................................................................................

Injuries stabilised on: ..................................................................................................................................................................................

7.2
7.3 □ with complete recovery
7.4 □ and will probably have the following consequences:

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

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

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

7.5

Detailed description of the victim’s condition after recovery or at the end of medical treatment:

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

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

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

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

8.

Institution in the place of residence or stay:

8.1

8.2

8.3

Name: ........................................................................................................................................................................................................

Number of the competent institution:  ........................................................................................................................................................

Address:  ....................................................................................................................................................................................................

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

8.4

Stamp

8.5

8.6

Date: .............................................................................

Signature: 

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

NOTES

Symbol  of  the  country  of  the  institution  completing  the  form:  BE  =  Belgium;  CZ  =  Czech  Republic;  DK  =  Denmark;
DE  =  Germany;  EE  =  Estonia;  GR  =  Greece;  ES  =  Spain;  FR  =  France;  IE  =  Ireland;  IT  =  Italy;  CY  =  Cyprus;  LV  =  Latvia; 
LT  =  Lithuania;  LU  =  Luxembourg;  HU  =  Hungary;  MT  =  Malta;  NL  =  Netherlands;  AT  =  Austria;  PL  =  Poland;  PT  =  Portugal;
SI  =  Slovenia;  SK  =  Slovakia;  FI  =  Finland;  SE  =  Sweden;  UK  =  United  Kingdom;  IS  =  Iceland;  LI  =  Liechtenstein;  NO  =  Norway;
CH = Switzerland  Indicate the type of examination and the date.

Form E 116 is not required for claims for maternity beneﬁ ts payable by Belgium. For Belgium, this form should always be sent ﬁ rst to the 
Belgian institution competent as regards sickness insurance. In the Czech Republic, Liechtenstein, Finland, Norway and Sweden the form 
is ﬁ lled in by the doctor the person concerned is visiting and veriﬁ ed by the insurance institution.

Give the full surname in the order of civil status.

Indicate the type of examination and the date.

For the purpose of Norwegian institutions.

Indicate the type and nature of the injuries and the part of the body injured: fracture of arm, bruising of head, ﬁ ngers, internal injuries, 
asphyxia, etc.

Indicate the certain or probable consequences of the injuries veriﬁ ed: death,  permanent or temporary incapacity, total or partial; in the 
case of temporary incapacity, indicate the probable duration.

If the injured person receives treatment in hospital, please give name of hospital.

(1) 

(2) 

(3) 

(4) 

(5) 

(6) 

(7) 

(8) 

3

 
ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY FOR
MIGRANT WORKERS

E 117

(1)

GRANTING OF CASH BENEFITS IN THE CASE OF MATERNITY AND INCAPACITY FOR WORK

Regulation (EEC) No 1408/71: Article(19)(1)(b); Article 22(1)(a)(ii); Article 25(1)(b); Article 52(b) and Article 55(1)(a)(ii)
Regulation (EEC) No 574/72: Article 18(6) and (8); Article 24; Article 26(7); Article 61(6) and (8) and Article 64

The competent institution should complete this form and send it to the institution in the place of residence or stay. The competent institution should 
also inform the worker if cash beneﬁ ts are paid by the institution in the place of residence.

Please complete this form in block letters, writing on the dotted lines only.  The form consists of two pages.

1.

Institution of the place of residence or stay

1.1

1.2

1.3

Name: ......................................................................................................................................................................................................

Identiﬁ cation number of the institution: ....................................................................................................................................................

Address:  ..................................................................................................................................................................................................

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

2.

Reference: your E 115 form of  ....................................................................................................................................................... (date)

3. □ Employed person

3.1

Surname(s) (2):

□ Self-employed person

□ Unemployed person

Surname(s) at birth (if different):

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

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

3.2

Forename(s):

Date of birth:

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

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

3.3

Address in the country of residence or stay:  ...........................................................................................................................................

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

3.4

Personal identiﬁ cation number:

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

The person referred to in box 3

4.
4.1 □ is provisionally entitled to receive cash beneﬁ ts

from ........................................................................  to ........................................................................ , with possibility of extension

4.2 □ is not entitled to cash beneﬁ ts

Reason:   see the E 118 form attached.

4.3 □ is no longer entitled to cash beneﬁ ts from ............................................................................................................................... (date)

Reason:   see the E 118 form attached.

These beneﬁ ts will be provided (3)

5.
5.1 □ by us
5.2 □ by you on our behalf (4)
5.3 □ by the employer (5)

from ............................................................................... to  ............................................................................................................(6)

6.

6.1

(7) (8)

The allowance should be paid for every day of the week, except

6.2

The daily net amount of this allowance is

□ Thursday

□ Monday
□ Friday

□ Tuesday
□ Saturday

□ Wednesday
□ Sunday

......................................................  (9)   if the insured person is not in hospital
......................................................  (9)   if the insured person is in hospital

6.3 □ If the allowance is paid monthly, the amount provided is for 30 days, regardless of the number of days in the month

1
1

 
 
 
 
E 117

Please inform us as soon as possible of the result of

7.
7.1 □ examination (10): ................................................................................................................................................................................
7.2 □ administrative checks:  ......................................................................................................................................................................
7.3 □ a further medical examination, to be carried out about  ...........................................................................................................(date)

8.

Competent institution

8.1

8.2

8.3

Name: ......................................................................................................................................................................................................

Identiﬁ cation number of the institution: ....................................................................................................................................................

Address:  ..................................................................................................................................................................................................

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

8.4

Stamp

8.5

8.6

Date: ...........................................................................

Signature:

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

NOTES

(1) 

(2) 

(3) 

(4) 

(5) 

(6) 

(7) 

(8) 

(9) 

Symbol  of  the  country  of  the  institution  completing  the  form:  BE  =  Belgium;  CZ  =  Czech  Republic;  DK  =  Denmark;
DE  =  Germany;  EE  =  Estonia;  GR  =  Greece;  ES  =  Spain;  FR  =  France;  IE  =  Ireland;  IT  =  Italy;  CY  =  Cyprus;  LV  =  Latvia; 
LT  =  Lithuania;  LU  =  Luxembourg;  HU  =  Hungary;  MT  =  Malta;  NL  =  Netherlands;  AT  =  Austria;  PL  =  Poland;  PT  =  Portugal;
SI  =  Slovenia;  SK  =  Slovakia;  FI  =  Finland;  SE  =  Sweden;  UK  =  United  Kingdom;  IS  =  Iceland;  LI  =  Liechtenstein;  NO  =  Norway;
CH = Switzerland.

Give the full name in the order of civil status.

Need not be completed for unemployed persons for whom a form E 119 has been issued.

The competent institution may indicate here the method of payment.

When this form is addressed to a French, a Polish, an Italian or a Hungarian institution, this box need not be ticked.

To be completed by Danish, German, Luxembourg, Polish, Hungarian or Slovak institutions.

To be completed by German, Luxembourg, Polish, Slovak and Spanish institutions.

Complete only in the case indicated at point 5.2.

Indicate the amount in national currency.

(10) 

Indicate the type of medical examination requested (radiography, analysis of…, etc.).

2
2

ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY FOR

MIGRANT WORKERS

E 118

(1)

NOTIFICATION OF NON-RECOGNITION OR OF END OF INCAPACITY FOR WORK

Regulation (EEC) No 1408/71: Article 19(1)(b); Article 22(1)(a)(ii), (b)(ii) and (c)(ii); Article 25(1)(b); Article 52(b); Article 55(1)(a)(ii), (b)(ii) and (c)(ii)

Regulation (EEC) No 574/72: Article 18(4) and (6); Article 24; Article 26(5) and (7); Article 61(4) and (6) and Article 64

If this form relates to an insured person in active employment, the institution in the place of residence or stay (or the competent institution) should 
draw up two copies of the form, one of which should be sent to the insured person himself and the other to the sickness and maternity insurance 
institution or to the institution for insurance against accidents at work and occupational diseases of the competent country (in the place of residence 
or stay). If it relates to an unemployed person, it is necessary to draw up, in addition to the copies mentioned (one of which is addressed to the 
unemployed person himself), two extra copies, one of which should be sent to the institution competent in unemployment insurance and the other 

to the institution of the country to which the unemployed person has gone to seek employment.

Please complete this form in block letters, writing on the dotted lines only. It consists of two pages and of a three-page Annex.

1.

The beneﬁ ciary

1.1

Surname(s):

Surname(s) at birth (if different):

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

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

1.2

Forename(s):

Date of birth:

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

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

1.3

Address in the country of residence or stay:  ...............................................................................................................................................

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

1.4

Personal identiﬁ cation number:

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

2. □ Competent institution

□ Institution in the place of residence or stay

2.1

2.2

2.3

Name: ..........................................................................................................................................................................................................

Identiﬁ cation number of the institution: ........................................................................................................................................................

Address:  ......................................................................................................................................................................................................

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

3. □ The facts which have been brought to our notice ..................................................................................................................................
□ The examination carried out by our doctor on ............................................................................................................................. (date)

shows

3.1

3.2

3.3

  □ that your incapacity for work is only partial
  □ that you are entitled to partial cash beneﬁ ts amounting to  ........................................................................................................  (2)
            from ...................................................................................................................................................................................... (date)
  □ that you are ﬁ t for work
  □ that your incapacity for work ended on  ......................................................................................................................................  (3)
3.4
3.5 □ The last day for which you will receive cash beneﬁ ts is  .......................................................................................................................
3.6 □ The competent institution shall determine the last day for which you receive cash beneﬁ ts
3.7 □ You are not entitled to beneﬁ ts because  ..............................................................................................................................................
....................................................................................................................................................................................................................

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

4. □ Institution in the place of residence or stay

□ Competent institution

4.1

4.2

4.3

Name: .........................................................................................................................................................................................................

Identiﬁ cation code of the institution:  ...........................................................................................................................................................

Address:  .....................................................................................................................................................................................................

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

4.4

Stamp

4.5

4.6

Date: ..............................................................................

Signature:

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

1
1

 
E 118

Information for the employed person, the self-employed person or the unemployed person.

