CELEX: 31973D0446
Language: en
Date: 1973-07-12 00:00:00
Title: 73/446/EEC: DECISION NO 88 OF 12 JULY 1973 ADAPTING THE MODEL FORMS NECESSARY FOR THE APPLICATION OF COUNCIL REGULATION ( EEC ) NO 1408/71 AND COUNCIL REGULATION ( EEC ) NO 574/72 FOR USE IN THE ENLARGED COMMUNITY ( E 101-127; E 201-214; E 301-303; E 401-410 )

30. 12. 73                       Official Journal of the European Communities                        No L 363 / 1
                                                        II
                                  (Acts whose publication is not obligatory)
                                           COMMISSION
                                     ADMINISTRATIVE COMMISSION
                                   OF THE EUROPEAN COMMUNITIES
                           ON SOCIAL SECURITY FOR MIGRANT WORKERS
                                               DECISION No 88
                                                of 12 July 1973
           adapting the model forms necessary for the application of Council Regulation (EEC)
           No 1408/71 and Council Regulation (EEC) No 574/72 for use in the enlarged Community
                             (E 101 — 127 : E 201 — 214 ; E 301 — 303 ; E 401 — 410)
                                                  73/446/EEC)
           THE ADMINISTRATIVE COMMISSION OF THE EUROPEAN COMMUNITIES ON
           SOCIAL SECURITY FOR MIGRANT WORKERS ,
           Having regard to Article 81(a) of Council Regulation (EEC) No 1408/71 of 14 June
           1971 on the application of social security schemes to employed persons and their families
           moving within the Community, under which it is the duty of the Administrative Com­
           mission to deal with all administrative questions arising from Regulation (EEC) No
           1408/71 and subsequent regulations ;
           Having regard to Article 2 (1) of Council Regulation (EEC) No 574/72 of 21 March 1972
           fixing the procedure for implementing Regulation (EEC) No 1408/71 , under which it is
           the duty of the Administrative Commission to draw up models of certificates, certified
           statements, declarations, applications and other documents necessary for the application
           of the regulations ;
           Having regard to Decision No 72 of 1 October 1972 laying down the model forms necess­
           ary for the application of Council Regulation (EEC) No 1408/71 and Council Regulation
           (EEC) No 574/72 ;
           Whereas the said model forms should be adapted for use in the enlarged Community,
 ---pagebreak--- No L 363 /2                        Official Journal of the European Communities                         30 . 12. 73
            HAS DECIDED AS FOLLOWS :
            1 . The model forms printed hereinafter shall be used for the purposes of applying
                Council Regulation (EEC) No 1408/71 and Council Regulation (EEC) No 574/72,
                which entered into force in the nine Member States on 1 April 1973 .
            2. Each form will be available in the official languages of the Community and laid out
                in such a manner that the different versions are perfectly superposable, thereby making
                it possible for each person or body to which a form is addressed (persons entitled to
                claim, institution, employer, etc.) to receive the form printed in their own language.
                The institution completing the form should fill out th : first copy and any additional
                copies it needs in the language it normally uses ; the other copies should be drawn
                up on the versions of the form printed in the language of each of the persons or bodies
                to whom they are to be sent.
                However, benefits in kind claimed during a stay in a Member State other than the
                competent State (form E 111 ) may not be refused if the person concerned submits a
                form drawn up in a language other than that of the country where the said benefits
                are claimed .
                The different forms consist of separate numbered sheets which should be stapled
                together once the information required has been filled in.
                                                    The Chairman of the Administrative Commission
                                                                           A. TRIER
 ---pagebreak--- 30. 12. 73                            Official Journal of the European Communities                               No L 363/3
                                                        List of Forms
E 101 — Certificate of posting
E 102 — Extension of term of posting
E 103 — Exercise of the right of option
E 104 — Certificate concerning the aggregation of periods of insurance, employment or residence
E 105 — Certificate concerning the members of the worker's family to be taken into consideration for the calculation of
           cash benefits in case of incapacity for work
E 106 — Certificate of entitlement to sickness and maternity insurance benefits in kind for persons residing in a country
           other than the competent country
E 107 — Application for a certificate of entitlement to benefits in kind
E 108 — Notification of suspension or withdrawal of the right to sickness and maternity insurance benefits in kind
E 109 — Certificate for the registration of members of the worker's family and the keeping of lists
E 110 — Certificate concerning workers in international transport
E 111 — Certificate of entitlement to benefits in kind during a stay in a Member State
E 112 — Certificate concerning the retention of the rights to sickness or maternity benefits currently being provided
E 113 — Hospitalization : Notification of entering and leaving hospital
E 114 — Grant of prostheses, major appliances, etc.
E 115 — Claim for cash benefits for incapacity for work
E 116 — Medical report relating to incapacity for work (sickness, maternity, accident at work, occupational disease)
E 117 — Granting of cash benefits in the case of incapacity for work
E 118 — Notification of non-recognition or of end of incapacity for work
E 119 — Certificate concerning the entitlement of unemployed persons and the members of their family to sickness and mater­
           nity insurance benefits
E 120 — Certificate of entitlement to benefits in kind for pension claimants and members of their family
E 121 — Certificate for the registration of pensioners and the keeping of lists
E 122 — Certificate for the grant of benefits in kind to members of the family of pensioners
E 123 — Certificate of entitlement to benefits in kind under insurance against accidents at work and occupational diseases
E 124 — Claim of death grant
E 125 — Individual record of actual expenditure
E 126 — Rates for refund of benefits in kind
E 127 — Individual record of monthly lump-sum payments
E 201 — Certificate concerning the aggregation of periods of insurance or periods of residence
E 202 — Investigation of a claim for an old-age pension
E 203 — Investigation of a claim for a survivor's pension
E 204 — Investigation of a claim for an invalidity pension
E 205 —    Certificate concerning insurance record in Belgium
       —   Certificate concerning periods of insurance and periods of residence in Denmark
       —   Certificate concerning insurance record in Germany
       —   Certificate concerning insurance record in France
       —   Certificate concerning insurance record in Ireland
       — Certificate concerning insurance record in Italy
       — Certificate concerning insurance record in Luxembourg
       — Certificate concerning insurance record in the Netherlands
       — Certificate concerning insurance record in the United Kingdom
 ---pagebreak--- No L 363 /4                         Official Journal of the European Communities                                30. 12. 73
E 206 — Certificate concerning periods of employment in mines and similar undertakings
E 207 — Information concerning the worker's insurance history
E 208 — Determination of rights to pensions
E 209 — Determination of pension amounts
E 210 — Notification of decision concerning a claim for pension
E 211 — Summary of decisions
E 212 — Legal remedies and periods allowed for appeals
E 213 — Detailed medical report
E 214 — Medical report concerning assessment of functional abilities and limitations
E 301 — Certificate concerning the periods to be taken into account for the grant of unemployment benefits
E 302 — Certificate relating to members of the family of an unemployed person who must be taken into account for the
          calculation of benefits
E 303 — Certificate concerning the retention of the right to unemployment benefits
       — Information for the unemployed person who intends to go to another Member State to seek employment
E 401 — Certificate concerning the composition of the family for the purpose of the granting of family benefits
E 402 — Certificate of continuation of studies for the purpose of the granting of family benefits
 E 403 — Certificate of apprenticeship for the purpose of the granting of family benefits
 E 404 — Medical certificate for the purpose of the granting of family benefits
 E 405 — Payment of family benefits or family allowances in the case of successive employment in several Member States
          between the dates on which payment is due according to the legislation of these states
 E 406 — Claim for family allowances to be submitted by a worker who is subject to French legislation and whose family
          resides in a Member State other than France
 E 407 — Certificate of periods of employment in France, or periods of unemployment in France for which benefits were paid,
          for the purpose of granting family allowances to members of the family of a worker or unemployed person who
          reside in a Member State other than France
 E 408 — Request for information
 E 409 — Verification of the declaration of absence of entitlement to family allowances by virtue of a professional or trade
           activity in the country of residence of the family
 E 410 — Notification of cancellation of entitlement to family allowances
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                          See ' Instructions' on page 3
Social - Security Regulations
                                                                                                     E 101                  C)
                                           CERTIFICATE OF POSTING
                   Reg. 1408/ 71 : Art. 14.1.a.i; Art. 14.2.a ; Art. 22.1 . a. i; Art. 22.3 ; Art. 55.1. a.i
                                     Reg. 574172: Art. 11.1 ; Art. 20.1 ; Art. 62.1
The designated institution of the country in which the undertaking has its registered office should complete points
1.1 — 7.5 and, if possible, also boxes 8 and 9. The form should be issued to the worker or to the employer. If the
worker is posted in Belgium a copy of the form should also be sent to the 'Office national de sécurité sociale', Brussels.
  1      Worker
 1.1     Surname                          Forenames                                           Maiden name
 1 ?     Date of birth :                                        Nationality :
 1.3     Permanent address ( 2):
 1.4     Insurance number :
  2      Members of the family who accompany the worker
 2.1     Surname                   Forenames                                      Maiden name                Date of birth
  3      Employer
 3.1     Name of employer or firm :
 3.2     Address ( 2):
 4       The abovementioned worker is posted for a period probably lasting
         from                                 to
 4.1     (3) [~| to the undertaking mentioned below :              \ on the ship mentioned below :
 5       Name of employer or firm :
 5.1     Address (2):
                                                                                                                               ©
 ---pagebreak---                                                                                                     E 101
6    During this period the worker remains subject to the legislation of the country in which the undertaking has
     its registered office, in accordance with Article
6.1  (3) Q 14.1 .a.i             □ 14.2.a        of Regulation No 1408/71 .
7 I  Designated institution of the country in which the undertaking has its registered office
7.1  Name :
7.2  Address ( 2 ):
7.3  Stamp
                                                                     7.4    Date :
                                                                     7.5    Signature
8 I To be completed by the designated institution or the worker
8.1  Institution competent for sickness and maternity insurance ( name and address) ( 2 ) ( 4):
8.2  Stamp
                                                                      8.3   Date :
 8.4 Signature of the institution 's representative                  8.5    Signature of the worker
 9 | To be completed by the designated institution or the employer
 9.1  Institution competent for insurance against accidents at work ( name and address) ( 2 ):
 9.2  Institution competent forinsurance against occupational diseases ( name and address) ( 2 ) ( 5 ):
 9.3  Stamp
                                                                      9.4   Date :
 9.5  Signature of the institution 's representative                  9.6   Signature of the employer
 ---pagebreak---                                                                                                                                  E 101
                                                                 INSTRUCTIONS
 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 even if it does not contain any relevant information .
 Information for the worker
a) This form enables the worker and the members of his family mentioned in box 2 to obtain from the insurance institutions of the place
      where he is posted benefits in kind in case of sickness, maternity, accident at work or occupational disease.
b) When one of the persons concerned has to seek benefits, including hospitalization, the form should be submitted to the insurance institution
      of the place of posting, i.e.
      — for benefits in case of sickness or maternity :
            in Belgium, the 'mutualité ' (local sickness insurance fund) of his choice;
           in Denmark, the competent 'amtskommune ' (local administration). In the commune of Copenhagen, the 'magistrat (municipal
           administration); in the commune of Frederiksberg, the 'kommunalbestyrelse ' (municipal administration). Assistance from a doctor,
           dentist or dispensing chemist may be sought without first contacting the said institutions. Particulars about doctors and dentists
           available may be obtained from the local 'social- og sundhedsforvaltning ' (social and health authority);
            in Germany, the 'Allgemeine Ortskrankenkasse ' (AOK, local general sickness fund);
           in France, the 'Caisse primaire d'assurance-maladie ' (local sickness insurance fund);
           in Ireland, the Health Board in whose area the benefit is sought;
           in Italy, the provincial office of the 'Istituto nazionale per l'assicurazione contro le malattie ' (INAM, national sickness insurance
           institute);
            in Luxembourg, the 'Caisse nationale d'assurance-maladie des ouvriers ' (national sickness insurance fund for manual workers);
            in the Netherlands, the 'Algemeen Nederlands Onderling Ziekenfonds ' (ANOZ, general sickness fund of the Netherlands), Utrecht.