If you disagree with the decision which is notiﬁ ed to you by this document, you may appeal against it. For details of the legal remedies and periods 
allowed for appeals, please see the Annex. For procedures and time limits you should follow the instructions indicated for the competent State.

NOTES

(1) 

(2) 

(3) 

Symbol of the country to which the institution completing the form belongs: AT = Austria; BE = Belgium; CY = Cyprus; CZ = Czech Republic; 
DE=Germany;  DK=Denmark; EE = Estonia; ES = Spain; FI = Finland; FR = France; UK = United Kingdom; GR = Greece; HU = Hungary; 
IE = Ireland; IT = Italy; LT = Lithuania;  LU = Luxembourg; LV = Latvia; MT = Malta;  NL = Netherlands; PL = Poland;  PT=Portugal; 
SE = Sweden; SI = Slovenia; SK = Slovakia;  IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland.

This information is to be provided only if the competent institution is completing the form. Indicate whether beneﬁ ts are provided daily, 
weekly or monthly.

Indicate the last day of incapacity for work.

2
2

LEGAL REMEDIES AND PERIODS ALLOWED FOR APPEALS

Regulation (EEC) No 574/72: Article 18(4) and Article 61(4)

E 118 Annex

Belgium

1. 
If you do not agree with the decision attached, you have the right to lodge an appeal in writing, dated and signed, to be submitted or sent by 
registered letter to the ofﬁ ce of the clerk of the competent labour court within a period of three months of the date on which you received notiﬁ cation 
of the decision.

Competent labour courts are:

(a) 

(b) 

(c) 

if you are domiciled in Belgium, the labour court of the district where you are domiciled;

if you are not or no longer domiciled in Belgium, the labour court of the district where you were last domiciled or resident in Belgium;

if you have not been domiciled or resident in Belgium, the labour court of the district where you were last employed in Belgium.

Czech Republic

2. 
If you do not agree with the notiﬁ cation attached, you have the right to lodge an appeal to the competent Czech institution indicated in point 2 or 
4 of the form within three days after the delivery of the notiﬁ cation. The method of, and the closing date for, appeal are stated in the decision.

Denmark

3. 
If you wish to contest the decision attached, you may, within four weeks of the date on which you received notiﬁ cation of the decision, lodge an 
appeal with ‘Den Sociale Ankestyrelse Dagpengeudvalget’, Amaliegade 25, PO. Box 3061, 1021 Copenhagen K (The Social Appeals Board, Daily 
Cash Beneﬁ ts Committee).

Germany

4. 
This ofﬁ cial act becomes binding if within three months of notiﬁ cation you have not submitted an appeal. Appeals should be lodged in writing within 
three months with the following German institution:

Name: ...........................................................................................................................................................................................................
Address:

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

Estonia

5. 
If you wish to contest the decision attached you may submit an appeal, within a period of 30 days to `Eesti Haigekassa`, Lembitu 10, Tallinn 
10114.

Greece

6. 
If you do not agree with the attached decision you may submit an appeal, within a period of 30 days of the date on which you received the attached 
decision to:

Name: ...........................................................................................................................................................................................................
Address:

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

Spain

7. 
You may, within a period of 30 working days of the date on which you received notiﬁ cation of the attached decision, submit an appeal against the 
decision to the following institution:

Name: ...........................................................................................................................................................................................................
Address:

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

France

8. 
If you wish to contest the decision attached, you may, within a period of two months of the date on which you received notiﬁ cation of the decision, 
lodge an appeal with the chief physician of the sickness insurance fund indicated in the box below:

Name: ...........................................................................................................................................................................................................
Address:

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

Ireland

9. 
If you do not agree with the decision attached, you may submit a request to the Social Welfare Appeals Ofﬁ ce, D’Olier House, D’Olier Street, Dublin 
2. Such a request should be made within 21 days of the date on which you received this decision.

3

E 118 Annex

Italy

10. 
Decisions of INPS (Sickness and Maternity)

An insured person may contest a decision of the INPS by lodging an administrative appeal with the competent Provincial Commission within 
90 days of receiving notice of the relevant decision.

Moreover, the person concerned may initiate legal proceedings within a period of one year of the date on which the Commission’s decision was 
notiﬁ ed or after 90 days have elapsed since lodging his appeal if the Commission has taken no decision.

Decisions of INAIL (accidents at work and occupational diseases)

An  insured  person  wishing  to  contest  a  decision  of  INAIL  may,  within  60  days  of  the  receipt  of  the  notiﬁ cation  sent  to  him,  inform  INAIL,  by 
registered  letter  with  advice  of  delivery  or  notice  of  receipt,  of  the  reasons  why  he  considers  that  the  decision  is  unjustiﬁ ed;  in  the  case  of 
permanent incapacity for work, he should indicate the amount of the allowance to which he feels entitled; in all cases, a medical certiﬁ cate in 
support of his claim should be sent with the letter of appeal.

If the person concerned has not received a reply within a period of 60 days of the date of the advice of delivery or the notice of receipt referred to 
above, or if he is not satisﬁ ed with the reply, he may take INAIL to court over the matter.

The letter setting out the reasons why the insured person does not agree with a decision of INAIL may be sent to INAIL either directly or through 
the institution of the place of residence or stay.

11.  Cyprus

If you are not satisﬁ ed by the decision attached you may within ﬁ fteen days of the notiﬁ cation of the decision appeal to the Minister of Labour 
and Social Insurance.  If you are not satisﬁ ed by the Minister’s decision you may appeal to the Supreme Court within 75 days from the day of the 
notiﬁ cation of the Minister’s decision.

12.  Latvia
If you do not agree with the attached decision you may submit an appeal, within a period of one month of the date on which you received the 
attached decision to:

Name:  ...........................................................................................................................................................................................................
Address:

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

13.  Lithuania
If you wish to contest the decision attached, you may lodge an appeal with the Administrative Disputes Commission within one month of the date 
on which you received notiﬁ cation of this decision.

14.  Luxembourg
If you do not agree with the decision attached, you have the right to lodge an appeal in principle with the ‘Conseil arbitral des assurances sociales’, 
within a period of 40 days of the date on which you received notiﬁ cation of the decision.

15.  Hungary
If you do not agree with the attached communication, you can request a decision from the competent Hungarian institution (box 2 or 4 of the form 
E 118). The decision of the competent institution is appealable within 15 days of the date on which you received notiﬁ cation of the decision.

16.  Malta
If you wish to contest the decision attached, you may lodge an appeal with the Department of Social Security, Valletta within 30 days of the date 
of decision.

17.  Netherlands
If  you  do  not  agree  with  the  communication  attached,  you  may  request  the  competent  Netherlands  institution  mentioned  in  box  2  or  4  of  the 
E 118 form to take an appealable decision within a reasonable period of time. The method of appealing and the time limit within which to appeal 
will be speciﬁ ed in the decision.

18.  Austria
If you do not agree with the attached information (form E 118), you can request a decision from the competent Austrian Institution mentioned in 
box 2 or 4 of the form referred to before, from which you can take the instruction about the admissible legal remedy.

19.  Poland
If you are not satisﬁ ed with the decision enclosed, you have the right to apply for decision to the Zaklad Ubezpieczen Spolecznych — ZUS (Social 
Insurance institution) with territorial jurisdiction over the seat of employer, and in the case of farmers, to the regional branch of Kasa Rolniczego 
Ubezpieczenia Spolecznego — KRUS (Agricultural Social Insurance Fund). In this branch you will be issued with the decision on eligibility for 
beneﬁ t and informed about possible measures of appeal against the decision.

20.  Portugal

If you do not agree with this decision, you may,

 If incapacity for work has not been recognised, lodge an appeal with the Regional Administrative Health Board (Commissão Instaladora da 
Administraçao Regional de Saude) within eight days of receiving notice of the decision,
or

if a claim of cash beneﬁ ts has been rejected on administrative grounds, lodge an appeal with the locally competent Administrative Tribunal 
(Tribunal Administrative de Circulo) within two months of receiving notice of the decision. If you have been residing outside of Portugal, 

— 

— 

4

 
 
E 118 Annex

21.  Slovenia
If you do not agree with the decision, you may ﬁ le a suit with the Labour and Social Court in Ljubljana, Komenskega 7, within 30 days of having 
been served with the decision.

22.  Slovakia
If you do not agree with the information stated and unless there was no decision issued in the case so far, you may ask the competent branch of 
the Social Insurance Agency to issue such a decision. You may appeal to the headquarters of the Social Insurance Agency within 15 days after the 
delivery of the decision issued by the local branch. The decision of the Social Insurance Agency HQ in the matter of beneﬁ ts is ﬁ nal; nevertheless 
within two months after its delivery you may ﬁ le an appeal against it at the competent regional court.

In matters other than beneﬁ ts you may ﬁ le for correction remedies against the decision of the Social Insurance Agency HQ within 30 days after 
its delivery at the competent regional court. The address of the Social Insurance Agency HQ is: Sociálna poist’ovňa, ústredie, ul. 29. augusta č. 
8–10, 813 63 Bratislava 1.

23.  Finland
If you wish to contest the decision attached, you may submit an appeal within 30 days of the date on which you received notiﬁ cation of the attached 
decision to either the Finnish insurance institution indicated in box 2 or 4 of the E 118 form, or the insurance institution nearest to your place of 
residence, which is also indicated in one of the abovementioned boxes.

24.  Sweden
You may within a period of two months from the actual taking part of the decision lodge an appeal to the competent Swedish institution indicated 
in boxes 2 or 4 of the E 118 form. In your appeal you should state why you consider that the decision is unjustiﬁ ed.

25.  United Kingdom
If you do not agree with the decision attached, you may, within 28 days of the date of receipt of the decision, lodge an appeal  with  the Pension 
Service, International pension Centre, Tyneview Park Newcastle-upon-Tyne, or the Northern Ireland Social Security Agency, Overseas Branch, 
Belfast, as appropriate.

Iceland

26. 
If you wish to contest the decision attached, you may lodge an appeal with the State Social Security Board, Reykjavik.