           Assistance from a doctor, dentist or dispensing chemist may be sought without first contacting ANOZ;
           in the United Kingdom, the medical service (doctor, dentist, hospital, etc.) from which treatment is requested.
      — for benefits in case of accident at work or occupational disease :
           in Belgium, the 'mutualité ' (local sickness insurance fund) of his choice;
           in Denmark, the 'Sikringsstyrelse ' (national office for social security), Copenhagen;
            in Germany, the 'Allgemeine Ortskrankenkasse ' (AOK, local general sickness fund);
           in France, the 'Caisse primaire d'assurance-maladie ' (local sickness insurance fund);
           in Ireland, the Health Board in whose area the benefit is sought;
           in Italy, the provincial office of the 'Istituto nazionale per l'assicurazione contro gli infortuni sul lavoro ' (INAIL, national institute
           for insurance against accidents at work);
           in Luxembourg, the 'Association d'assurance contre les accidents ' (accident insurance association);
           in the Netherlands, the 'Algemeen Nederlands Onderling Ziekenfonds ' (ANOZ, general sickness fund of the Netherlands), Utrecht.
           Assistance from a doctor, dentist or dispensing chemist may be sought without first contacting ANOZ;
           in the United Kingdom, the medical service (doctor, dentist, hospital, etc.) from which treatment is requested.
c) If boxes 2, 8 and 9 have not been completed by the institution, boxes 2 and 8 should be completed by the worker and box 9 by his
      employer before the worker leaves for the country to which he is posted.
d) In order to receive benefits in kind the worker may present form E 111 instead of this form.
                                                                      NOTES
( 1 ) Symbol of the country in which the undertaking has its registered office : B = Belgium ; Dk = Denmark ; D = Germany; F = France ;
      Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
( 2 ) Postal code, town , street, number, country.
( 3 ) Put a cross in the square preceding the appropriate subject .
( 4) For the Netherlands indicate the sickness fund ('ziekenfonds').
( 5 ) Complete only if different from the institution mentioned at point 9.1 .
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                      See ' Instructions on page 4
Social Security Regulations
                                                                                                   E 102               n
                                     EXTENSION OF TERM OF POSTING
                  Reg. 1408/ 71 : Art. 14.1.a.ii; Art. 14.2.a ; Art. 22.1 . a.i; Art. 22.3 ; Art. 55.1 . a.i
                                   Reg. 574/72: Art. 11.2 ; Art. 20.1 ; Art. 62.1
A. To be completed by the employer
  1     Institution to which the form is addressed ( 2 )
  1.1    Name :
  1 .2  Address ( 3 ) :
  2     Worker
  2.1   Surname                          Forenames                                               Maiden name
  ? ?    Date of birth :                                          Nationality :
  2.3    Permanent address (3 ):
  2.4   Insurance number :
  3     Competent institution
  3.1   for insurance against accidents at work ( name and address) ( 3 ):
  3.2   for insurance against occupational diseases ( name and address) ( 3 ) (4):
 4     The abovementioned worker has been posted, in accordance with Article
 4.1   ( 5 ) □ 14.1 .a.i □ 14.2.a         of Regulation 1408/71 ,
 4.2   for the period from                               to
 4.3   ( 5)      to the undertaking mentioned below :       [    on the ship mentioned below :
 5     Name of employer or firm :
 5.1   Address ( 3 ):
 ---pagebreak---                                                                                                       E 102
  6    This worker held a Certificate of Posting (form E 101 )
  6.1  issued by the following institution ( name and address) ( 3 )
  6.2  on                               and expiring on
  7    We request that this worker may continue to be subject to the legislation of
                             1
       the country
 7.1   for the period from                               to                             ( 6 ).
   8    Employer
  8.1   Name of employer or firm :
  8.2  Address (3 ):
  8.3  Stamp
                                                                        8.4    Date :
                                                                        8.5   Signature
B. To be completed by the competent authority or the designated body of the country of employment ( 7 )
 9    We declare that
 9.1             (5) Q it is agreed           Q it is not agreed
      that the worker mentioned in box 2 shall continue to be subject to the social security legislation of
      the country :        n
 9.2  for the period from                               to
 10    Competent authority or designated body of the country of employment
 10.1 Name     :
 10.2 Address ( 3):
10.3 Stamp
                                                                     10.4   Date :
                                                                     10.5 Signature
 ---pagebreak---                                                                                      E 102
C. To be completed by the worker
 11   Institution competent for sickness and maternity insurance ( 8 )
 11.1 Name :
 11.2 Address ( 3):
 12   Members of the family who accompany the worker
 12.1 Surname                  Forenames                                Maiden name Date of birth
                                                                 13    Date :
                                                                 14    Signature
                                                                                                  (D
 ---pagebreak---                                                                                                                                    E 102
                                                                   INSTRUCTIONS
Please complete four copies of this form in block letters, writing on the dotted lines only. It consists
of four pages, none of which may be left out even if it does not contain any relevant information .
Information for the employer
a) The employer should complete part A of four copies of the form, which he should send to the competent authority or to the designated
      body of the country to which the worker has been posted, i.e.
      in Belgium, the 'Ministère de la prévoyance sociale ' (ministry of social welfare), Brussels, or the 'Office national de security sociale '
       (national office for social security), Brussels;
      in Denmark, the 'Sikringsstyrelse ' (national office for social security), Copenhagen;
      in Germany, the 'Bundesministerium fur Arbeit und Sozialordnung ' (federal ministry of labour and social affairs), Bonn;
      in France, the 'Direction regionale de la sécurité sociale ' (regional directorate for social security);
      in Ireland, the Department of Social Welfare, Dublin;
      in Italy, the 'Ministero del lavoro e delta previdenza sociale ' (ministry of labour and social welfare), Rome;
      in Luxembourg, the 'Ministère du travail et de la sécurité sociale ' (ministry of labour and social security), Luxembourg;
      in the Netherlands, the 'Ministerie van sociale zaken ' (ministry of social affairs). The Hague;
      in the United Kingdom, the Department of Health and Social Security, Overseas Group, Newcastle-upon-Tyne, or the Ministry
       of Health and Social Services, Overseas Branch, Belfast, as appropriate.
b) Two copies of the form, with part B completed, will be sent to the employer, who should give one of them to the worker.
Information for the worker
a) This form enables the worker and the members of his family mentioned in box 12 to obtain from the insurance bodies of the place
       where he is posted benefits in kind in case of sickness, maternity, accident at work or occupational disease.
b) When one of the persons concerned has to seek benefits, including hospitalization, the form should be submitted to the insurance
       institution of the place of posting, i.e.
      — for benefits in case of sickness or maternity :
             in Belgium, the 'mutualité ' (local sickness insurance fund) of his choice;
             in Denmark, the competent 'amtskommune ' (local administration). In the commune of Copenhagen, the 'magistrat' (municipal
              administration); in the commune of Frederiksberg, the 'kommunalbestyrelse ' (municipal administration). Assistance from a doctor,
              dentist or dispensing chemist may be sought without first contacting the said institutions. Particulars about doctors and dentists
              available may be obtained from the local 'social- og sundhedsforvaltning ' (social and health authority);
             in Germany, the 'Allgemeine Ortskrankenkasse ' (AOK, local general sickness fund);
              in France, the 'Caisse primaire d'assurance-maladie ' floral sickness insurance fund);
              in Ireland, the Health Board in Whose area the benefit is sought;
              in Italy, the provincial office of the 'Istituto nazionale per l'assicurazione contro le malattie ' (INAM, national sickness insurance
              institute);
              in Luxembourg the 'Caisse nationale d'assurance-maladie des ouvriers ' (national sickness insurance fund for manual workers);
              in the Netherlands, the 'Algemeen Nederlands Onderling Ziekenfonds ' (ANOZ, general sickness fund of the Netherlands), Utrecht.
             Assistance from a doctor, dentist or dispensing chemist may be sought without first contacting ANOZ;
              in the United Kingdom, the medical service (doctor, dentist, hospital, etc.) from which treatment is requested.
       — for benefits in case of accident at work or occupational disease :
              in  Belgium, the 'mutualité ' local sickness insurance fund) of his choice;
              in  Denmark, the 'Sikringsstyrelse ' (national office for social security), Copenhagen;
              in  Germany, the 'Allgemeine Ortskrankenkasse ' (AOK, local general sickness fund);
              in  France, the 'Caisse primaire d'assurance-maladie ' (local sickness insurance fund);
              in  Ireland, the Health Board in whose area the benefit is sought;
              in Italy, the provincial office of the 'Istituto nazionale per l'assicurazione contro gli infortuni sul lavoro ' (INAL, national institute
              for insurance against accidents at work);
              in Luxembourg, the 'Association d'assurance contre les accidents ' (accident insurance association);
              in the Netherlands, the 'Algemeen Nederlands Onderling Ziekenfonds ' (ANOZ, general sickness fund of the Netherlands),
               Utrecht. Assistance from a doctor, dentist or dispensing chemist may be sought without first contacting ANOZ;
              in the United Kingdom, the medical service (doctor, hospital, etc.) from which tretament is requested.
c) The worker should complete part C of the form, taking particular care to indicate in box 12 the members of his family who are entitled
        to sickness or maternity insurance benefits.
 d) In order to receive benefits in kind the worker may present form E 111 instead of this form.
                                                                          NOTES
 (1 )     Symbol of the country in which the undertaking has its registered office : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
          Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
 (2)      See the information given at point a ) of ' Information for the employer'.
 (3)      Postal code, town , street, number, country.
 ( 4)     Complete only if different from the institution mentioned at point 3.1 .
 (5)      Put a cross in the square preceding the appropriate subject.
 (6)      This period must not be more than 24 month from the date of the commencement of posting .
 (7)     Two copies should be returned to the claimant and one copy sent to the designated institution of the country in which the undertaking
          has its registered office .
 (8)     For the Netherlands indicate the sickness fund ('ziekenfonds').
                                                                                                                                                      ©
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                         See ' Instructions overleaf
 Social Security Regulations
                                                                                                     E 103               V)
                                       EXERCISE OF THE RIGHT OF OPTION
                                             Reg. 1408/ 71 : Art 16.2 and 3
                                     Reg. 574/72: Art. 13.2 and 3 ; Art. 14. 1 and 2
After having completed part A of the form in accordance with points (a) and (b) of the instructions, the worker should
hand it over or dispatch 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 worker.
A. Option
m       The undersigned
  1.1   Surname                              Forenames                                        Maiden name
  1.2   Date of birth :                                                  Nationality :
  1.3   Address (2):
  1.4   Insurance number :
  2     employed since
  2.1   (3) Q as                                                    by the diplomatic mission or consular post
        named hereafter
  2.2   (3) □ as n
        in the private staff of the following employer ( 5 )
        agent of the diplomatic mission or consular post named hereafter :
  2.3   (3) [J as a member of the auxiliary staff of the European Communities,
  3     hereby opts to be subject to the social security legislation
  3-1   (6 ) Q of the Member State of which he is a national :
  3.2   ( 6) ri of the Member State to whose legislation he was last subject, viz. the legislation of
        (6) [_J Belgium           [ I Denmark               I [ Germany                | | France               [J Ireland
        ( 6) □ Italy              I I Luxembourg            [ | Netherlands            I I United Kingdom .
                                                         4       Place and date :
                                                         5       Signature
        Authority of the European Communities which has concluded the contract with the member of the
  6     auxiliary staff
  6.1   Name :
  6.2   Address ( 2) :
  6.3   Stamp
                                                                           6.4    Date :
                                                                           6.5    Signature
                                                                                                                            ©
 ---pagebreak---                                                                                                                                                        E 103
B. Declaration
  7          We note that the worker mentioned in box 1 above is subject to the legislation of
             (6) Q Belgium                     [J Denmark                           Q Germany                             Q France                      Q Ireland
             (6) Q Italy                       Q Luxembourg                         Q Netherlands                         Q 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       Address ( 2 ):
   8.3       Stamp
                                                                                                           8.4      Date :
                                                                                                           8.5      Signature
                                                                             INSTRUCTIONS
Please complete three copies of this form in block letters, writing on the dotted lines only.