27.  Liechtenstein

(a)  Concerning sickness insurance: if you do not agree with a decision of a sickness insurance fund, you might ask for a formal decree that 

must contain the reasons and the information concerning the course of law.
Within 60 days after having received this formal decree the persons concerned can ﬁ le a legal suit with the respective court.

(b)  Concerning accident insurance: if you do not agree with a decree of an accident insurer, you can within two months after having received 

this decree ask the respective accident insurer to reconsider its decree.
If you do not agree with a decree of an accident insurer, you can also, within two months after having received this decree ﬁ le a legal 
suit  with  the  respective  court. This  also  applies  to  the  decision  of  the  accident  insurers  concerning  the  abovementioned  application  for 
reconsideration.

28.  Norway
An appeal against a Norwegian decision must be sent to the institution indicated in box 2 or 4 in form E 118 within six weeks after receiving notice 
of the decision.

29.  Switzerland
If you do not agree with the decision attached, you may lodge an objection with the institution within 30 days of the date of receipt of the decision. 
The decision on the objection will specify the remedy and the period for lodging an appeal.

5

 
 
ADMINISTRATIVE COMMISSION 
ON SOCIAL SECURITY FOR 
MIGRANT WORKERS

E 120

(1)

CERTIFICATE OF ENTITLEMENT TO BENEFITS IN KIND FOR PENSION CLAIMANTS

 AND MEMBERS OF THEIR FAMILY

Regulation (EEC) No 1408/71: Article 26(1)

Regulation (EEC) No  574/72: Article 28

The competent institution should complete part A of the form and issue two copies to the person concerned, who should submit them to the 
institution in his place of residence. On receipt of the two copies, the institution in the place of residence should complete part B and send one 
of the copies to the institution mentioned in section 6. Where appropriate, both copies should ﬁ rst be sent to the institution that has to complete 
sections 5 and 6.

Please complete this form in block letters, writing on the dotted lines only. The form consists of three pages.

A.   Notiﬁ cation of entitlement

1.

Institution of the place of residence (2) 

1.1

1.2

1.3

Name: .........................................................................................................................................................................................................

Identiﬁ cation number of the institution: .......................................................................................................................................................

Address: ...................................................................................................................................................................................................... 

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

1.4

Reference: your E 107 form of  ...................................................................................................................................................................

2.

Pension claimant

2.1

Surname(s) (3): 

Surname(s) at birth (if different):

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

2.2

Forename(s): 

Date of birth:

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

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

2.3

Address in the country of residence: ..........................................................................................................................................................

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

2.4

Personal identiﬁ cation number:

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

3.

To be completed by the institution to which the claim for a pension has been submitted 

3.1

The claimant indicated above submitted on ............................................................................................................................................... 

a claim for a pension for

□ old age
□ accident at work
□ The investigation of this claim has shown that the person concerned is entitled to receive a pension from us.

 □ invalidity
 □ occupational disease

 □ survivor

3.2

4.

Institution which completed section 3

4.1

4.2

4.3

Name: .........................................................................................................................................................................................................

Identiﬁ cation number of the institution: .......................................................................................................................................................

Address: ......................................................................................................................................................................................................

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

4.4

Stamp

4.5

4.6

Date: ...............................................................................

Signature:

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

1
1

E 120

5.

To be completed by the institution to which the claim for a pension was submitted or by the sickness and maternity insurance institution 
in the country in which this claim was submitted

5.1

Identiﬁ cation number of the investigating institution: ..................................................................................................................................

The claimant indicated in section 2 and the members of his family are entitled to sickness and maternity insurance beneﬁ ts in kind

5.2
5.3 □ from  ........................................................................................................................    until this certiﬁ cate is cancelled
5.4 □ for one year starting on .............................................................................................................................................................  (date)

6.

6.1

6.2

6.3

Institution which completed section 5

Name:..........................................................................................................................................................................................................

Identiﬁ cation number of the institution:........................................................................................................................................................

Address: ......................................................................................................................................................................................................

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

6.4

Stamp 

B.  Notiﬁ cation of registration or non-registration

7.

 □ (4)

6.5 

6.6 

Date:  .................................................................................

Signature:

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

7.1

The person indicated in section 2 and the members of his family could not be registered because

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

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

8. □ (4)

8.1

The person indicated in section 2 and the members of his family were registered on 

..........................................................................................................................................................................................................(date)

9.

Registered family members 

9.1

Surname(s) (3)

Forename(s)

Sex

9.2

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

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

9.3

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

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

9.4

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

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

9.5

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

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

9.6

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

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

9.7

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

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

9.8

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

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

F M
......................................... □ □
.........................................
......................................... □ □
.........................................
......................................... □ □
.........................................
......................................... □ □
.........................................
......................................... □ □
.........................................
......................................... □ □
.........................................
......................................... □ □
.........................................

10.

Institution in the place of residence

Date of birth

Personal identiﬁ cation 
number

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

10.1 Name:..........................................................................................................................................................................................................

10.2

10.3

Identiﬁ cation number of the institution:........................................................................................................................................................

Address: ......................................................................................................................................................................................................

…………………………………………………………………………………………………………………………………………………………....

10.4

Stamp

2
2

10.5

10.6

Date:...............................................................................

Signature:
......................................................................................

 
 
E 120

Information for the insured person

(a)  This certiﬁ cate gives you and the members of your family the right to receive beneﬁ ts in kind in the case of sickness or maternity in the 

country of residence.

(b)  You should, as soon as possible, submit the two copies of this certiﬁ cate in your possession to one of the following insurance institutions:

in Belgium, the ‘mutualité’ (local sickness insurance fund) of your choice;

in the Czech Republic, the ‘Zdravotní pojišťovna’ (sickness insurance fund) of the place of residence;

in Cyprus, ‘ Υπουργείο Υγείας’ (Ministry of Health, 1448 Lefkosia).  Upon application, the person concerned will be provided with a Cyprus 
Medical Card, without which no beneﬁ ts in kind can be provided at the Government Medical Institutions;

in Denmark, the  municipal authority of the place of residence; 

in Germany, the ‘Krankenkasse’  (sickness insurance fund) of the place of residence;

in Greece, normally the regional or local branch of the Social Insurance Institute (IKA), which will issue the person concerned with a ‘health 
book’ without which no beneﬁ ts in kind can be provided;

in  Spain,  the  ‘Dirección  Provincial  del  Instituto  Nacional  de  la  Seguridad  Social’  (Provincial  Directorate  of  the  National  Social  Security 
Institution) at the place of residence or stay. If you require beneﬁ ts you may apply to the medical or hospital services of the Spanish social 
security health system. You must submit the form together with a photocopy; 

in Estonia, the ‘Eesti Haigekassa’ (Health Insurance Fund);

in France, the ‘Caisse primaire d’assurance-maladie’ (local sickness insurance fund);

in Ireland, the Health Board in whose area the beneﬁ t is claimed;

in Italy, the ‘Unità sanitaria locale’ (local health administration unit) responsible for the area concerned;

in Latvia, the ‘ Veselības obligātās apdrošināšanas valsts aģentūra’ (Health Compulsory Insurance State Agency);

in Lithuania, the ‘Teritoriné ligoniu kasa’ (Territorial Patient Fund); medical service assistance is available without contacting the institution ﬁ rst;

in Luxembourg, the ‘Caisse de maladie des ouvriers’ (sickness fund for manual workers);

in Hungary, the competent ‘Megyei Egészségbiztosítási Pénztár’ (regional sickness insurance fund);

in Malta, the Ministry of Health, Valetta;

in the Netherlands, any sickness fund competent for the place of residence;

in Austria, the ‘Gebietskrankenkasse’ (regional sickness insurance fund) competent for the place of residence;

in Poland, the regional branch of the ‘Narodowy Fundusz Zdrowia’ (National Health Fund), competent for the place of residence;

in  Portugal,  for  metropolitan  Portugal:  the  ‘Centro  Distrital  de  Solidariedade  e  Segurança  Social’  (Regional  Centre  for  Solidarity  and 
Social Security) of the  place of residence; for Madera: the ‘Centro de Segurança Social da Madeira’ (Madeira Social Security Centre), 
Funchal; for the Azores: the ‘Centro de Prestações Pecuniárias’ (Centre for Cash Beneﬁ ts) of the place of residence;

in Slovenia, the competent regional service of the ‘Zavod za zdravstveno zavarovanje Slovenije (ZZZS)’ (Slovenian Sickness Insurance 
Institution) at the place of residence;

in Slovakia, the ‘zdravotná poist ovňa’ (health insurance company) of the insured person’s choice;

in Finland, the local ofﬁ ce of the ‘Kansaneläkelaitos’ (Social Insurance Institution);

in Sweden, the ‘försäkringskassan’ (Social Insurance Ofﬁ ce) at the place of residence. Medical service assistance (hospital, doctor, dentist, 
etc.) may be requested without contacting the institution ﬁ rst;

in Iceland, the ‘Tryggingastofnun rikisins’ (The State Social Security Institute), Reykjavik;

in Liechtenstein,  the ‘Amt für Volkswirtschaft’ (Ofﬁ ce of National Economy), Vaduz;

in Norway, the ‘lokale trygdekontor’ (local Insurance ofﬁ ce) at the place of residence;

in Switzerland, the ‘Institution commune LAMal — Instituzione commune LAMal — Gemeinsame Einrichtung KVG’ (Joint institution under 
the Federal Sickness Insurance Act), Solothurn.

(c)  You must inform the insurance institution to which you submit the form of any change in circumstances which might affect the right to beneﬁ ts 
in kind, such as the granting of the pension claimed or a change in the place of residence or stay of yourself or a member of your family.

NOTES

(1)  Symbol  of 

the 

the  country  of 

form:  BE  =  Belgium;  CZ  =  Czech  Republic;  DK  =  Denmark;
DE  =  Germany;  EE  =  Estonia;  GR  =  Greece;  ES  =  Spain;  FR  =  France;  IE  =  Ireland;  IT  =  Italy;  CY  =  Cyprus;  LV  =  Latvia; 
LT  =  Lithuania;  LU  =  Luxembourg;  HU  =  Hungary;  MT  =  Malta;  NL  =  Netherlands;  AT  =  Austria;  PL  =  Poland;  PT  =  Portugal;
SI  =  Slovenia;  SK  =  Slovakia;  FI  =  Finland;  SE  =  Sweden;  UK  =  United  Kingdom;  IS  =  Iceland;  LI  =  Liechtenstein;  NO  =  Norway;
CH = Switzerland.

institution  completing 

the 

(2)  Complete only if the form is issued at the request of the institution in the place of residence. If the pension claimant is resident in the United 
Kingdom, both copies of the form should be sent directly to the Department for Work and Pensions, Pension Service, International Pension 
Centre, Tyneview Park, Newcastle upon Tyne.