To the staff of diplomatic missions or consular posts and their private domestic staff
a) After having completed part A of the form, excluding box 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 Member State for whose legislation you have opted, i.e.
     in Belgium, the ' Office national de sicurite sociaie' (national office for social security), Brussels;
     in Denmark, the 'Sikringsstyrelse' (national office for social security), Copenhagen;
     in Germany, the 'Allgemeine Ortskrankenkasse Bonn ' (AOK, local general sickness fund), Bonn;
     in France, the ' Caisse primaire centrale d'assurance maladie de la region parisienne' (central sickness insurance fund of the Paris region);
     in  Ireland, the Department of Social Welfare, Dublin ;
     in Italy, the provincial office of the 'Istituto nazionale per i'assicurazione contro le malattie' (INAM, national sickness insurance institute);
     in Luxembourg, the 'Ministhre du travail et de la security sociaie ' (ministry of labour and social security). Luxembourg;
     in the Netherlands, the 'Sociaie verzekeringsraad' (social insurance council). The Hague;
     in the United Kingdom, the Department of Health and Social Security, Overseas Group, Newcastle-upon-Tyne, or the Ministry of Health and Social Services
      Overseas Branch, Belfast, as appropriate.
To the authority of the European Communities empowered to conclude contracts of employment with auxiliary staff
b) When a person is engaged as a member of the auxiliary staff and he expresses the wish to use his right of option, the empowered authority of the European Commu­
     nities must ensure that he completes part A of the form, with the exception of box 6 which must be completed by that 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 point a) above).
                                                                                     NOTES
(')    Symbol of the country of employment of the person who completes the form : B = Belgium ; Dk = Denmark; D = Germany ; F = France ; Irl = Ireland ; I = Italy
       L = Luxembourg ; N = Netherlands; UK = United Kingdom .
(2)    Postal code, town , street, number, country.
(3)    Give information at 2.1 , 2.2 or 2,3, according to the position of the worker completing the form, and put a cross in the corresponding square.
( 4)   State the occupation of the person concerned : chauffeur, cook, etc.
(5)    State surname and forenames of employer.
(6)    Put a cross in the square preceding the appropriate subject. Please note that workers 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 Member 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.
                                                                                                                                                                       ©
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                     See ' Instructions on page 3
 Social Security Regulations
                                                                                                   E 104                1
CERTIFICATE CONCERNING THE AGGREGATION OF PERIODS OF INSURANCE, EMPLOYMENT
                                                    OR RESIDENCE
                           Sickness — Maternity — Death (grant) — Tuberculosis
                                      Reg. 1408/ 71 : Art. 9.2 ; Art. 18.1 ; Art. 64
                                        Reg. 574/ 72: Art. 6.2 ; Art. 16 ; Art. 79
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 that has to issue it should complete part B and give or send the form to the person concerned.
Part A
    1 | Institution to which the form is addressed
    1.1  Name :
    1.2 Address ( 2 ):
   2     Insured person
    2.1  Surname                     Forenames                                   Maiden name               Date of birth
    2.2  Insurance number :
    2.3   Last employer in the country to whose legislation the worker was last subject :
    2.4   Name of employer or firm :
    2.5 Address ( 2 ):
    3     In order to deal with a claim submitted by the insured person mentioned above, we request you to indicate
         the periods of insurance, employment or residence completed by him
    3.1  from
    3.2 under the legislation of your country, for the following risk :
          (3 ) Q sickness and maternity              Q] death (grant)                       tuberculosis
                                                                                                                          ©
 ---pagebreak---                                                                                             E 104
  4    Competent institution
 4.1   Name :
 4.2   Address ( 2 ):
 4.3   Stamp
                                                                       4.4   Date :
                                                                       4.5   Signature
Part B
  5    Competent institution (4)
 5.1   Name :
 5.2   Address ( 2):
m 6     Insured person ( 5 )
 6.1   Surname                   Forenames                                    Maiden name Date of birth
 6.2   Insurance number :
 7     The insured person mentioned ( 3) [_J in box 2                  in box 6
       completed (3)      Q during the past two years (6)
                      (3)  Q during the past three years (7)
                     (3)  Q since
  8 I the following periods of insurance :
 8.1  from                   to                  for ( 8 ) the risk of                                □ (9>
 8.2  from                   to                  for / 8 ) the risk of                                □ <9>
 8.3  from                   to                  for ( 8 ) the risk of                                □ (9)
 8.4  from                   to                  for ( 8 ) the risk of                                □ (9>
 8.5  from                   to                  for ( 8 ) the risk of                                □ <a>
 8.6  from                   to                  for ( 8 ) the risk of                                □ (9)
 8.7  from                   to                  for ( 8 ) the risk of                                □ n
 8.8  from                   to                  for ( 8 ) the risk of                                □ (9>
 8.9  from                   to                  for ( 8 ) the risk of                                □ (9 >
 8.10 from                   to                  for ( 8 ) the risk of                                □ <9 >
                                                                                                           ©
 ---pagebreak---                                                                                                                               E 104
  9        the following periods of residence :
 9.1     from                       to                           for ( 8 \ the risk of                                                  □ (9)
 9.2     from                       to                           for ( 8 ) the risk of                                                  □ <»>
 9.3     from                       to                           for ( 8 ) the risk of                                                  □ (9)
 9.4     from                       to                           for ( 8 ) the risk of                                                  □ C)
 9.5     from                       to                           for ( 8 ) the risk of                                                  □O
 9.6     from                       to                           for ( βλ the risk of                                                   □ (9>
 9.7     from                       to                           for ( 8 ) the risk of                                                  □ <9>
  9.8    from                       to                           for ( 8 ) the risk of                                                  □ <9>
  9.9     from                      to                           for ( 8 ) the risk of                                                  □ <a>
  9.10 from                         to                           for ( 8 ) the risk of                                                  □ (9)
 10         Institution completing part B
  10.1     Name :
  10.2 Address (2 ):
  1 0.3 Stamp
                                                                                         10.4    Date :
                                                                                         10.5 Signature
                                                                INSTRUCTIONS
Please complete of this form in block letters, writing on the dotted lines only. It consists of three
      pages, none of which may be left out even if it does not contain any relevant information .
                                                                        NOTES
(1 )  Symbol of the country to which the institution which first completes the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ;
      F = France ; Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)   Postal code, town , street, number, country.
(3)   Put a cross in the square preceding the appropriate subject.
( 4)  Complete only if the form is issued at the request of the competent institution .
(5)   Complete only it the form is issued directly to the person concerned .
(6)   If the certificate is addressed to an Italian institution and relates to benefits in the case of tuberculosis, and the person concerned has
      not paid contributions for one full year during the last two years, the periods of insurance completed by him during the last five years
      should be indicated .
(7)   Complete only if the competent institution is an Irish or United Kingdom institution .
(8)   Indicate the risk covered by using the following symbols :
      A = sickness and maternity
      B = death ( grant )
      C = tuberculosis .
(9)   Where the competent institution is an Irish or United Kingdom institution , put a cross in this square if the period of insurance or the
      period of residence corresponds to a period of actual employment.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                       See Instructions' overleaf
 Social Security Regulations
                                                                                                E 105                 1)
CERTIFICATE CONCERNING THE MEMBERS OF THE WORKER 'S FAMILY TO BE TAKEN INTO
CONSIDERATION FOR THE CALCULATION OF CASH BENEFITS IN CASE OF INCAPACITY FOR
                                                          WORK
                                           Reg. 1408/ 71 : Art. 23.3 ; Art. 58.3
                                        Reg. 574/ 72 : Art. 25.1 and 2 ; Art. 70.1
This form should be completed by the sickness insurance institution or by a designated institution of the place of
residence of the members of the family, and forwarded to the worker.
  1     Worker
  1.1   Surname                     Forenames                                 Maiden name            Date of birth
  1 .2  Address ( 2 ) in the country of residence or the country of stay :
  1.3   Insurance number :
 2      The following persons are dependants of the abovementioned worker :
  3 I Members of the family
  3.1   Surname                  Forenames                         Maiden name      Date of birth         Relationship
  4      Institution of the place of residence of the members of the family
  4.1   Name :
  4.2   Address ( 2 ):
  4.3   Stamp
                                                                           4.4    Date :
                                                                            4.5   Signature
                                                                                                                         ©
 ---pagebreak---                                                                                                                              E 105
                                                               INSTRUCTIONS
                      Please complete this form in block letters, writing on the dotted lines only.
Information for the worker
a) If you are entitled to cash benefits for incapacity for work in Germany, Belgium, France, Ireland or the United Kingdom, under whose
     legislation the amount of these benefits varies with the number of members of the family, you should present this certificate to the in­
     stitution with which you are insured.
b) This certificate is valid for a period of twelve months as from its date of issue (see point 4.4); on expiry of this period you may apply for
     renewal to the institution of the place of residence of the members of your family (see points 4.1 and 4.2).
 c)   You are obliged to inform immediately the institution with which you are insured of any changes which have occurred in the
     information shown on this certificate.
                                                                      NOTES
(1 )   Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
       Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
( 2)   Postal code, town , street, number, country .
 ---pagebreak---  EUROPEAN COMMUNITIES                                                                    Sea ' Instructions on page 3
 Social Security Regulations
                                                                                                     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
Workers and members of their family residing with them ; members of the family of unemployed persons
                                    Reg. 1408/ 71 : Art. 19.1 . a ; Art. 19.2 ; Art. 25.3.i
                               Reg. 574/ 72: Art. 17.1 and 4 ; Art. 27 (first sentence)
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 of 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.
A.    Notification of entitlement
  1 |    Institution of the place of residence (2)
  1.1    Name :
  1.2   Address ( 3 ):
  1.3   Reference : your form E 107 of
   2     ( 4) n Worker                              fj Frontier worker                        M Unemployed person
  2.1   Surname                     Forenames                                    Maiden name               Date of birth
  2.2   Address in the country of residence ( 3 ):
  2.3   Insurance number :
   3     Member of the family ( 5 )
  3.1   Surname                     Forenames                                    Maiden name               Date of birth
  3.2   Address in the country of residence ( 3 ):
 4      (4) [_j The abovementioned worker and the members of his family ( 6) residing with him
 4-1    (4) Q] The members of the family ( 6) of the unemployed person mentioned above
 5      are entitled to sickness and maternity insurance benefits in kind ( 7 )
        as from
  6 j The persons concerned will retain their entitlement
 6-1    (4) d] unt| l this certificate is cancelled
 6.2    ( 4) n for a period of three months from the date of issue of this certificate ( 8 )
                                                                                                                           ©
 ---pagebreak---                                                                                      E 106
  7     Competent institution ( 7 )
 7.1    Name :
 7.2    Address ( 3 ):
  7.3   Stamp
                                                                7.4    Date :
                                                                7.5    Signature
B. Notification of registration ( 9 )
| 8 j Competent institution
  8.1   Name :
  8.2   Address ( 3 ):
   9
   9-1   (4) LJ The worker named in box 2 and the members of his family
   9.2   (4) Q The members of the family of the unemployed person named in box 2
         (4) EU were registered with us on
   9-4   (4) □ cou 'd not be registered with us because :
   10     Registered members of the family
   10.1  Surname                    Forenames                           Maiden name Date of birth
   10.2
   10.3
   10.4
   10.5
   10.6
   10.7
   10.8
   10.9
 ---pagebreak---                                                                                                                                                         E 106
   111          Institution of the place of residence
    11.1       Name :
    11.2 Address ( 3 ):
    1 1 .3 Stamp
                                                                                                              11.4     Date :
                                                                                                              11.5     Signature
                                                                               INSTRUCTIONS
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 even if it does not contain any relevant information .