(3)  Give the full surname in the order of civil status.

(4)  Complete section 7 or 8, as appropriate, and put a cross in the corresponding box.

3

ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY FOR
MIGRANT WORKERS

E 121

(1)

CERTIFICATE FOR THE REGISTRATION OF PENSIONERS AND MEMBERS OF THEIR FAMILY 
AND THE UPDATING OF LISTS

Regulation (EEC) No 1408/71: Article 28(1)(a) and Article 29(1)(a)
Regulation (EEC) No  574/72: Article 29(1), (2) and (3); Article 30(1) and Article 95(4)

The institution which has to draw up the certiﬁ cate in accordance with Article 29(2) or Article 30(1) of Regulation (EEC) No 574/72 should 
complete part A of the form and issue two copies to the pensioner or family member or send them to the institution in the place of residence if 
the form was requested by that institution. Where appropriate, both copies should ﬁ rst be sent to the institution which has to complete sections 
6 and 7. On receipt of the two copies, the institution in the place of residence should complete part B and send one copy per pensioner or family 
member to the institution indicated in section 7.

Please complete the form in block letters, writing on the dotted lines only. The form consists of four pages.

A.  Notiﬁ cation of entitlement

1.

1.1

1.2

1.3

Institution of the place of residence (2) 

Name: .........................................................................................................................................................................................................

Identiﬁ cation number of the institution: .......................................................................................................................................................

Address:  .....................................................................................................................................................................................................

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

1.4

Reference: your E 107 form of  ...................................................................................................................................................................

2.

Pensioner

2.1

Surname(s) (3):

Surname(s) at birth (if different):

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

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

2.2

Forename(s):

Date of birth:

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

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

2.3

Address in the country of residence: ..........................................................................................................................................................

2.4

2.5

2.6

3.

3.1

3.2

4.

4.1

4.2

4.3

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

Date of transfer of residence: .....................................................................................................................................................................

Personal identiﬁ cation number: .................................................................................................................................................................

The pensioner used to be 
□ an employed person
□ a self-employed person
□ a frontier worker (employed)
□ a frontier worker (self employed)
□ an unemployed worker

To be completed by the institution responsible for payment of the pension

The person indicated above has been entitled to a pension for
□ old age
□ accident at work
since: .........................................................................................................................................................................................................

□ invalidity
□ occupational disease

□ survivor

Institution which completed section 3 (4)

Name: ........................................................................................................................................................................................................

Identiﬁ cation number of the institution: ......................................................................................................................................................

Address:  .....................................................................................................................................................................................................

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

4.4

Stamp

4.5

4.6

Date: ..............................................................................

Signature:

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

1
1

E 121

5.

5.1

Member of the pensioner’s family

Surname(s) (3): 

                                                  Surname(s) at birth (if different) (3):

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

5.2

Forename(s):

Date of birth:

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

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

5.3

Address in the country of residence:  ..........................................................................................................................................................

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

5.4

5.5

Personal identiﬁ cation number:  ..................................................................................................................................................................

Date of transfer of residence:  .....................................................................................................................................................................

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

6.

To be completed by the institution responsible for payment of the pension or by the sickness and maternity insurance institution in the 
country responsible for payment of the pension (5)

Identiﬁ cation number of the investigating institution: ..................................................................................................................................

6.1
6.2 □ The person indicated in section 2
□ The person indicated in section 5 
is entitled to sickness and maternity insurance beneﬁ ts in kind as from  ....................................................................................................
The cost of the beneﬁ ts to be provided in the country of residence — unless the person resides in the competent country — will be 
borne by us.

6.3
6.4 □ from  ...........................................................................................   until the certiﬁ cate is cancelled
6.5 □ for one year from  ..........................................................................  (6)
6.6 □ this certiﬁ cate invalidates the E  .................................................   form dated  ....................................................................................

7. □ Please return the European Health Insurance card of the  in section 2 or 5  mentioned  person with number 

................................................................................................. and valid until  .........................................................................................

8.

8.1

8.2

8.3

Institution which completed section 6 (4)

Name: .........................................................................................................................................................................................................

Identiﬁ cation number of the institution: .......................................................................................................................................................

Address:  .....................................................................................................................................................................................................

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

8.4

Stamp

8.5

8.6

Date: ..............................................................................

Signature:
.......................................................................................

B.  Notiﬁ cation of registration or non-registration

9. □ (7)
9.1 □ The person indicated in section 2
□ The person indicated in section 5

could not be registered

9.2 □ because he or she is already entitled to beneﬁ ts in kind under the legislation of our country 
9.3 □ other reasons:  ......................................................................................................................................................................................
      ...............................................................................................................................................................................................................

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

2
2

 
E 121

10. □ (7)
10.1 □ The person indicated in section 2
□ The person indicated in section 5

has been registered

10.2 □  The cost of these beneﬁ ts are to be borne by you; the date from which the lump sum provided for in Article 95 of Regulation (EEC) 
No 574/72 should be calculated is  .......................................................................................................................................................

European Health Insurance Card

11.
11.1 □ Please ﬁ nd attached the European Health Insurance Card with number  ............. as requested  in section 7
11.2 □   Please  indicate  the  measures  to  be  applied  concerning  the  European  Health  Insurance  card  issued  to  the  in  section  2  or  5 
mentioned person with number .......................................................................  and valid until  ...........................................................

12.

12.1
12.2

12.3

Institution in the place of residence of the pensioner or family member

Name: .........................................................................................................................................................................................................
Identiﬁ cation number of the institution: .......................................................................................................................................................

Address:  .....................................................................................................................................................................................................

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

12.4

Stamp

12.5

12.6

Date: ..............................................................................

Signature:

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

Information for the pensioner or family member

You should send the two copies of this form to the following insurance institution as soon as possible: 

in Belgium, the ‘mutualité’ (local sickness insurance fund) of your choice;
in the Czech Republic, the ‘Zdravotní pojišťovna’ (sickness insurance fund) of the place of residence;
in Cyprus,‘Υπουργείο Υγείας’ (Ministry of Health, 1448 Lefkosia).  Upon application, the person concerned will be provided with a Cyprus Medical 
Card, without which no beneﬁ ts in kind can be provided at the Government Medical Institutions; 

in Denmark, the  municipal authority of the place of residence; 
in Germany, the ‘Krankenkasse’  (sickness insurance fund) of the place of residence;
in Greece, normally the regional or local branch of the Social Insurance Institute (IKA), which will issue the person concerned with a ‘health book” 
without which no beneﬁ ts in kind can be provided;

in Spain, the ‘Dirección Provincial del Instituto Nacional de la Seguridad Social’ (Provincial Directorate of the National Social Security Institution) 
at the place of residence;

in Estonia, the ‘Eesti Haigekassa’, (Health Insurance Fund);
in France, the ‘Caisse primaire d’assurance-maladie’ (local sickness insurance fund);
in Ireland, the Health Board in whose area the beneﬁ t is claimed;
in Italy, the ‘Unità sanitaria locale’ (local health administration unit) responsible for the area concerned;
in Latvia, the ‘Veselības obligātās apdrošināšanas valsts aģentūra’ (Health Compulsory Insurance State Agency);
in Lithuania, the ‘Teritoriné ligoniu kasa’ (Territorial Patient Fund);
in Luxembourg, the ‘Caisse de maladie des ouvriers’ (sickness fund for manual workers);
in Hungary, the competent ‘Megyei Egészségbiztosítási Pénztár’ (regional sickness insurance fund);
in Malta, the Entitlement Unit, Ministry of Health, 23. St. John Street, Valetta;
in the Netherlands, any sickness fund competent for the place of residence;
in Austria, the ‘Gebietskrankenkasse’ (regional sickness insurance fund) competent for the place of residence;
in Poland, the regional branch of the ‘Narodowy Fundusz Zdrowia’ (National Health Fund) competent for the place of residence;
in Portugal, for metropolitan Portugal: the ‘Centro Distrital de Solidariedade e Segurança Social’ (Regional Centre for Solidarity and Social 
Security) of the  place of residence; for Madera: the ‘Centro de Segurança Social da Madeira’ (Madeira Social Security Centre), Funchal; for the 
Azores: the ‘Centro de Prestações Pecuniárias’ ( Centre for Cash Beneﬁ ts) of the place of residence;
in Slovenia, the competent regional service of the ‘Zavod za zdravstveno zavarovanje Slovenije (ZZZS)’ (Slovenian Sickness Insurance Institution) 
at the place of residence;

in Slovakia, the ‘zdravotná poist’ovňa’ (health insurance company) of the insured person’s choice;
in Finland, the local ofﬁ ce of the ‘Kansaneläkelaitos’ (Social Insurance Institution);
in Sweden, the ‘försäkringskassan’ (Social Insurance Ofﬁ ce) at the place of residence;

3

 
in Iceland, the ‘Tryggingastofnun rikisins’ (The State Social Security Institute), Reykjavik;
in Liechtenstein,  the ‘Amt für Volkswirtschaft’ (Ofﬁ ce of National Economy), Vaduz;
in Norway, the ‘lokale trygdekontor’ (local Insurance ofﬁ ce) at the place of residence;
in Switzerland, the ‘Institution commune LAMal — Instituzione commune LAMal — Gemeinsame Einrichtung KVG’ (Joint institution under the 
Federal Sickness Insurance Act), Solothurn.