Information for the insured person
a) This form entitles you to receive sickness and maternity insurance benefits in kind
     — for yourself and the members of your family, if you are employed;
     — for the members of your family who reside in a Member State other than the one where you are insured, if you are unemployed.
b)    The two copies of the form which are in your possession must be submitted as soon as possible
     — by yourself, to the sickness and maternity insurance institution of your place of residence , if you are employed;
     — by the members of your family, to the sickness and maternity insurance institution of their place of residence, if you are unemployed.
c) These sickness and maternity insurance institutions are :
     in Belgium, the 'mutuality (local sickness insurance fund) of your choice;
     in Denmark, the competent 'amtskommune (local administration). In the commune of Copenhagen, the 'magistrat' (municipal administration); in the commune of
     Frederiksberg, the 'kommunalbestyrelse' (municipal administration). Assistance from a doctor, dentist or dispensing chemist may be sought without first contacting
     the said institutions. Particulars about doctors and dentists available may be obtained from the local 'social- og sundhedsforvaltning ' (social and health authority);
     in Germany, the 'Allgemeine Ortskrankenkasse ' (AOK, local general sickness fund);
     in France, the ' Caisse primaire d'assurance-maladie ' (local sickness insurance fund);
     in I reland, the Health Board in whose area the benefit is sought;
     in Italy, the provincial office of the 'Istituto nazionaie per i'assicurazione contro le malattie ' (INAM, national sickness insurance institute);
     in Luxembourg, the ' Caisse nationale d'assurance-maladie des ouvriers' (national sickness insurance fund for manual workers);
     in the Netherlands, any sickness fund competent for the place of residence;
     in the United Kingdom, the Department of Health and Social Security, Overseas Group, Newcastle-upon-Tyne, or the Ministry of Health and Social Services, Over­
      seas Branch, Belfast, as appropriate.
d) This form is valid from the date indicated at point 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 sent of any change of circumstances which might affect the
     right to benefits 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.
                                                                                      NOTES
(1 )   Symbol of the country to which the institution completing part A of the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France; Irl = Ireland ; 1 = Italy
       L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)    Complete only if the form is drawn up at the request of the institution of the place of residence.
(3)    Postal code, town , street, number, country.
(4)    Put a cross in the square preceding the appropriate subject .
(5)    Complete only if the form relates to members of the family of an unemployed person ; in that case give the information for one member of the family only.
(6)    The legislation of the country of residence determines which members of the family are entitled to benefit.
(7)     For persons insured in Italy, benefits for tuberculosis can be provided only on production of a certificate issued by the ' Istituto nazionaie della previdenza~ sociale'
        ( INPS , national social welfare institute ).
 (a)    If the form is issued by a French institution .
 (9)    If this form is issued in renewal of a certificate previously provided, part B need not be completed .
                                                                                                                                                                              ©
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                                  See ' Instructions' on page 3
 Social Security Regulations
                                                                                                               E 107                1
           APPLICATION FOR A CERTIFICATE OF ENTITLEMENT TO BENEFITS IN KIND
Reg. 1408/ 71 : Art. 19.1 . a ; Art. 19.2 ; Art. 22.1 . a. i, b.i and c.i ; Art. 22.3 ; Art. 25.1 . a and 3.i ; Art. 26.1 ; Art. 28.1 . a ;
                                 Art. 29.1 . a ; Art. 31 . a ; Art. 52.a ; Art. 55.1 . a. i, b.i and c.i
Reg. 574/ 72: Art. 17.1 ; Art. 20.3 and 4 ; Art. 21.1 ; Art. 22. 1 and 3 ; Art. 23 ; Art. 27 (first sentence) ; Art. 28 ; Art. 29.2;
                       Art. 30.1 ; Art. 31.1 and 3 ; Art. 60.1 ; Art. 62.3, 4 and 7 ; Art. 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 com­
petent institution, taking into account the provisions of the abovementioned articles of Regulation 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 verified or a disease
recognized as an occupational disease.
A. To be completed by the institution of the place of residence or stay
Pi f Institution to which the form is addressed
  1.1    Name :
  1.2    Address ( 2 ):
          (3) [j Worker                    [H Pensioner
  o
          (3) Q] Unemployed person [H Pension claimant
  2.1    Surname                         Forenames                                          Maiden name                Date of birth
  2.2    Permanent address ( 2 ):
  2.3    Insurance number :
  2-4     (3) Q Person entitled to           Q Claimant of
         the pension in respect of
                    (3) Q old age                     Q invalidity                                    Q survival
                    (3) Q accident at work             Q] occupational disease
          No.                                (4)                  category :                                    (4)
  2.5     Institution responsible for payment of the pension :
                                                                                                                                         ©
 ---pagebreak---                                                                                                   E 107
3 J Last employer (5)
3.1 Name of employer or firm :
3.2 Address ( 2 ):
3.3 Branch of activity ( 6):
3.4 Institution for insurance against accidents at work with which the employer is insured :
4 1 Members of the family ( 7 )
4.1 Surname                       Forenames                                 Maiden name         Date of birth
4.2 Address in the country of residence (2 ) (8 ):
5    On                                                       we received a claim from the person shown
      (3) Q in box 2             EH ' n box 4
     for :
5-1   (3) [E] the granting of benefits in kind
5-2   (3) O the retention of the right to benefits in kind
5.3   (3) Q registration with us as a person entitled to benefits in kind.
6    The benefits in kind          (3) Q have been awarded                Q have not been awarded
6.1  in accordance with Article (3) Q 20.3 Q 29.2 Q 60.1 Q 62.3 of Reg. 574/72.
6.2  The claimant                  (3) Q has not worked since the date indicated at point 5 above
                                        | | has held the following occupation after that date :
7    Please send us the certificate of entitlement to benefits on form :                              E
     or inform us if you are unable to issue it.
8    [~] Medical report attached. (9)
m   Institution of the place of residence or stay
9.1 Name :
9.2 Address (2 ):
9.3 Stamp
                                                                      9.4  Date :
                                                                      9.5   Signature
 ---pagebreak---                                                                                                                        E 107
B. To be completed by the competent institution
I 1 0 1 Institution of the place of residence or stay ( 10)
   10.1     Name :
   10.2 Address ( 2 ):
 11           We are unable to issue the certificate asked in part A, because
    1?       Competent institution
    12.1    Name :
    12.2 Address ( 2 ):
    12.3 Stamp
                                                                                        12.4    Date :
                                                                                        12.5    Signature
                                                                 INSTRUCTIONS
 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 even if it does not contain any relevant information .
                                                                       NOTES
 (1 )   Symbol of the country to which the institution completing part A of the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ;
        F = France ; Irl = Ireland ; I = Italy; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
 (2)     Postal code, town , street, number, country.
 (3)    Put a cross in the square preceding the appropriate subject.
  (4)    Complete only if the institution responsible for the payment of the pension is an Italian institution .
 (5)    Complete only if the form concerns an employed or unemployed person .
 (6)    Complete only if the form concerns a worker assumed to have sustained an accident at work.
 (7)    Complete only for members of the family for whom a claim for benefits or a request for registration has been made. For registration ,
        indicate one member of the family only.
 (8)    Complete only if the address of the members of the family is different from that of the head of household .
 (9)    To be attached only if necessary. In that case, put a cross in the corresponding square .
 ( 10 )  Institution mentioned in box 9 .
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                        See ' Instructions overleaf
 Social Security Regulations
                                                                                                   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
                  Reg. 1408/ 71 : Art. 19.1 . a and 2; Art. 25.3.i ; Art. 26.1 ; Art. 28.1 . a ; Art. 29.1 .a
             Reg. 574/ 72: Art. 17.2 and 3 ; Art. 27 ; Art. 28 ; Art. 29.5 ; Art. 30 ; Art. 94.4 ; Art. 95.4
The competent institution should complete part A of the form and send two copies to the institution of the place of
residence (where appropriate through the liaison body). The institution of the place of residence should complete
part B and return one copy to the competent institution as soon as possible.
A. Notification
pi I Institution to which the form is addressed
  1.1   Name :
  1.2   Address ( 2 ):
         ( 3) I I Worker                 | | Frontier worker            [ j Pensioner
  2
         (3) Q Unemployed person Q] Pension claimant
  2.1   Surname                       Forenames                                  Maiden name               Date of birth
  2.2   Address in the country of residence (2 ):
  2.3   Insurance number :
  3      Member of the family ( 4)
  3.1   Surname                       Forenames                                  Maiden name               Date of birth
  3.2   Address in the country of residence ( 2 ):
  4      Entitlement to benefits certified on our
        form                                      of                                (date )
        has been suspended or withdrawn for the following reason ( 3 )
 4.1    (3 ) | | The abovementioned worker has not been insured with us since
 4.2    (3 ) Q] The pension of the abovementioned pensioner has been suspended or withdrawn since
 4.3    ( 3 ) n A" the persons registered with you have not resided in your country since
 4-4    ( 3 ) LJ The person entitled to benefits died on
 4.5    (■') n <■■)
                                                                                                                           ©
 ---pagebreak---                                                                                                                          E 108
  5       Competent institution
  5.1     Name :
  5.2    Address ( 2 ):
  5.3     Stamp
                                                                                      5.4     Date :
                                                                                      5.5     Signature
B. Acknowledgement of receipt
   6 I    Competent institution
  6.1     Name :
  6.2     Address ( 2 ) :
  7       We received the above notification ( part A) on
  8       ( 3 ) Q] The person indicated in part A                          [J The persons indicated in part A
          ( 3 ) Q has not received                                         Q have not received
          ( 3 ) Q will no longer receive                                  Q will no longer receive
          benefits since/as from :
                                                (date ).
m         Institution of the place of residence
  9.1     Name :
  9.2     Address ( 2 ) :
  9.3     Stamp
                                                                                       9.4    Date :
                                                                                       9.5    Signature
                                                                INSTRUCTIONS
                  Please complete this form in block letters, writing on the dotted lines only
                                                                     NOTES
(1 )  Symbol of the country to which the institution completing part A of the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ;
      F = France ; Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)   Postal code, town , street, number, country.
(3)   Put a cross in the square preceding the appropriate subject.
(4)   Complete only if the withdrawal or suspension of the right to benefits in kind notified by this form affects the members of the family
      only ; in such case, indicate only one of them .
(5)   Other reasons, if any.
                                                                                                                                           @
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                     See Instructions on page 3
Social Security Regulations
                                                                                                 E 109               (1 )
       CERTIFICATE FOR THE REGISTRATION OF MEMBERS OF THE WORKER 'S FAMILY
                                         AND THE KEEPING OF LISTS
                                               Reg. 1408171 : Art, 19.2
                                    Reg. 574/ 72: Art. 17.1r 2, 3 and 4 ; Art 94.4
The competent institution should complete part A of the form and issue two copies to the worker or send them
— where necessary — through the liaison body to the institution of the place of residence if the form was drawn
up at that institution's request. Where the members of the worker's family are resident in the United Kingdom, the
competent institution should send the two copies to the Department of Health and Social Security, Overseas Group,
Newcastle-upon-Tyne. On receipt of the two copies, the institution of the place of residence should complete part B
and return one copy to the competent institution. Where the members of the family are resident in different countries,
a separate certificate should be drawn up for each of these countries.
A. Notification of entitlement
pj I Institution of the place of residence (2)
  1.1   Name :
  1 .2  Address ( 3 ) :
  1.3   Reference : your form E 107 of                                            ( date)
m        (4) Q] Worker                     Q Seasonal worker
 2.1    Surname                      Forenames                                 Maiden name               Date of birth
 2.2   Address ( 3 ):
 2.3    Insurance number :
I3 I    Member of the family ( 5 )
 3.1    Surname                      Forenames                                 Maiden name              Date of birth
 3.2   Address ( 3 ) :
 4     The members of the family of the abovementioned worker are entitled to sickness and maternity insurance
        benefits in kind unless :
        (4) Q they are already entitled to such benefits under the legislation of the country in which they reside
        (4) Q they are pursuing a professional or trade activity ( 6).