E 121

NOTES

Symbol  of  the  country  of  the  institution  completing  the  form:  BE  =  Belgium;  CZ  =  Czech  Republic;  DK  =  Denmark;
DE  =  Germany;  EE  =  Estonia;  GR  =  Greece;  ES  =  Spain;  FR  =  France;  IE  =  Ireland;  IT  =  Italy;  CY  =  Cyprus;  LV  =  Latvia; 
LT  =  Lithuania;  LU  =  Luxembourg;  HU  =  Hungary;  MT  =  Malta;  NL  =  Netherlands;  AT  =  Austria;  PL  =  Poland;  PT  =  Portugal;
SI  =  Slovenia;  SK  =  Slovakia;  FI  =  Finland;  SE  =  Sweden;  UK  =  United  Kingdom;  IS  =  Iceland;  LI  =  Liechtenstein;  NO  =  Norway;
CH = Switzerland.

Complete only if the form is issued at the request of the institution in the place of residence. If the pensioner or family member is resident 
in  the  United  Kingdom,  both  copies  of  the  form  should  be  sent  directly  to  the  Department  for  Work  and  Pensions,  Pension  Service, 
International Pension Centre, Tyneview Park, Newcastle upon Tyne.

Give the full surname in the order of civil status.

In Hungary, this section must be ﬁ lled in by the sickness and maternity insurance institution.

In Italy, sections 6 and 7 should be completed by the ASL or Ministry of Health.

If the form is issued by a German, French, Hungarian, Italian or Portuguese institution and concerns a family member.

Complete section 8 or 9 as appropriate, and put a cross in the corresponding box.

(1) 

(2) 

(3) 

(4) 

(5) 

(6) 

(7) 

4

ADMINISTRATIVE COMMISSION 
ON SOCIAL SECURITY FOR
MIGRANT WORKERS

E 123

(1)

CERTIFICATE OF ENTITLEMENT TO BENEFITS IN KIND UNDER INSURANCE AGAINST 
ACCIDENTS AT WORK AND OCCUPATIONAL DISEASES

Regulation (EEC) No 1408/71: Article 52(a); Article 55(1)(a)(i); (b)(i) and (c)(i)
Regulation (EEC) No 574/72: Article 60(1); Article 62(4) and (6); Article 63(1) and (3)

If the form has been requested by the institution in the place of residence or stay of the person concerned by means of form E 107, it should 
be sent to that institution; otherwise, it should be issued to the insured person. 

Please complete this form in block letters, writing on the dotted lines only. The form consists of three pages.

1.

Institution of the place of residence or stay (2) 

1.1

1.2

1.3

Name: .........................................................................................................................................................................................................

Identiﬁ cation number of the institution: .......................................................................................................................................................

Address:  .....................................................................................................................................................................................................

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

1.4

Reference: your E 107 form of  ...................................................................................................................................................................

2.

Insured person

2.1

2.2

2.3

Surname(s) (3):  ...........................................................................................................................................................................................

Surname(s) at birth (if different):  ................................................................................................................................................................

Forename(s):

Date of birth:

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

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

2.4

Personal identiﬁ cation number: ..................................................................................................................................................................

2.5

The insured person is 

□ an employed person
□ a self-employed person
□ a frontier worker (employed)
□ a frontier worker (self employed)
□ an unemployed worker

3.

3.1

3.2

On the grounds of 
 □ the information supplied in your E 107 form of  ..................................................................................................................................
 □ the accident at work which occurred on  .............................................................................................................................................

and has had the following consequences:

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

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

............................................................................................................................................................................................................
 □ the occupational disease diagnosed on   ............................................................................................................................................

3.3

which has had the following consequences:

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

3.4 □ the authorisation which we have granted to the person concerned to retain the right to beneﬁ ts  

in kind in   …….…………………………………………………………….   (country) where he is going
□ to receive medical treatment

□ to take up residence

1
1

 
 
  
  
   
 
  
 
E 123

4.

The abovementioned person may receive beneﬁ ts in kind
□ for an accident at work

□ for an occupational disease

4.1 □ for the period laid down in the provisions of the legislation of the country of residence 
4.2 □ since  .....................................................................................  □ until ...........................................................................................
4.3 □ for a maximum of three months
4.4 □ for an unlimited period

5.
The report of our examining doctor
5.1 □ is attached in a sealed envelope
5.2 □ was sent on  ...................................................................  to (4) .............................................................................................................
............................................................................................................................................................................................................

5.3 □ may be obtained from us on request
5.4 □ has not been drawn up

6.

Competent institution

6.1

Name: ........................................................................................................................................................................................................

6.2

Identiﬁ cation number of the institution: ......................................................................................................................................................

6.3

Address:  .....................................................................................................................................................................................................

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

6.4

Stamp

6.5

6.6

Date: ..................................................................................

Signature:

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

Information for the insured person

You should submit this certiﬁ cate as soon as possible to the insurance institution of the country to which you have gone, i.e.:

in Belgium, 

(a)   in case of a beneﬁ t in kind provided due to a sickness or an accident in private life: the ‘mutualité’ (local sickness insurance fund) of your 

choice;

(b)   in case of a beneﬁ t in kind provided due to an occupational disease: ‘le Fonds des maladies professionnelles’ in 1210 Brussels;

in the Czech Republic, the competent ‘Zdravotní pojišťovna’ (sickness insurance fund);

in Cyprus, ‘Υπουργείο Υγείας’ (Ministry of Health, 1448 Lefkosia).  Upon application, the person concerned will be provided with a Cyprus 
Medical Card without which no beneﬁ ts in kind can be provided at the Government Medical Institutions; 

in Denmark, assistance from a doctor or dentist may be obtained by contacting a public health service general practitioner or dentist. Persons 
needing emergency hospital treatment may go directly to a public hospital;

in Germany, the accident insurance institution responsible for the place of residence or stay;

in Greece, normally the regional or local branch of the Social Insurance Institute (IKA), which will issue the person concerned with a ‘health 
book’ without which no beneﬁ ts in kind can be provided;

in Spain, the medical or hospital services in the health system covered by social insurance. You must submit the form together with a 
photocopy;

in Estonia, the ‘Eesti Haigekassa’, (Health Insurance Fund );

in France, the ‘Caisse primaire d’assurance-maladie’ (local sickness insurance fund);

in Ireland, the Health Board in whose area the beneﬁ t is claimed;

in Italy,

(a)   for beneﬁ ts in kind, the ‘ASL’ (local health administration unit) responsible for the area concerned; for mariners and civilian aircrews, the 

Ministry of Public Health (Navy or Civil Aviation Health Ofﬁ ce) responsible for the area concerned;

(b)   for prostheses, major appliances, legal-medical beneﬁ ts and medical examinations  or certiﬁ cates, the provincial ofﬁ ce of the ‘Istituto 

nazionale per l’assicurazione contro gli infortuni’ (National Institute for Insurance against Accidents at Work - INAIL);

2
2

 
E 123

in Latvia, the ‘Veselības obligātās apdrošināšanas valsts aģentūra’ (Health Compulsory Insurance State Agency);

in Lithuania, the ‘Teritoriné ligoniu kasa’ (Territorial Patient Fund). Medical service assistance may be obtained without contacting the  institution 
ﬁ rst;

in Luxembourg, the ‘Association d’assurance contre les accidents’ (Accident Insurance Association);

in Hungary, the competent ‘Megyei Egészségbiztosítási Pénztár’ (regional sickness insurance fund);

in Malta, 

in the Netherlands, any sickness fund competent for the place of residence; or, in the case of a temporary stay, the ‘Agis zorgverzekeringen’ 
(General Mutual Sickness Insurance Association), Utrecht. Assistance from a doctor, dentist or pharmacist can be obtained without contacting 
the Agis zorgverzekeringen ﬁ rst;

in Austria, the ‘Gebietskrankenkasse’ (regional sickness insurance fund) competent for the place of residence or stay, or the ‘Allgemeine Unfallv
ersicherungsanstal’ (General Accident Insurance Institution), Vienna;

in Poland, the regional branch  of the ‘Narodowy Fundusz Zdrowia’ (National Health Fund) competent for the place of stay;

in Portugal, the ‘Centro Nacional de Protecção contra os Riscos Proﬁ ssionais’ (National Centre for Protection against Occupational Risks), 
Lisbon;

in Slovenia, the competent regional service of the ‘Zavod za zdravstveno zavarovanje Slovenije (ZZZS)’ (Slovenian Sickness Insurance 
Institution) at the place of residence or stay;

in Slovakia, the ‘zdravotná poist’ovňa’ (health insurance company) of the insured person’s choice;

in Finland, the ‘Tapaturmavakuustuslaitosten Liitto’ (Federation of Accident Insurance Institutions);

in Sweden, the ‘försäkringskassan’ (Social Insurance Ofﬁ ce). Medical service assistance (hospital, doctor, dentist, etc.) may be requested 
without contacting the institution ﬁ rst;

in the United Kingdom, the medical service (doctor, dentist, hospital, etc.) providing treatment;

in Iceland, the ‘Tryggingastofnun rikisins’ (The State Social Security Institute), Reykjavik;

in Liechtenstein,  the ‘Amt für Volkswirtschaft’ (Ofﬁ ce of National Economy);

in Norway, the ‘lokale trygdekontor’ (local Insurance ofﬁ ce). Assistance may be requested without contacting the institution ﬁ rst;

in Switzerland, the ‘Caisse nationale Suisse d’assurance en cas d’accidents — Schweizerische Unfallversicherungsanstalt — Cassa nazionale 
svizzera di assicurazione in caso di infortunio’ (Swiss National Accident Insurance Fund), Lucerne. Medical service assistance (hospital, doctor, 
pharmacist) may be obtained without contacting the institution ﬁ rst.

NOTES

(1)  Symbol  of 

the 

the  country  of 

form:  BE  =  Belgium;  CZ  =  Czech  Republic;  DK  =  Denmark;
DE  =  Germany;  EE  =  Estonia;  GR  =  Greece;  ES  =  Spain;  FR  =  France;  IE  =  Ireland;  IT  =  Italy;  CY  =  Cyprus;  LV  =  Latvia; 
LT  =  Lithuania;  LU  =  Luxembourg;  HU  =  Hungary;  MT  =  Malta;  NL  =  Netherlands;  AT  =  Austria;  PL  =  Poland;  PT  =  Portugal;
SI  =  Slovenia;  SK  =  Slovakia;  FI  =  Finland;  SE  =  Sweden;  UK  =  United  Kingdom;  IS  =  Iceland;  LI  =  Liechtenstein;  NO  =  Norway;
CH = Switzerland.

institution  completing 

the 

(2)  Complete only if the form is issued at the request of the institution in the insured person’s place of residence or stay. If the insured person 
is going to the United Kingdom, one copy of the form should also be sent to the Department for Work and Pensions, Pension Service, 
International Pension Centre, Tyneview Park, Newcastle upon Tyne.