 5     This entitlement begins on
El      and continues
 6-1   (4) L] until this certificate is cancelled
 6.2   (4)       for three months from the date of issue of this certificate ( 7 )
 6.3   (4) Q until the date on which the seasonal work ends, i.e.
       until                                   unless notification of cancellation is given before that date
                                                                                                                          ©
 ---pagebreak---                                                                                                          E 109
 7      Competent institution
 7.1    Name :
 7.2    Address ( 3 ):
 7.3    Stamp
                                                                       7.4     Date :
                                                                       7.5     Signature
B. Notification of registration ( 8 )
 8      Competent institution
 8.1    Name :
 8.2    Address ( 3 ):
 9      □ (9)
 9.1    The members of the family of the worker named in box 2 have not been registered because :
 9.2    ( 4)       no member of the family is entitled to benefits
 9.3    (4) Q all the members of the family are already entitled to benefits in kind under the legislation of our country
 9-4    (4)        the spouse or the person looking after the children pursues a professional or trade activity in our
                   country ( 10 )
 9.5    (4) [H the required 'declaration of family status' has not been submitted
 9-6    (4) □ ( 11 )
  1 ° | □ (9)
 10.1     The following members of the family of the worker named in box 2 have been registered :
 10.2     Surname                     Forenames                                  Maiden name           Date of birth
 1 0.3
 10.4
 10.5
  10.6
  10.7
  10.8
  10.9
  10.10 The cost of these benefits are payable by you ; the date from which the lump sum referred to in Article 94
           of Reg . 574/72 should be calculated is :
                                                                                                                         ©
 ---pagebreak---                                                                                                                                   E 109
   11        Institution of the place of residence
   11.1      Name :
   11.2 Address ( 3 ):
   1 1 .3 Stamp
                                                                                           11.4    Date :
                                                                                           11.5    Signature
                                                                  INSTRUCTIONS
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 even if does not contain any relevant information .
Information for the worker
a)    This form enables the members of your family to receive benefits 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 benefits under that legislation.
b) As soon as you have received the two copies of this form, you should send them to the members of your family, who should submit
      them immediately to the sickness and maternity insurance institution of their place of residence, i.e.
      in Belgium, the 'mutualite ' (local sickness insurance fund) of their choice;
      in Denmark, the competent 'amtskommune ' (local administration). In the commune of Copenhagen, the 'Magistral (municipal
      administration); in the commune of Frederiksberg, the 'kommunalbestyrelse ' ( municipal administration);
      in Germany, the 'Allgemeine Ortskrankenkasse ' (AOK, local general sickness fund);
      in France, the 'Caisse primaire d'assurance-maladie ' (local sickness insurance fund);
      in Ireland, the Health Board in whose area the benefit is sought;
      in Italy, the provincial office of the 'Istituto nazionale per I'assicurazione contro le malattie ' (INAM, national sickness insurance
      institute);
      in Luxembourg, the 'Caisse nationale d'assurance-maladie des ouvriers ' (national sickness insurance fund for manual workers);
      in the Netherlands, any sickness fund competent for the place of residence.
c)     This form is valid from the date mentioned at point 5 and for the period indicated in box 6 at the square marked with a cross.
d)     You or the members of your family must inform the institution of the place of residence of any change of circumstances which might
      affect the right to benefits 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.
                                                                        NOTES
(1)     Symbol of the country to which the institution completing part A of the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ;
        F = France ; Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)     Complete only if the form is drawn up at the request of the institution of the place of residence.
(3)     Postal code, town , street, number, country.
(4)     Put a cross in the square preceding the appropriate subject .
(5)     Complete for one member of the family only.
(6)     Put a cross in the preceding square if the form is addressed to a Danish , Irish or United Kingdom institution .
(7)     If the form is drawn up by a French institution .
(8)     If this certificate is issued in renewal of a previously issued certificate which has expired, the institution of the place of residence need
        not complete part B.
(9)     Complete box 9 or box 1 0 as applicable and put a cross in the corresponding square .
( 10 ) Put, if applicable , a cross in the preceding square if part B is completed by a Danish , Irish or United Kingdom institution .
( 11 ) Other reasons.
                                                                                                                                                   <D
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                             See ' Instructions' on page 3
 Social Security Regulations
                                                                                                          E110 | I           I (i)
               CERTIFICATE CONCERNING WORKERS IN INTERNATIONAL TRANSPORT
                          Reg. 1408/ 71 : Art. 1 4.1 . b ; Art. 22.1 . a. i ; Art. 22.3 ; Art. 55.1 . a.i
                                          Reg. 574172: Art. 20.2 ; Art. 62.2
The form should be completed and, if necessary, signed for extension by the employer, who should then give it to
the worker.
A. First certified statement
  1     Worker
  1.1   Surname                        Forenames                                                       Maiden name
  1.2   Date of birth :                                                                Nationality :
  1.3   Permanent address ( 2 ):
  2     Members of the family who accompany the head of household
  2.1   Surname                    Forenames                                          Maiden name                Date of birth
   3     Institution competent
   3.1  for insurance against accidents at work ( name and address) ( 2 ):
   3.2  for insurance against occupational diseases ( name and address) ( 2 ) ( 3 ):
 4        The undersigned certifies that the abovementioned worker has been in his employ since
 ---pagebreak---                                                                                                     E 110
  5 j Employer
  5.1 Name of employer or firm :
  5.2 Nature of business :
  5.3 Address ( 2):
  5.4 Stamp
                                                                    5.5     Date :
                                                                    5.6     Signature of employer or his
                                                                            representative
  6   Institution competent for sickness and maternity insurance ( 4) ( 5 )
  6.1 Name :
  6.2 Address ( 2 ):
  6.3 Worker's insurance number :
                                                                    6.4     Date :
  6.5 Worker's signature                                            6.6     Signature of employer or his
                                                                            representative
B. Extensions ( 6 )
7      The employer named in box 5 certifies that the abovementioned worker is still in his employ on the date
       shown below :
  8    Date                                                     8.1     Signature of employer or his
                                                                        representative
                                                                                                            (2)
 ---pagebreak---                                                                                                                                      E 110
                                                                    INSTRUCTIONS
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 even if it does not contain any relevant information .
Information for the worker
a)    This document is valid for the month during which it was issued and the two calendar months following (see points 5.5 and 8).
b) During this term of validity it enables you and the members of your family listed in box 2 to receive benefits in kind in the territory of
      the Member State where you are staying whilst carrying out your work.
c)    When you need benefits in kind, you should submit this form as soon as possible to the insurance institution of the country in which you
      are staying, i.e.
      — for benefits in case of sickness or maternity :
           in Belgium, the 'mutualité ' (local sickness insurance fund) of your choice ;
            in Denmark, the competent 'amtskommune ' (local administration). In the commune of Copenhagen, the 'magistrat (municipal
            administration); in the commune of Frederiksberg, the 'kommunalbestyrelse ' (municipal administration). Assistance from a doctor,
            or dispensing chemist may be sought without first contacting the said institutions. Particulars about doctors and dentists available
            may be obtained from the local 'social- og sundhedsforvaltning ' (social and health authority);
            in Germany, the 'Allgemeine Ortskrankenkasse ' (AOK, local general sickness fund);
            in France, the 'Caisse primaire d'assurance-maladie ' (local sickness insurance fund);
            in Ireland, the Health Board in whose area the benefit is sought;
            in Italy, the provincial office of the 'Istituto nazionale per l'assicurazione contro le malattie ' (INAM, national sickness insurance
            institute);
            in Luxembourg, the 'Caisse nationale d'assurance-maladie des ouvriers ' (national sickness insurance fund for manual workers);
            in the Netherlands, the 'Algemeen Nederlands Onderling Ziekenfonds ' (ANOZ, general sickness fund of the Netherlands), Utrecht.
            Assistance from a doctor, dentist or dispensing chemist may be sought without first contacting ANOZ;
            in the United Kingdom, the medical service (doctor, dentist, hospital, etc.) from which treatment is requested.
      — for benefits in case of accident at work or occupational disease :
             in Belgium, the 'mutualité ' (local sickness insurance fund) of your choice;
            in Denmark, the 'Sikringsstyrelse ' (national office for social security), Copenhagen;
             in Germany, the 'Allgemeine Ortskrankenkasse ' (AOK, local general sickness fund);
             in France, the 'Caisse primaire d'assurance-maladie ' (local sickness insurance fund);
             in Ireland, the Health Board in whose area the benefit is sought;
             in Italy, the provincial office of the 'Istituto nazionale per l'assicurazione contro gli infortuni sul lavoro' (INAIL, national institute for
             insurance against accidents at work);
             in Luxembourg, the 'Association d'assurance contre les accidents ' (accident insurance association);
             in the Netherlands, the 'Algemeen Nederlands Onderling Ziekenfonds ' (ANOZ, general sickness fund of the Netherlands), Utrecht.
             Assistance from a doctor, dentist or dispensing chemist may be sought without first contacting ANOZ;
             in the United Kingdom, the medical service (doctor, dentist, hospital, etc.) from which treatment is requested.
 d) If your employer has not done so, please complete box 6 of the form.
 e) In order to receive benefits in kind, you may present form E 111 instead of this form.
                                                                           NOTES
 (1 )   Symbol of the country where the undertaking has its registered office : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
        Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
 (2)     Postal code, town , street, number, country.
 (3)     Complete only if different from the institution mentioned at point 3.1 .
 (4)     If the employer, under the legislation of the competent country, is not obliged to know which institution is competent for sickness and
         maternity insurance , this box should be completed by the worker.
 (5)     For the Netherlands indicate the sickness fund (' ziekenfonds').
 ( 6)   This part may only be completed if no change has taken place in the information given in part A.
                                                                                                                                                         ®
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                         See   Instructions" overleaf
Social Security Regulations
                                                                                                     E 111                (1 )
                  CERTIFICATE OF ENTITLEMENT TO BENEFITS IN KIND DURING
                                         A STAY IN A MEMBER STATE
                                   Reg. 1408/ 71 : Art. 22,1 . a. i; Art. 22.3 ; Art. 31 . a
                             Reg. 574172: Art. 20.5 ; Art. 21.1 ; Art. 23 ; Art. 31.1 and 3
 1     Institution of the place of stay (2 )
 1 1   Name :
 1.2   Address ( 3 ):
 1.3   Reference : your form E 107 of                                           (date)
 2 |(4)Π Worker                       Q] Pensioner
 2.1   Surname                        Forenames                                     Maiden name             Date of birth
 2.2   Permanent address ( 3 ):
 2.3   Insurance number :
 3     Members of the family ( 5 )
 3.1   Surname                        Forenames '                                   Maiden name             Date of birth
 3.2   Permanent address ( 3 ) ( 6):
 4     The abovenamed persons are entitled to benefits in kind under sickness and maternity insurance.
       These benefits may be provided :
 4.1   (7) Q] from                                  to
 4.2   (7) F] for all cases of illness occurring up to                                        inclusive
                and for                                         days                                 v . weeks .
 5     Competent institution
 5.1   Name :
 5.2   Address ( 3 ):
 5.3   Stamp
                                                                                 5.4    Date
                                                                                 5.5    Signature
 ---pagebreak---                                                                                                                                 E 111
                                                                 INSTRUCTIONS
                     Please complete this form in block letters, writing on the dotted lines only .
The competent institution or, where appropriate, the institution of the place of residence of the pensioner should
complete this form and send it to the person concerned, or send it to the institution of the place of stay if the form
has been drawn up at the latter's request. This form is not required if the person concerned is staying in the United
Kingdom.
Information for the insured person and the members of his family
a) This document enables
       — the worker and the members of his family named in box 3, who are staying temporarily in a Member State other than the com­
             petent State.
       — the pensioner and the members of his family named in box 3, who are staying temporarily in a Member State other than that in
             which they habitually reside.
       to obtain benefits in kind from insurance bodies in the country of stay, in the case of sickness or maternity and, provisionally, in the
       case of an accident at work or occupational disease.
b) When one of the persons concerned has to seek benefits, including hospitalization, he should submit this form to the insurance body
       in the country in which he is staying, i.e.
       in Belgium, the 'mutualité ' (local sickness insurance fund) of his choice;
        in Denmark, the competent 'amtskommune ' (local administration). In the commune of Copenhagen, the 'magistrat (municipal
       administration); in the commune of Frederiksberg, the 'kommunalbestyrelse ' (municipal administration). Assistance from a doctor,
       dentist or dispensing chemist may be sought without first contacting the said institutions. Particulars about doctors and dentists
        available may be obtained from the local 'social- og sundhedsforvaltning ' (social and health authority);
       in Germany, the 'Allgemeine Ortskrankenkasse ' (AOK, local general sickness fund);
       in France, the 'Caisse primaire d'assurance-maladie ' (local sickness insurance fund);
       in Ireland, the Health Board in whose area the benefit is sought;
       in Italy, the provincial office of the 'Istituto nazionale per l'assicurazione contro le malattie ' (INAM, national sickness insurance insti­
       tute);
       in Luxembourg, the 'Caisse nationale d'assurance-maladie des ouvriers ' (national sickness-insurance fund for manual workers);
        in the Netherlands, the 'Algemeen Nederlands Onderling Ziekenfonds ' (ANOZ, general sickness fund of the Netherlands), Utrecht.