(3)   Give the full surname in the order of civil status.

(4)  Name and address of the institution to which the medical report has been sent.

3

ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY
FOR MIGRANT WORKERS

E 124

(1)

CLAIM FOR DEATH GRANT

Regulation (EEC) No 1408/71: Article 65
Regulation (EEC) No 574/72: Article 78

Please complete the form in block letters, writing on the dotted lines only. The form consists of three pages.

1.

1.1

1.2

I, the undersigned:

Surname(s) (2):
.......................................................................................................  

Surname(s) at birth (if different):
........................................................................................................

Forename(s):
.......................................................................................................  

Date of birth:
........................................................................................................

1.3

Personal identiﬁ cation number:  

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

1.4

Institution with which I am insured (3) (4):   
.....................................................................................................................................................................................................................

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

1.5

Family relationship with the deceased: 

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

1.6

Address:  ......................................................................................................................................................................................................

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

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

2. 

hereby claim a grant by reason of the death of the following person (5):

3.

3.1

3.2

3.3
3.4

3.5

3.6

4. 

5. 

6. 

Surname(s): 
....................................................................................................................................................................................................................
Forename(s):
......................................................................................................

Date of birth:
.......................................................................................................

Surname(s) at birth (if different):

Personal identiﬁ cation number: ..................................................................................................................................................................

Date of death: ..............................................................................................................................................................................................
Cause of death: 
□ illness
□ occupational disease
Institution with which the deceased was insured (3) (4):  ...............................................................................................................................

□ accident
□ action by a third party

□ accident at work
□ other cause

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

The claimant 

The deceased  

□ was 
□ was 
□ was 

□ was not  
□ was not  
□ was not  

dependent on the deceased

dependent on me

The deceased  
□ by the claimant
□ in an establishment of which the claimant is the manager, a member of the staff or a resident (6)

accommodated in return for payment

7. 

The claimant 

The claimant 

□ is 
□ is 

□ is not 
□ is not 

 a funeral undertaker or an agent or representative of an 
undertaker (6) (7)
 a legal person under private law who, on the basis of an  
insurance contract, has covered some or all of the costs (6)

8. 

9. 

The cost of the funeral amounts to (8)  ........................................................... ; it has been paid by ............................................................

The following documents are attached: ......................................................................................................................................................

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

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

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

1
1

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
E 124

10.

Please pay the sum due to my account No IBAN ......................................................................................................................................

with the  .......................................................................................... (BIC/SWIFT code) .............................................................................  

in.............................................................................................................................................................................................................  (9)

11.

11.1

Date: ....................................................................................

Signature:
.............................................................................................

Instructions for the claimant

(a) 

In order to receive a death grant you must submit a claim, using this form
–  either to the competent insurance institution,
–  or to the insurance institution in the place where you live, i.e.:
in Belgium, a ‘mutualité’ (local sickness insurance fund);
in the Czech Republic, the ‘Úřad práce’ (employment ofﬁ ce) in the place of residence or stay;
in Denmark, the Ministry of the Interior and Health, Copenhagen;
in Greece, the local branch of the Social Insurance Institute (IKA);
in  Spain,  the  ‘Dirección  Provincial  del  Instituto  Nacional  de  la  Seguridad  Social’  (Provincial  Directorate  of  the  National  Social  Security 
Institution) at the place of residence;
in France, the body which provides or would provide beneﬁ ts in kind under sickness insurance;
in Ireland, the Department of Social Welfare, Dublin;
in Italy, the provincial ofﬁ ce of the INAIL;
in Latvia, the ‘Valsts sociālās apdrošināšanas aģentūra’ (State Social Insurance Agency);
in Lithuania, the ‘Savivaldybés socialinés paramos skyrius’ (Municipal Social Assistance department) at the place of residence or stay;
in Luxembourg, the ‘Union des caisses de maladie’ (Union of Sickness Insurance Funds);
in Austria, the ‘Gebietskrankenkasse’ (Regional Sickness Insurance Fund) competent for the place of residence;
in Poland, the ‘Zaklad Ubezpieczin Spolecznych’ (Social Insurance Institution — ZUS), ofﬁ ce responsible for the place of residence or stay 
or, for agricultural workers, the competent regional branch of the ‘Kasa Rolniczego Ubezpieczenia Spolecznego’ (Social Insurance Fund for 
Agriculture —KRUS), the ‘Zaklad Emerytalno-Rentowy Ministerstwa Spraw Wewnetrznych i Administacji’ (Pensions Ofﬁ ce of the Ministry of 
Internal Affairs and Administration — liaison body for special schemes);
in Portugal, for metropolitan Portugal: the ‘Centro Distrital de Solidariedade e Segurança Social’ (Regional Centre for Solidarity and Social 
Security) of the  place of residence; for Madera: the ‘Centro de Segurança Social da Madeira’ (Madeira Social Security Centre), Funchal; for 
the Azores: the ‘Centro de Prestações Pecuniárias’ ( Centre for Cash Beneﬁ ts) of the place of residence;
in  Slovenia,  the  competent  regional  service  of  the  ‘Zavod  za  zdravstveno  zavarovanje  Slovenije  (ZZZS)’  (Slovenian  Sickness  Insurance 
Institution) at the place of residence or stay;
in Slovakia, the ‘Úrad práce, sociálnych vecí a rodiny’ (Ofﬁ ce of Labour, Social Affairs and Family) at the place of residence or stay of the 
deceased person;
in Finland, the ‘Kansaneläkelaitos’ (Social Insurance Institution), Helsinki;
in Sweden, the ‘försäkringskassan’ (Social Insurance Ofﬁ ce) at the place of residence or stay;
in Estonia, the ‘Sotsiaalkindlustusamet’ (Social Insurance Board), Tallinn; 
in Iceland, the ‘Tryggingastofnun rikisins’ (The State Social Security Institute), Reykjavik;
in Liechtenstein, the Ofﬁ ce of National Economy;
in Norway, the ‘lokale trygdekontor’ (local insurance ofﬁ ce) at the place of residence or stay;
in Switzerland, the ‘Institution commune LAMal — Instituzione commune LAMal — Gemeinsame Einrichtung KVG’ (Joint Institution under 
the Federal Sickness Insurance Act), Solothurn.

(b)  You must submit the following documents with your claim:

for Belgium, 

for Denmark,  

for Greece,  

for Spain,  

for France, 

2
2

copy of death certiﬁ cate, issued by the municipal administration;
receipted bills for funeral expenses;
all documents proving the family relationship or relationship through marriage with the deceased or, where appropriate, 
cohabitation with the deceased;

death certiﬁ cate;
please  read  carefully  the  ‘vejledning  om  ansøgning  for  begravelseshælp’  (instructions  for  claiming  a  death  grant) 
which you will subsequently receive;

death certiﬁ cate, health book, insurance cards and, where applicable, receipted bills for funeral expenses;

death certiﬁ cate;
certiﬁ cate  attesting  to  the  family  relationship,  or  receipted  bills  for  funeral  expenses  if  the  claimant  has  no  family 
relationship with the deceased;

in every case the death certiﬁ cate for the insured person;
in addition, as appropriate:
—  if you are the insured person’s spouse, the ‘ﬁ che familiale’ (family record from the register ofﬁ ce);
—  if you are a descendant of the deceased (son, daughter, grandson, etc.) 

the ‘ﬁ che familiale’ (family record from the register ofﬁ ce) showing your relationship to the deceased,

—  if you are an ascendant of the deceased (parent, grandparent etc.), the 

deceased person’s ‘ﬁ che individuelle’ (individual record from the register ofﬁ ce),

—  if you were dependent on the deceased in any other way, a declaration on 

your honour that you were totally, effectively and permanently dependent on the deceased;

 
 
 
 
 
 
 
 
E 124

for ‘Ireland, 

for Italy, 

for Latvia, 

death certiﬁ cate;
marriage certiﬁ cate, where applicable;
undertaker’s account or estimate for funeral expenses, or the receipt if you have paid;

death certiﬁ cate;
document of insurance registration;
declaration of family status, where applicable;
death certiﬁ cate;

for Lithuania, 

death certiﬁ cate;

for Luxembourg, 

death certiﬁ cate;
receipted bills for funeral expenses;
where applicable, a declaration from the municipal administration testifying to cohabitation;

for Austria, 

for Poland, 

death certiﬁ cate;
receipted bills for funeral expenses;

 death certiﬁ cate, original bills for funeral expenses, claimant’s declaration certifying that no similar grant has been 
paid;

for Portugal, 

death certiﬁ cate and receipted bills for funeral expenses;

for Slovenia: 

 for funeral allowance: death certiﬁ cate or registration of the insured person’s death, the original copy of an invoice for
funeral services;
for death grant: death certiﬁ cate or registration of the insured person’s death;
in the case of the death of a spouse – marriage certiﬁ cate;
in the case of the death of a parent, the child must submit a birth certiﬁ cate and certiﬁ cate of enrolment in school or 
university (when older than 18 years;
claimants not insured as family members of the deceased person must submit a suitable document certifying that the 
deceased was obliged to support them until his/her death;

for Slovakia, 

for Estonia, 

death certiﬁ cate and receipted bills for funeral expenses;

death certiﬁ cate;
if the claimant is a funeral undertaker, a letter from the entitled person’s solicitor;

for Finland, 

for Sweden, 

for Liechtenstein, 

if  death  occurred  on  Estonian  territory,  a  certiﬁ cate  for  the  purposes  of  the  claim  must  be  attached  to  the  death 
certiﬁ cate;

death certiﬁ cate;
documents proving the relationship with the deceased;
if the claimant is a funeral undertaker, a letter from the entitled person’s solicitor;

death certiﬁ cate;
certiﬁ cate showing the cause of death;

death certiﬁ cate;
certiﬁ cate showing the cause of death;
receipted bills for funeral expenses;

for Norway, 

death certiﬁ cate.