       Assistance from a doctor, dentist or dispensing chemist may be sought without first contacting ANOZ.
(c) For persons insured in Italy, benefits for tuberculosis can be provided only on production of a certificate issued by the 'Istituto nazionale
       del/a previdenza sociale ' (INPS, national social welfare institute).
                                                                         NOTES
( 1 ) Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
        Irl = Ireland, I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
( 2 ) Complete only if the form is drawn up at the request of the institution of the place of stay.
( 3 ) Postal code, town , street, number, country.
( 4) Put a cross in the box preceding the appropriate subject .
( 5 ) Include only those members of the family who are temporarily going to another Member State .
 ( 6 ) Complete only if the address of the members of the family differs from that of the worker or pensioner.
 ( 7 ) These two items are alternative . Give only that which is applicable and put a cross in the corresponding box .
                                                                                                                                                 CD
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                           See Instructions overleaf
 Social Security Regulations
                                                                                                     E 112               (1 )
                   CERTIFICATE CONCERNING THE RETENTION OF THE RIGHT TO
                SICKNESS OR MATERNITY BENEFITS CURRENTLY BEING PROVIDED
                                   Reg. 1408/ 71 : Art. 22.1 . b.i; Art. 22.1 . c.i; Art. 22.3
                                           Reg. 574172: Art. 22.1 and 3 ; Art. 23
The competent institution should issue this form to the worker. If the worker is going to the United Kingdom, one
copy of the form should also be sent to the Department of Health and Social Security, Overseas Group, Newcastle­
upon-Tyne
  1     Worker
  1.1   Surname                        Forenames                                     Maiden name            Date of birth
  1.2   Address in the competent country ( 2 ):
  1.3   Address in the country to which the worker is going ( 2 ) ( 3 ):
  1.4   Insurance number :
  2      Member of the family going to another Member State
  2.1   Surname                        Forenames                                     Maiden name            Date of birth
  2.2   Address in the competent country ( 2 ) ( 4 ):
  2.3   Address in the country to which the person concerned is going ( 2 ):
 3      The person shown         ( 5 ) [j in box 1       [j in box 2
        is authorized to retain the right to receive sickness and maternity insurance benefits in kind
        in                                               ( country), where he/she is going
 3.1    ( 5 ) Q] to take up his/her residence there
 3.2    (5 ) P] to receive treatment there at/from :
                                                                                                       ( 6)
 4      These benefits may be provided on production of this certificate,
 4.1    until
                                                                                                                              ©
 ---pagebreak---                                                                                                                              E 112
   5       The report of our examining doctor
  5-1      ( 5 ) [J is attached to this form in a sealed envelope
   5.2     (5 ) Q] was sent on                                      to ( 7)
   5.3     (5 ) Q will be sent by us on request
   5-4     ( 5) [~] has not been drawn up.
   6        Competent institution
   6.1     Name :
   6.2     Address ( 2 ):
   6.3      Stamp
                                                                                        6.4     Date :
                                                                                        6.5     Signature
                                                                INSTRUCTIONS
                   Please complete this form in block letters, writing on the dotted lines only.
 Information for the insured person
 You should submit this form as soon as possible to the sickness and maternity insurance institution of the place where you are going, i.e.
in Belgium, the mutualité ' (local sickness insurance fund) of your choice;
in Denmark, the competent 'amtskommune ' (local administration). In the commune of Copenhagen, the 'magistrat (municipal ad­
ministration) ; in the commune of Frederiksberg, the 'kommunalbestyrelse ' (municipal administration). Assistance from a doctor, dentist
 or dispensing chemist may may be sought without first contacting the said institutions. Particulars about doctors and dentists available
may be obtained from the local 'social- og sundhedsforvaltning ' (social and health authority);
in Germany, the 'Allgemeine Ortskrankenkasse ' (AOK, local general sickness fund);
in France, the ' Caisse primaire d'assurance-maladie ' (local sickness insurance fund);
in Ireland, the Health Board in whose area the benefit is sought;
in Italy, the provincial office of the ' Istituto nazionale per l'assicurazione contro le malattie ' (INAM, national sickness insurance institute);
 in Luxembourg, the ' Caisse nationale d'assurance-maladie des ouvriers ' (national sickness insurance fund for manual workers);
 in the Netherlands, any sickness fund competent for the place of residence or, in case of temporary stay, the 'Algemeen Nederlands
 Onderling Ziekenfonds ' (ANOZ, general sickness fund of the Netherlands), Utrecht. Assistance from a doctor, dentist or dispensing chemist
 may be sought without first contacting ANOZ;
 in the United Kingdom, the medical service (doctor, dentist, hospital, etc.) from which treatment is requested.
                                                                       NOTES
  (1 ) Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
       Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
  (2)  Postal code, town , street, number, country.
  (3)  Indicate only if the form concerns the worker himself.
  (4)  Indicate only if the address of the member of the family is different from that of the worker.
  (5)  Put a cross in the square preceding the appropriate subject.
  (6)   Specify who will be providing treatment, if known .
  (7)   Name and address of the institution to which the medical report has been sent.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                        See ' Instructions' overle af
 Social Security Regulations
                                                                                                    E 113                 C1 )
             HOSPITALIZATION : NOTIFICATION OF ENTERING AND LEAVING HOSPITAL
                 Reg. 1408/ 71 : Art. 19 ; Art. 22 ; Art. 25.1 and 3.i; Art. 31 . a ; Art. 52.a ; Art. 55.1
                 Reg. 574/ 72: Art. 17.6 ; Art. 20.6 ; Art. 21.2 ; Art. 22.2 and 3 ; Art. 23 ; Art. 26.3 ;
                              Art. 27 ; Art. 31.2 and 3 ; Art. 60.5 ; Art. 62.8 ; Art. 63.2
This form should be drawn up in the event of refund of benefits in kind on the basis of actual expenditure. To be
completed by the institution of the place of residence or stay: part A to notify entry into hospital, part B to notify
leaving hospital. To be sent to the competent institution. If the competent institution is an institution of the United
Kingdom, this form is not required.
  1     Competent institution
  1 .1  Name :
  1 .2  Address ( 2 ) :
        (3) Qj Worker                              j_| Pensioner
  2
         (3 ) [H Unemployed person                 Q Pension claimant
  2.1   Surname                     Forenames                                  Maiden name                  Date of birth
  2.2   Address in the country of residence or stay ( 2 ):
  2.3   Insurance number :
  3      Member of the family who is in hospital
  3.1   Surname                     Forenames                                  Maiden name                  Date of birth
  3.2   Address in the country of residence or stay ( 2 ) (4):
  4      Reference :
  4-1    (3) Q your form                                   of                                 (5)
  4.2    (3 ) □ our form E 107 of                                             (date).
                                                                                                                               ©
 ---pagebreak---                                                                                                                         E 113
A. Notification of entry into hospital
  5          The person shown              ( 3 ) Q in box 2          Q] in box 3
  5.1        entered hospital on                                                          (date),
  5.2        namely ( 6 )                                                                                                    ,
  5.3        because of                    ( 3 ) Q] sickness         Q maternity                       an accident at work ( 7 )
                                           (3 ) Q an occupational disease ( 8).
  5.4        He/she will probably stay in hospital until :
   5.5       Q ( 9 ) Supporting documents or medical report attached .
B. Notification of leaving hospital
   6.        The hospitalization notified
              ( 3 ) Q by our form E 113 dated
              ( 3 ) Q at part A above
             ended on
        I
    7         Institution of the place of residence or stay
    7.1      Name :
    7.2      Address ( 2 ):
    7.3      Stamp
                                                                                       7.4      Date :
                                                                                        7.5     Signature
                                                                  INSTRUCTIONS
                   Please complete this form in block letters, writing on the dotted lines only.
                                                                        NOTES
 ( 1 ) Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
       Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
 ( 2 ) Postal code, town , street, number, country.
 ( 3 ) Put a cross in the square preceding the appropriate subject.
 ( 4 ) To be indicated if the address of the member of the family is different from that mentioned in box 2 .
 ( 5 ) Number and date of issue of the form certifying the insured person 's entitlement to benefits .
 ( 6 ) Name of hospital .
 ( 7 ) If the patient is insured in Belgium , indicate in the box below the name and address of the employer :
             Name of employer or firm :
             Address ( 2 ):
 (8)      Indicate if possible .
 (9)      Put a cross in this square, if applicable .
                                                                                                                                        ©
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                            See ' Instructions ' on page 3
 Social Security Regulations
                                                                                                        E 114                  (1 )
                           GRANT OF PROSTHESES, MAJOR APPLIANCES, ETC .
               Reg. 1408/ 71 : Art. 19 ; Art. 22 ; Art. 24 ; Art. 25.1 and 3. i ; Art. 31 . a ; Art. 52.a ; Art. 55.1
                   Reg. 574172: Art. 17.7 ; Art 20.6 ; Art. 21.2 ; Art. 22.2 and 3 ; Art. 23 ; Art. 26.3 ;
                            Art. 27 ; Art. 31.2 and 3 ; Art. 60.6 ; Art. 62.8 ; Art. 63.2 and 3
This form should be drawn up in the event of refund of benefits in kind on the basis of actual expenditure. The insti­
tution of the place of residence or stay should complete part A, and send to the competent institution one or two
copies of the form depending on whether this notification concerns the case provided for at point 7. 1 or at point
7.2. If the competent institution decides it must oppose the granting of benefits, it should complete part B and return
a copy of the form to the institution of the place of residence or stay. If the competent institution is an institution of
the United Kingdom, this form is not required.
A. Notification
  1 | Competent institution
  1.1    Name :
  1.2    Address ( 2 ):
  2 J (3) (4) O Worker                       Q Unemployed person Q Pensioner
  2.1    Surname                        Forenames                                  Maiden name                  Date of birth
  2.2    Address in the country of residence or stay ( 2 ):
  2.3    Insurance number :
m         Member of the family concerned
  3.1    Surname                        Forenames                                  Maiden name                  Date of birth
  3.2    Address in the country of residence or stay ( 2 ) ( 5 ):
  4       Reference :
  4-1     (3 ) Q your form                                                of                                         ( 6)
  4.2     ( 3) □ our form E 107 of                                                      (date).
                                                                                                                                    ©
 ---pagebreak---                                                                                                E 114
5    Our medical service has recognized, for the person shown
     (3) EH in box 2                  EH ' n ^ox ^
5.1  (3) EH the necessity             EH the extreme urgency
 5.2 of the following benefits :
 6   [J Please find attached the report of our examining doctor (7 ).
 7   The benefits mentioned at point 5.2
 7.1 (3) EH have already been provided in view of the urgent nature of the case, on
 7.2 (3) EH wiH be provided unless we receive any reasons for objection on your part within fifteen days of the
               date of despatch of this notification .
 8   Institution of the place of residence or stay
 8.1 Name :
 8.2 Address ( 2 ):
 8.3 Stamp
                                                                     8.4     Date :
                                                                     8.5     Signature
B. Reasons for objection on the part of the competent institution, if any
  9   Institution of the place of residence or stay
 9.1 Name :
 9.2 Address ( 2 ):
 10  With reference to point 7.2 above, we hereby inform you that the benefits indicated at point 5.2 cannot be
     granted .
      Reason :
                                                                                                              ©
 ---pagebreak---                                                                                                                     E 114
  11        Competent institution
   11.1     Name :
   11.2 Address ( 2 ):
   1 1 .3 Stamp
                                                                                        11.4  Date :
                                                                                        11.5  Signature
                                                                INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                                       NOTES
( 1 ) Symbol of the country to which the institution completing part A of the form belongs : B = Belgium ; Dk = Denmark ; D = Germany;
      F = France ; Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
( 2 ) Postal code, town , street, number, country.
( 3 ) Put a cross in the square preceding the appropriate subject.
( 4) If the patient is insured in Belgium, give name and address of employer in the box below :
          Name of employer or firm :
          Address ( 2 ):
( 5 ) Indicate only if the address of the member of the family is different from that mentioned in box 2 .
( 6 ) Number and date of issue of the form certifying that the person concerned is entitled to benefits.
( 7 ) If the medical report is attached to the form , put a cross in the square provided .
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                               See ' Instructions ' on page 3
 Social Security Regulations
                                                                                                           E 115                  (1 )
                        CLAIM FOR CASH BENEFITS FOR INCAPACITY FOR WORK
                     Reg. 1408/ 71 : Art. 1 9.1 . b ; Art 22.1 . a.ii ; Art 25.1 . b ; Art 52.b ; Art 55.1 . a.ii
                  Reg. 574/ 72: Art 18.2 and 3 ; Art 24 ; Art 26.5 and 7 ; Art 61.2 and 3 ; Art 64
If the form is drawn up for a worker in active employment, one copy only should be completed and sent to the com­
petent institution for sickness and maternity insurance or for 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 competent institution for unemployment insurance, the other to the corresponding institution
of the country to which the unemployed person has gone to seek employment (see also note 8).
   1     Competent institution
  1.1    Name :
  1.2    Address ( 2 ):
   2     (3 ) LJ Worker                FL Unemployed person
  2.1    Surname                      Forenames                                         Maiden name                Date of birth
  2.2    Address in the competent country ( 2 ):
  2.3    Address in the country of residence or stay ( 2 ):
  2.4    Insurance number :
  2.5    holds form E 119 issued on                                                              ( 4)
         and form E 303 issued on                                                                ( 4)
   3 J Employer (5)
  3.1    Name of employer or firm :
  3.2    Address ( 2 ):
  3.3    Nature of business :
m A       I I ( 6) Claim for benefits
  4      The person shown in box 2 applied on                                                    ( date)
         for cash benefits for incapacity for work due to
  4.1    ( 3 ) Q] sickness ( 7 )         Q maternity
         (3) Q accident at work sustained on                                                      (date )
         ( 3 ) Q] occupational disease
                                                                                                                                       CD
 ---pagebreak---                                                                                                          E 115
 5       The certificate of the doctor treating him/ her
         (3 ) □ is attached                \~\ could not be supplied .
  6      In the opinion of our examining doctor,                           (3) Q whose report is attached
                                                                          (3 ) I I whose report will be sent to you
                                                                                   as soon as possible ,
  6.1    (3) Q the incapacity for work began on
                   and will probably continue until
  6.2    ( 3 ) Q there is no incapacity for work (8).
 7       ( 3 ) M The person concerned has not complied with the conditions of our legislation , Explain below :
  8      ( 3 ) [j The incapacity for work was presumably caused by an accident for which a third party was
                    responsible.
8.1       (3) Q A report on this accident with the address of the third party involved is attached to this form .
  9       (3) CH We are willing to provide cash benefits 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 benefits .
  10      ( 3) n We are not w ' H ' n9 t0 provide cash benefits to the person concerned on your behalf.
  B       M ( 6 ) Extension of the incapacity for work
  11     with reference to
  11.1 (3) Q our form E 115 of                                                     (date)
  1 1 .2 (3 ) Q your form E 117 of                                                 (date)
  11.3 we wish to inform you that, in the opinion of our examining doctor
         ( 3 ) Q] whose report is attached
          ( 3 ) Q whose report will be sent to you as soon as possible,
         the person shown in box 2 will probably remain incapable of work until
                                            inclusive .
  12      Institution of the place of residence or stay
  12.1    Name :
  12.2 Address ( 2 ):
  12.3 Stamp
                                                                          12.4   Date :
                                                                          1 2.5  Signature
                                                                                                                      (D
 ---pagebreak---                                                                                                                       E 115
                                                               INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                                      NOTES
( 1 ) Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany; F = France ;
      Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
( 2 ) Postal code, town , street, number, country.
( 3 ) Put a cross in the square preceding the appropriate subject.
( 4) Complete only if the form concerns an unemployed person .
( 5 ) For unemployed persons, indicate the last employer.
( 6 ) Complete either part A or part B and put a cross in the square corresponding to the part completed .
( 7 ) Or accident other than accident at work .
( 8 ) Please attach a copy of form E 118 sent to the person concerned .
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                                See ' Instructions' on page 3
 Social Security Regulations
                                                                                                             E 116                  n
                        MEDICAL REPORT RELATING TO INCAPACITY FOR WORK
              ( SICKNESS, MATERNITY, ACCIDENT AT WORK, OCCUPATIONAL DISEASE )
  Reg. 1408/ 71 : Art. 19.1 . b ; Art. 22.1 . a. ii, l.b.ii and l.c.ii ; Art. 25.1 .b ; Art. 52.b ; Art. 55.1 . a. ii, 1 . b.ii and 1 . c.ii
         Reg. 574/ 72: Art. 18.2 and 3 ; Art. 24 ; Art. 26.5 and 7 ; Art. 61.2 and 3 ; Art. 64 ; Art. 65.2 and 4
 To be completed by the doctor of the institution which draws up form E 1 15 ; to be attached to that form and sent
under sealed cover in case of sickness or maternity. For Belgium, this form should always be sent first to the Belgian
institution competent for sickness insurance.
  1      Competent institution to which the form is addressed
  1.1    Name :
  1.2    Address ( 2 ):
  1.3    Reference : our form E 116 of                                                               (date)
  2      Attached to form                     (3 ) □ E 115 of                                                         (date )
  3       (3) rj Worker                 I I Unemployed person
  3.1    Surname                         Forenames                                       Maiden Name                  Date of birth
  3.2    Address in the country of residence or stay ( 2 ):
  3.3    Insurance number :
  4      [] (4) Part A. First medical report
  5       I the undersigned,                                                doctor of medicine, after having examined the person
         mentioned above
         on
  5.1    consider that it is
          (3) Q] a case of sickness (5)              Q a case of maternity
  5.2    that it is probably
          (3) Q an accident at work                      an occupational disease
  5.3    and certify as follows :
                                                                                                                                             ©
 ---pagebreak---                                                                                                E 116
6    To be completed in the case of sickness ( 5 ), maternity, or occupational disease
6.1  Medical history and present symptoms ( 6 ):
6.2  Clinical examination :
6.3  General condition :                  Weight :                Height :             (6)
6.4  Other observations :
6.5  Special examinations ( 7 ):
6.6  Diagnosis :
6.7  Conclusions :
6.8  ( 3 ) Q The person concerned has not been found unfit for work
6.9  ( 3 ) Q The person concerned has been found to be unfit for work
     from                              to
6.10 ( 3) Q] The person concerned will be given a further medical examination
              on
7    To be completed in the case of a verified or presumed accident at work
7.1  This accident has resulted in the following injuries ( 8 ):
7.2  These injuries         ( 3) fj have had                Q will have the following effects ( 9):
7.3  \_j ( 10) The person concerned needs medical treatment.
7.4  His incapacity for work began on
7.5  The injured person is being treated
     (3) Q at his home                             Q at the doctor's home
     ( 3 ) [J in hospital                          Q elsewhere.
     Address ( 2 ) ( 11 ):
 ---pagebreak---                                                                                                                                   E 116
   8         [_J (4) Part B. Final medical report ( 12 )
   9         The treatment ended on
   10       The injuries
   10.1 (3) Q were consolidated on
                                              without after-effects .
   10.2 (3) Q] were consolidated on
                                              and will probably have the following consequences :
   11        Detailed description of the injured person 's condition after recovery or at the end of the medical treatment :
   12        Part C
   12.1 ( 10) Q The person concerned needs further treatment.
   12.2 ( 10 )            The person concerned is fit for work from
   131       Institution of the place of residence or stay
   13.1      Name :
   13.2     Address ( 2 ) :
   13.3     Stamp
                                                                                          13.4    Date :
                                                                                          13.5    Doctor's signature
                                                                INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                                       NOTES
( 1 ) Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
       Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
( 2)   Postal code, town , street, number, country.
(3)    Put a cross in the square preceding the appropriate subject .
(4)    Complete either part A or part B , as applicable, and put a cross in the corresponding square .
(5)    Including accidents other than accidents at work .
(6)    Information to be given only where necessary.
(7)    Indicate the type of examination and the date .
(8)      Indicate the type and nature of the injuries and the part of the body injured : fracture of arm , bruising of head , fingers, internal injuries,
       asphyxia, etc .
( 9 ) Indicate the certain or probable consequences of the injuries verified : death , permanent or temporary incapacity, total or partial , in
        case of temporary incapacity indicate the probable duration .
( 10 ) Put a cross in this square, if applicable.
( 11 ) If the injured person receives treatment in hospital, please give name of hospital .
( 12 ) To be completed in the case of accident at work.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                                    See Instructions overleaf
 Social Security Regulations
                                                                                                             E 117                C)
              GRANTING OF CASH BENEFITS IN THE CASE OF INCAPACITY FOR WORK
                     Reg. 1408/ 71 : Art. 1 9.1 . b ; Art. 22.1 . a.ii ; Art. 25.1 . b ; Art. 52.b ; Art. 55.1 . a.ii
                     Reg. 574172: Art. 18.6 and 8 ; Art. 24 ; Art. 26.7 ; Art. 61.6 and 8 ; Art. 64
The competent institution should complete this form and send it to the institution of the place of residence or stay.
The competent institution should also inform the worker if cash benefits are paid by the institution of the place of
residence (Reg. 574/ 72, Art. 61.8).
   1 j Institution of the place of residence or stay
  1.1   Name
  1.2   Address ( 2 ):
  2     Reference : your form E 115 of                                                         (date ).
   3     (3) r~] The worker                                   [_] The unemployed person named below
  3.1   Surname                      Forenames                                            Maiden name                Date of birth
  3.2   Address in the country of residence or stay ( 2 ):
  3.3   Insurance number :
  4     (3) [_J is provisionally entitled to receive cash benefits
                  from                                     to                                     with possibility of extension
  4.1   ( 3 ) Q is not entitled to cash benefits.
                  Reason : see E 118 attached .
  4.2   (3) Q is no longer entitled to cash benefits from                                                                (date).
                  Reason : see E 118 attached .
  5     These benefits will be provided (4 )
  5-1   (3 )  Q   by us by international money order to the address given at point 3.2
  5.2    (3)  Q   by us on the return of the person concerned to our country
  5.3    (3)  Q   by you on our behalf
  5-4    (3 ) Q   by the employer to the address given at point 3.2 (5 )
  5.5    (3 ) [~] by the employer, from                                        to                             (6
                                                                                                                                     ©
 ---pagebreak---                                                                                                                       E 117
   6        ( 4) ( 7 )
   6.1     The allowance should be paid :
   6.2     for every day of the week, except                         (3)     Monday        Q Tuesday           j I Wednesday
                                           (3 ) j ( Thursday             I I Friday        [[] Saturday        j I Sunday.
   6.3     The daily net amount of this allowance is
                                                     ( 8 ) if the insured person is not in hospital
                                                     ( 8 ) if the insured person is in hospital .
  7         Please inform us as soon as possible of the result of
  7.1       (3) Q a                                                                   examination (9) .
  7.2       (3) Q administrative checks
  7.3       (3) Q a further medical examination, to be carried out about                         (date):.
    8 I Competent institution
   8.1      Name :
   8.2      Address ( 2 ):
   8.3      Stamp
                                                                                     8.4   Date :
                                                                                     8.5   Signature
                                                                INSTRUCTIONS
                   Please complete this form in block letters, writing on the dotted lines only.
                                                                     NOTES
( 1 ) Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
      Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
( 2 ) Postal code, town , street, number, country.
( 3 ) Put a cross in the square preceding the appropriate subject.
( 4) Need not be completed for unemployed persons for whom a form E 119 has been issued .
( 5 ) To be completed , where appropriate, by Danish institutions .
( 6 ) To be completed by German institutions.
( 7 ) Complete only in the case indicated at point 5.3 .
( 8 ) Indicate the amount in the currency of the competent country.