NOTES

(1) 

(2) 

(3) 

(4) 

(5) 

(6) 

(7) 

(8) 

(9) 

Symbol  of  the  country  of  the  institution  completing  the  form:  BE  =  Belgium;  CZ  =  Czech  Republic;  DK  =  Denmark;
DE  =  Germany;  EE  =  Estonia;  GR  =  Greece;  ES  =  Spain;  FR  =  France;  IE  =  Ireland;  IT  =  Italy;  CY  =  Cyprus;  LV  =  Latvia; 
LT  =  Lithuania;  LU  =  Luxembourg;  HU  =  Hungary;  MT  =  Malta;  NL  =  Netherlands;  AT  =  Austria;  PL  =  Poland;  PT  =  Portugal;
SI  =  Slovenia;  SK  =  Slovakia;  FI  =  Finland;  SE  =  Sweden;  UK  =  United  Kingdom;  IS  =  Iceland;  LI  =  Liechtenstein;  NO  =  Norway;
CH = Switzerland.

Give the full surname in the order of civil status.

Only in the case of a worker, pensioner or pension claimant.

Give name and address.

For the Portuguese institutions ﬁ ll in the annexed additional page. 

To be completed where the grant is claimed under Belgian legislation, if the claimant is not the deceased person’s spouse, relative or 
relative through marriage to the third degree.

If the claimant is a funeral undertaker, a letter from the solicitor of the person entitled to the grant must be provided when the grant is 
claimed under Finnish or Estonian legislation.

Give the amount in the currency of the claimant’s country of residence.

Does not apply to Irish institutions.

3

 
 
 
 
 
 
 
 
 
 
 
 
 
ADDITIONAL INFORMATION
FOR THE PURPOSES OF PORTUGUESE INSTITUTIONS

E 124 additional

1.

Spouse

1.1

1.2

Civil status
□ Widow/widower
At the time of death, was the deceased living under the same roof as, and being supported by, the deceased?
□ yes

□ remarried

□ divorced

□ no

2.

Children entitled to family allowances

Surname(s)

Forenames

Relationship

Date of birth

Disabled child

2.1 ………………………………… ………………………… ………………. …………….. ……………………….. ……………………

………………………………… ………………………… ………………. …………….. ……………………….. ……………………

………………………………… ………………………… ………………. …………….. ……………………….. ……………………

………………………………… ………………………… ………………. …………….. ……………………….. ……………………

2.2 ………………………………… ………………………… ………………. …………….. ……………………….. ……………………

………………………………… ………………………… ………………. …………….. ……………………….. ……………………

………………………………… ………………………… ………………. …………….. ……………………….. ……………………

………………………………… ………………………… ………………. …………….. ……………………….. ……………………

2.3 ………………………………… ………………………… ………………. …………….. ……………………….. ……………………

………………………………… ………………………… ………………. …………….. ……………………….. ……………………

………………………………… ………………………… ………………. …………….. ……………………….. ……………………

………………………………… ………………………… ………………. …………….. ………………………. ……………………

2.4 ………………………………… ………………………… ………………. …………….. ………………………. ……………………

………………………………… ………………………… ………………. …………….. ………………………. ……………………

………………………………… ………………………… ………………. …………….. ……………………….. ……………………

………………………………… ………………………… ………………. …………….. ……………………….. ……………………

2.5 ………………………………… ………………………… ………………. …………….. ……………………….. ……………………

………………………………… ………………………… ………………. …………….. ……………………….. ……………………

………………………………… ………………………… ………………. …………….. ……………………….. ……………………

………………………………… ………………………… ………………. …………….. ……………………….. ……………………

2.6 ………………………………… ………………………… ………………. …………….. ……………………….. ……………………

………………………………… ………………………… ………………. …………….. ……………………….. ……………………

………………………………… ………………………… ………………. …………….. ……………………….. ……………………

………………………………… ………………………… ………………. …………….. ……………………….. ……………………

4

ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY FOR
MIGRANT WORKERS

E 125

(1)

INDIVIDUAL RECORD OF ACTUAL EXPENDITURE

Regulation (EEC) No 1408/71: Article 36(1) and (2); Article 63(1); Article 87(1)
Regulation (EEC) No  574/72: Article 93(1), (2), (4) and (5); Article 105(1)

A separate form should be completed for each recipient of the care.

Please complete this form in block letters, writing on the dotted lines only. The form consists of three pages.

1.

2.

2.1

2.2

2.3

3.

3.1

3.2

3.3

Invoice No  ..........................

□ First half year

□ Second half year

of the ﬁ nancial year 20  .........................

Competent institution to which the form is addressed

Name: ......................................................................................................................................................................................................... 

Identiﬁ cation number of the institution: .......................................................................................................................................................

Address:  .....................................................................................................................................................................................................

Recipient of the care

Surname(s) (2): ............................................................................................................................................................................................

Surname(s) at birth (if different):  ................................................................................................................................................................

Forename(s):

Date of birth:

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

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

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

3.4

Personal identiﬁ cation number (3):

(a) allocated by the competent institution

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

(b) allocated by the creditor institution

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

3.5

The insured person is 
□ an employed person
□ a self-employed person
□ a frontier worker (employed)
□ a frontier worker (self employed)
□ an unemployed worker

4.

The person mentioned above has received beneﬁ ts 

on the basis of the following document:

4.1 □ European Health Insurance Card number:  ............................................  

Expiry date:  .........................................................
□ certiﬁ cate provisionally replacing the European Health Insurance Card number:  ...............................................................................
dated:  ..................................................................   Valid from  ......................................... to ..................................................................
□ E.........  

form dated .......................................................... valid from ................................................to  .............................................

4.2

The person mentioned above

underwent the medical examination requested on .....................................................................................................................................

1
1

5.

Expenditure incurred

5.1

For beneﬁ ts in kind provided

in consequence of (5)

5.2

5.3

5.4

5.5

Medical treatment

Dental treatment

Medicaments

Hospitalisation

E 125

Amount (4)  

to ....................................

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

from ................................
□ disease

□ not professional accident
□ professional accident or disease
.....................................................................................

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

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

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

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

from ................................

to ....................................

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

from ................................

to ....................................

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

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

5.6

Other beneﬁ ts (6)

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

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

5.7

Total beneﬁ ts in kind

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

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

5.8

Medical examinations (7)

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

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

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

5.9

For cash beneﬁ ts provided

from ................................

to ....................................

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

5.10

Total expenditure

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

6.

6.1

6.2

6.3

Creditor institution

Name:  ........................................................................................................................................................................................................

Identiﬁ cation number of the institution:  ......................................................................................................................................................

Address: .....................................................................................................................................................................................................

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

6.4

Stamp (8)

6.5

6.6

Date:  ..............................................................................

Signature:

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

7.

Reserved for the institution in the competent country

2
2

NOTES

E 125

(1) 

(2) 

(3) 

the 

the  country  of 

Symbol  of 
form:  BE  =  Belgium;  CZ  =  Czech  Republic;  DK  =  Denmark;
DE  =  Germany;  EE  =  Estonia;  GR  =  Greece;  ES  =  Spain;  FR  =  France;  IE  =  Ireland;  IT  =  Italy;  CY  =  Cyprus;  LV  =  Latvia; 
LT  =  Lithuania;  LU  =  Luxembourg;  HU  =  Hungary;  MT  =  Malta;  NL  =  Netherlands;  AT  =  Austria;  PL  =  Poland;  PT  =  Portugal;
SI  =  Slovenia;  SK  =  Slovakia;  FI  =  Finland;  SE  =  Sweden;  UK  =  United  Kingdom;  IS  =  Iceland;  LI  =  Liechtenstein;  NO  =  Norway;
CH = Switzerland.

institution  completing 

the 

Give the full surname in the order of civil status.

 If the recipient of care is a member of family registered on the basis of E 106, please indicate the personal identiﬁ cation number of the 
insured person.

(4) 

Indicate the amount in national currency.

(5)  When the form is sent to a Swiss Institution.

(6) 

(7) 

(8) 

Indicate the kind of beneﬁ ts: conﬁ nement, dentures, orthopaedic prostheses, spa treatment, ambulance, additional diagnostic means, etc.

Indicate the kind of medical checks and examinations carried out.

An electronically sent and signed form does not need to be stamped.

3

 
 
 
 
ADMINISTRATIVE COMMISSION 
ON SOCIAL SECURITY FOR
 MIGRANT WORKERS

E 126

  (1)

RATES FOR REFUND OF BENEFITS IN KIND

Regulation (EEC) No 1408/71: Article 22(1)(a)(i); Article 22(3); Article 22(a); Article 31(a) and Article 34(a);
Regulation (EEC) No 574/72: Article 34

The competent institution should complete part A of the form and send, either directly or through the liaison body, two copies to the institution which 
would have had to provide the beneﬁ ts to the person concerned in the country of stay. The institution in the place of stay, after completing part B 
of the form, should return one copy to the competent institution.

Please complete this form in block letters, writing on the dotted lines only. It consists of three pages.

A.  Request

1.

Institution to which this form is addressed (2)

1.1 

1.2 

1.3 

Name: ........................................................................................................................................................................................................

Identiﬁ cation number of the institution: ......................................................................................................................................................

Address: .....................................................................................................................................................................................................

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

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

2. □ Entitled person 

2.1 

2.2 

Surname(s) (3): ..........................................................................................................................................................................................

Surname(s) at birth (if different):  ..............................................................................................................................................................

2.3 

Forename(s): 

Date of birth:

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

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

2.4 

Personal identiﬁ cation number:

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

2.5 

3. 

3.1 

3.2 

3.3 

The person is/was:
□  an employed person
□  a self-employed person
□  a frontier worker (employed)
□  a frontier worker (self-employed)
□  an unemployed worker

Family member of the entitled person if he or she received the care:

Surname(s) (3):  ..........................................................................................................................................................................................

Forename(s):  ...............................................................................  

Date of birth: ................................................................................

Personal identiﬁ cation number:
...................................................................................................................................................................................................................

4. 

The above mentioned person

4.1 

4.2 

4.3 

5. 

during a stay in  ............................................................................................................................................................................(country)

at  .................................................................................................................................................................................................... (town)

himself paid for the beneﬁ ts which he required:  ........................................................................................................................................

 Please indicate on the receipts attached, for each beneﬁ t separately, the amount to be refunded to the person concerned according 
to the rates administered by the institution of the place of stay. Only in the case of Luxembourg, indicate the amount he/she has to 
contribute to the cost of treatment.

6. 

Attached ...................................... receipts.

1
1

 
 
 
 
 
 
 
 
 
 
 
7.

7.1

7.2

7.3

7.4

Competent institution

Name: ........................................................................................................................................................................................................

Identiﬁ cation number of the institution: ......................................................................................................................................................

Address:  ....................................................................................................................................................................................................

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

Stamp 

7.5 

7.6 

Date:  ..............................................................................

Signature:
........................................................................................

E 126

B.  Reply

Attached  ....................... receipts indicating the requested rates

8.
9. □ Amount to be reimbursed    ..............................................................    □ No reimbursement

10.

11.

11.1

11.2

11.3

Remarks:    .................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................
...................................................................................................................................................................................................................

Institution of the play of stay

Name: ........................................................................................................................................................................................................

Identiﬁ cation number of the institution: ......................................................................................................................................................

Address:  ....................................................................................................................................................................................................

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

11.4

Stamp 

11.5 

11.6 

Date:  ...............................................................................

Signature:
........................................................................................

NOTES

(2) 

(1)  Symbol of the country of the institution completing the form: BE = Belgium; CZ = Czech Republic; DK = Denmark; DE = Germany; EE = Estonia; 
GR = Greece; ES = Spain; FR = France; IE = Ireland; IT = Italy; CY = Cyprus; LV = Latvia; LT = Lithuania; LU = Luxembourg; HU = Hungary; 
MT = Malta; NL = Netherlands; AT = Austria; PL = Poland; PT = Portugal; SI Slovenia; SK = Slovakia; FI = Finland; SE = Sweden; UK = United 
Kingdom; IS = Iceland; LI = Liechtenstein; NO = Norway; CH = Switzerland.
If the institution which would have to provide the beneﬁ ts in kind is not known, the form may be sent to the liaison body in the country of stay, i.e.:
in Belgium, the ‘Institut national d’assurance maladie-invalidité’ (INAMI)’ (National Sickness and Invalidity Insurance Institute), Brussels;
in the Czech Republic, the ‘CMU’ (Centre for International Reimbursements), Prague;
in Denmark, the ‘Indenrings- og Sundhedsministeriet’ (Ministry of the Interior and Health), Copenhagen;
in Germany, the ‘DVKA’ (German Liaison Agency Health Insurance - International), Bonn;
in Estonia, the ‘Eesti Haigekassa’, (Health Insurance Fund);
in Greece, the regional or local branch of the Social Insurance Institute (IKA); for mariners, the Seamen’s Pension Fund (NAT);
in Spain, the ‘Instituto Nacional de la Seguridad Social’ (National Social Security Institute), Madrid;
in France, the ‘Centre des Liaisons Européennes et Internationales de Sécurité Sociale’ (Centre of European and International Liaisons for 
Social Security), Paris;
in Ireland, the Department of Health, Dublin;
in Italy, the ‘Ministero della Sanità’ (Ministry of Health), Rome;
in Cyprus, in Cyprus, the ‘Υπουργείο Υγείας’ (Ministry of Health, 1448 Lefkosia; 
in Latvia, the ‘Veselības obligātās apdrošināšanas valsts aģentūra’ (Health Compulsory Insurance State Agency), in Riga;
in Lithuania, the ‘Valstybinė ligonių kasa’ (State Patient Fund), Vilnius;
in Luxembourg, the ‘Union des Caisses de Maladie’, Luxembourg;
in Hungary, the ‘Országos Egészségbiztositási Pénztár’ (National Health Insurance Fund), Budapest;
in Malta, the Entitlement Unit, Ministry of Health, 23, St. John Street, Valletta;
in the Netherlands, the ‘Agis Zorgverzekeringen’, Utrecht;
in Austria, the ‘Hauptverband der österreichischen Sozialversicherungsträger’ (Main Association of Austrian Social Insurance Institutions), Vienna;
in Poland, the Narodowy Fundusz Zdrowia (National Health Fund), Warsaw;
in Portugal, the ‘Departamento de Relações Internacionais e Convenções de Segurança Social’ (Department of International Relations 
and Social Security Conventions), Lisbon;
in Slovenia, the ‘Zavod za zdravstveno zavarovanje Slovenije-Direkcija’ (Health Insurance Institute of Slovenia-Directorate), Ljubljana;
in Slovakia, the ‘Úrad pre dohl’ad nad zdravotnou starostlivost’ou’, (Health Care Supervision Authority), Bratislava;

2
2

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
in Finland, the ‘Kansaneläkelaitos’ (Social Insurance Institution), Helsinki;

in Sweden, the ‘Riksförsäkringsverket’ (National Social Insurance Board), Stockholm;

in Iceland, the ‘Tryggingastofnun rikisins’ (The State Social Security Institute), Reykjavik;

in Liechtenstein, the ‘Amt für Volkswirtschaft’ (Ofﬁ ce of National Economy), Vaduz;

in Norway, the ‘Rikstrygdeverket’ (National Insurance Administration), Oslo;

in Switzerland, the ‘Institution commune LAMal — Gemeinsame Einrichtung KVG — Istituzione commune LAMal’’ (Joint Institution under 
the Federal Sickness Insurance Act), in Solothurn.

(3)  Give the full surname in the order of civil status.

E 126

3

 
 
 
 
 
 
ADMINISTRATIVE COMMISSION
ON SOCIAL SECURITY FOR
MIGRANT WORKERS

E 127

(1)

INDIVIDUAL RECORD OF MONTHLY LUMP-SUM PAYMENTS

Regulation (EEC) No 1408/71: Article 36(1) and (2)
Regulation (EEC) No  574/72: Article  94; Article 95

The institution in the place of residence should draw up the form for one calendar year and send it to the competent institution through the body 
designated for the implementation of Article 102(2) of Regulation (EEC) No 574/72.

Please complete three copies of this form in block letters, writing on the dotted lines only. A separate form must be completed for 
each pensioner and each member of the family of a pensioner.

1.

Record No ............................................................................................

of year 20 ......................................................................................... .(2)

2.

2.1

2.2

2.3

Competent institution

Name:  ........................................................................................................................................................................................................

Identiﬁ cation number of the institution:  ......................................................................................................................................................

Address: .....................................................................................................................................................................................................

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

The right to beneﬁ ts in kind has been acquired for the

3. □ employed 

□ self-employed person

□ pensioner 

3.1

3.2

3.3

Surname(s) (3) : ...........................................................................................................................................................................................

Surname(s) at birth (if different): ................................................................................................................................................................

Forename(s): 

 Date of birth:

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

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

3.4

Personal identiﬁ cation number allocated by the competent institution:

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

3.5

Personal identiﬁ cation number allocated by the creditor institution:   

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

This individual record concerns:

4.
4.1 □ the family of the person named in box 3 living at the following address: ..............................................................................................
.....................................................................................................................................................................................................................
4.2 □ the pensioner named in box 3 living at the following address:  .............................................................................................................
.....................................................................................................................................................................................................................

4.3 □ the following member of the family of the pensioner named in box 3
□ the following member of the family of the person named in box 3 (4)

4.3.1 Surname(s) (3):  ...............................................................................................................................................................................

4.3.2

Forename(s):

Date of birth:

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

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

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

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

4.3.3 Address: .........................................................................................................................................................................................

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

4.3.4 Personal identiﬁ cation number allocated by the competent institution:

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

4.3.5 Personal identiﬁ cation number allocated by the creditor institution: 

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

1
1

5.

The right to beneﬁ ts in kind is held by the members of the family of the worker named above or by the pensioner named above and the 
members of his family, as certiﬁ ed by your

  E  ..................................   form of  .................................................................................  (date)

6.

For the period during which this existed

(from  ..........................................    to   ................................................. )

E 127

6.1

the number of monthly lump-sum payments is ........................................................................................................................................

6.2 □ per family irrespective of the number of family members and one tariff rate;

□  per pensioner or his/her family members – for every one the individual E-form and the same tariff rate for the pensioner as well as 

for his/her family members;

□ per individual (4).

7.

Creditor institution

7.1

7.2

7.3

Name: .........................................................................................................................................................................................................

Identiﬁ cation number of the institution: .......................................................................................................................................................

Address:  .....................................................................................................................................................................................................

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

7.4

Stamp (5) 

7.5

7.6

Date: ..............................................................................

Signature:

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

NOTES

the 

the  country  of 

 Symbol  of 
form:  BE  =  Belgium;  CZ  =  Czech  Republic;  DK  =  Denmark;
DE  =  Germany;  EE  =  Estonia;  GR  =  Greece;  ES  =  Spain;  FR  =  France;  IE  =  Ireland;  IT  =  Italy;  CY  =  Cyprus;  LV  =  Latvia; 
LT  =  Lithuania;  LU  =  Luxembourg;  HU  =  Hungary;  MT  =  Malta;  NL  =  Netherlands;  AT  =  Austria;  PL  =  Poland;  PT  =  Portugal;
SI  =  Slovenia;  SK  =  Slovakia;  FI  =  Finland;  SE  =  Sweden;  UK  =  United  Kingdom;  IS  =  Iceland;  LI  =  Liechtenstein;  NO  =  Norway;
CH = Switzerland.

institution  completing 

the 

Give the full surname in order of civil status.

The year to be indicated here is that in which the beneﬁ ts were provided.

In case of special lump sum payment scheme. 

An electronically sent and signed form does not need to be stamped.

(1) 

(2) 

(3) 

(4) 

(5) 

2
2