( 9 ) Indicate the type of medical examination requested ( radiography, analysis of           , etc .).
                                                                                                                                       ©
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                                     See ' Instructions' overleaf
 Social Security Regulations
                                                                                                                E 118                 n
          NOTIFICATION OF NON-RECOGNITION OR OF END OF INCAPACITY FOR WORK
              Reg. 1408/ 71 : Art. 19.1 .b ; Art. 22.1 . a. ii, b.ii, c.ii ; Art. 25.1 . b ; Art. 52.b ; Art. 55.1 . a.ii, b.ii, c.ii
                   Reg. 574/ 72: Art. 18.4 and 6 ; Art. 24 ; Art. 26.5 and 7 ; Art. 61.4 and 6 ; Art. 64
If this form relates to a worker in active employment, the institution of 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 worker 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 (of 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 for unemployment insu­
rance and the other to the institution of the country to which the unemployed person has gone to seek employment.
       j (2)        Worker                                      Q Unemployed person
  1.1     Surname                         Forenames                                           Maiden name                Date of birth   I
  1.2     Address in the country of residence or stay ( 3 ):
   1.3    Insurance number :
m          (2) Q Competent institution                          j I Institution of the place of residence or stay
  2.1     Name :
   2.2    Address ( 3 ) :
  3        ( 2 ) Q The facts which have been brought to our notice
          (2) Q] The examination carried out by our doctor on
                    show(s)
  3.1               (2 ) Q that your incapacity for work is only partial
  3.2              (2 ) Q that you are not unfit for work
  3.3              (2) Q] that your incapacity for work ended on                                                            (4)
          The last day for which you will receive cash benefits is
 [7]       (2) Q Institution of the place of residence or stay                               I I Competent institution
   4.1    Name :
   4.2    Address ( 3 ):
   4.3    Stamp
                                                                                     4.4      Date :
                                                                                     4.5      Signature
                                                                                                                                        ©­
 ---pagebreak---                                                                                                                       E 118
                                                               INSTRUCTIONS
Please complete this form in block letters, writing on the dotted lines only. It consists of four pages,
including the Annex, none of which may be left out even if it does not contain any relevant information .
Information for the worker or unemployed person
You may appeal against the decision which is notified to you by this document to the authority competent to hear your appeal in the com­
petent State or you may send your appeal to the authority competent to hear appeals in the country where you are staying or where you
are resident.
The names of these authorities are given in the Annex together with the time-limits and procedures for appeals.
For procedures and time-limits for appeal indicated in the Annex, you should follow the instructions given for the competent State.
In your case, the instructions given under number           apply­
                                                                     NOTES
( 1 ) Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
       Irl = Ireland ; I = Italy; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
( 2 ) Put a cross in the square preceding the appropriate subject.
 ( 3 ) Postal code, town , street, number, country.
 (4 ) Indicate the last day of incapacity for work.
                                                                                                                                       <D
 ---pagebreak---                                                                                               E 118 Annex
                              LEGAL REMEDIES AND PERIODS ALLOWED FOR APPEALS
                                             Reg . 574/72 : Art. 18.4 ; Art. 61.4
1 . BELGIUM
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 office of the clerk of the competent labour court within a period of one
month from the date on which you received notification of the decision .
Competent labour courts are :
a ) if you are domiciled in Belgium, the labour court of the district where you are domiciled ;
 b) 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 ;
 c ) if you have not been domiciled or resident in Belgium, the labour court of the district where you were last employed
       in Belgium .
 2 . DENMARK
 If you wish to contest the decision attached, you may,
 a ) as regards the daily allowance payable during the five weeks following the first day of absence in cases where
       the employer is bound to provide the daily allowance ( employer's period ), lodge an appeal with the 'dag
        pengeudvalg ' ( daily allowances committee );
 b) as regards the daily allowance payable beyond the 'employer's period ' or in cases where there is no 'employer's
        period ', lodge an appeal with the ' Sikringsstyrelse' ( national office for social security) within four weeks from
        the date on which you received notification of the decision .
 3 . GERMANY
 You may, within a period of one month from the date on which you received notification of the attached decision ,
 submit a written appeal against the decision to the German competent institution indicated in box 2 or box 4 of form
  E 1 18 or to the institution of the place of residence or stay indicated in the same boxes .
  4.   FRANCE
  If you wish to contest the decision attached, you may, within a period of two months from the date on which you
  received notification of the decision , lodge an appeal with the chief physician of the local sickness insurance fund
  indicated in the box below :
             Name : ...
             Address :
   5 . IRELAND
   If you do not agree with the decision attached, you may submit a request to the Department of Social Welfare, Dublin ,
   stating your wish that your case be laid before an Appeals Officer. Such a request should be made within 21 days from
  the date on which you received this decision .
   6.   ITALY
   Decisions of I NAM ( sickness insurance)
   Insured persons wishing to contest a decision rejecting a claim , taken by the competent medical authority of I NAM
   (' Primo Medico di Sezione') in medical matters ( existence of a state of illness, incapacity for work, objective need
   for a benefit, etc .), may lodge an appeal within 15 days from the date on which notification of the decision
   was received, with the ' Collegio Medico Provinciale' through the ' Sezione Territoriale I NAM '.
                                                                                                                           <D
 ---pagebreak---                                                                                               E 118 Annex
 Where appropriate, the person concerned should name in his letter of appeal a doctor of his choice who, in that case,
 will form part of the said ' Collegio' attached to the competent provincial office of INAM .
 In all cases, the cost of fees due to the doctor designated by the person concerned and any travel expenses incurred
 by him should be borne by the insured person .
 If the ' Collegio Medico Provinciale' confirms the official medical decision of the ' Primo Medico di Sezione', the person
 concerned may appeal , within a period of one year from the date on which notification of the decision was received,
 to the ' Comitato Esecutivo ' of INAM , through the ' Sede provinciale' ( provincial office) (Art. 6 of Law No 138 of 11
January 1943 ).
 Any appeals against a rejection of a claim for benefits on grounds of non-compliance with the requirements of the
 legislation of the country of residence should likewise be submitted to the ' Comitato Esecutivo' of INAM .
 Decisions of IN PS ( tuberculosis)
An appeal against a decision rejecting a claim, taken by INPS as regards benefits for tuberculosis, may in the first
 instance be lodged , within a period of 90 days from the date on which notification of the decision was received,
 with the ' Comitato Provinciale ' attached to the provincial office that took the decision .
 If, at the end of the period of 90 days from the date on which the appeal was submitted, the ' Comitato Provinciale
 has still not issued a ruling , the appeal must be regarded as rejected ; in that case, the person concerned may, within
 90 days from the end of that period, lodge an appeal in the second instance with the ' Comitato speciale per I'assicura­
zione contro la tubercolosi ' .
 If, within 90 days from the date on which it was submitted, no decision has been taken on the second appeal , the person
 concerned may, within a period of five years, take the matter to court.
 Decisions of I NAIL (accidents at work and occupational diseases)
An insured person wishing to contest a decision of I NAIL may, within 60 days from the receipt of the notification
sent to him, inform I N Al L, by registered letter with advice of delivery or notice of receipt, of the reasons why he considers
that the decision is unjustified ; 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 certificate 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 from the date of the advice of delivery
or the notice of receipt referred to above, or if he is not satisfied with the reply, he may take I NAIL to court over the
matter (Art. 104 of the 'Testo unico ' approved by presidential decree DPR No 1124 of 30 June 1965 ).
The letter setting out the reasons why the insured person does not agree with a decision of I NAIL may be sent to I NAIL
either directly or through the institution of the place of residence or stay.
7 . 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' in Luxembourg , within a period of 40 days from the date on which you received
notification of the decision .
Together with your appeal , you should send a detailed statement from the ' Inspection des institutions sociales' in
Luxembourg , testifying that you have already applied to that inspectorate for an administrative settlement of the dispute.
8 . NETHERLANDS
If you do not agree with the decision attached, you have the right to lodge an appeal with the competent Netherlands
institution within a reasonable period of time.
9 . UNITED KINGDOM
If you do not agree with the decision attached, you may, within 21 days from the date of receipt of the decision ,
lodge an appeal with the Department of Health and Social Security, Overseas Group, Newcastle-upon-Tyne, or
the Ministry of Health and Social Services, Overseas Branch , Belfast, as appropriate .
                                                                                                                              ©
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                     See ' Instructions' on page 3
Social Security Regulations
                                                                                                  E 119                1
                  CERTIFICATE CONCERNING THE ENTITLEMENT OF UNEMPLOYED
                   PERSONS AND THE MEMBERS OF THEIR FAMILY TO SICKNESS
                                    AND MATERNITY INSURANCE BENEFITS
                                             Reg. 1408/ 71 : Art. 25.1 and 3.i
                                                 Reg. 574/ 72: Art. 26. 1
The competent institution should issue the form to the unemployed person, or send it to the institution of the place
of residence or stay if it was drawn up at the latter institution's request.
pi I Institution of the place of residence or stay (2)
  1.1   Name :
  1.2   Address ( 3 ):
  1.3   Reference : your form             (4) M E 107 of                        \_\ E 115 of
  2 J Unemployed person
  2.1   Surname                        Forenames                               Maiden name                Date of birth
  2.2   Address in the country where the person concerned is seeking employment ( 3 ):
  2.3    Insurance number :
  3 | Last employer
  3.1    Name of employer or firm :
  3.2    Address ( 3 ):
  4      The person concerned mentioned above is entitled to sickness and maternity insurance benefits ( benefits
         in kind and cash benefits for himself, benefits in kind for the members of his family), provided that the unem­
         ployment insurance institution of the country where he has gone to seek employment has sent to the sickness
         and maternity insurance institution of that country a form E 303 containing the certified statement provided
         for in Article 26.2, first subparagraph, of Regulation 574/72 .
  5       Benefits in kind may be provided
  5-1     (4) Q for a period not exceeding that fixed for entitlement to unemployment benefits
 5.2      (4) Q for cases of sickness that have occurred until                                     inclusive
                             and for                                                days                     weeks .
                                                                                                                         ©
 ---pagebreak---                                                                                                        E 119
6      In the case of incapacity for work, cash benefits may be provided
61     (4) Q for a period not exceeding that fixed for entitlement to unemployment benefits
6.2    (4) Q for cases of sickness that have occurred until                                   inclusive
                and for                                                             days             weeks .
7     These cash benefits will be paid
7.1    (4) Q by us by international money order to the above address
7.2   (4) r~] by you on our behalf.
8 | (5)
8.1   The benefit should be paid :
8.2   (4) Q for the same days of the week as those laid down for unemployment insurance
8.3   (4) Q for every day of the week, except                      (4) Q Monday            Q Tuesday
                (4) [~] Wednesday              Thursday       [H Friday            Q Saturday      F] Sunday.
9 | (5)
9.1   The daily net amount of this benefit :
9.2   (4) Q is the same as that laid down for unemployment insurance
9.3   (4) Qj is                                     (6) if the insured person is not in hospital
                                                    ( 6 ) if he is in hospital .
10    Competent institution ( 7 )
10.1  Name :
10.2 Address ( 3 ):
1 0.3 Stamp
                                                                       10.4     Date :
                                                                       10.5     Signature
                                                                                                              <D
 ---pagebreak---                                                                                                                                    E 119
                                                                 INSTRUCTIONS
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 even if it does not contain any relevant information .
Information for the unemployed person
a) In order to obtain sickness insurance benefits in kind for yourself and for members of your family, you should apply to one of the
     following institutions:
     in Belgium, the 'mutualité ' (local sickness insurance fund) of your choice;
     in Denmark, the competent 'amtskommune ' (local administration). In the commune of Copenhagen, the 'magistrat (municipal
     administration); in the commune of Frederiksberg, the 'kommunalbestyrelse ' (municipal administration). Assistance from a doctor,
     dentist or dispensing chemist may be sought without first contacting the said institutions. Particulars about doctors and dentists
      available may be obtained from the local 'social- og sundhedsforvaltning ' (social and health authority);
     in Germany, the 'Allgemeine Ortskrankenkasse ' (AOK, local general sickness fund);
     in France, the 'Caisse primaire d'assurance-maladie ' (local sickness insurance fund);
     in Ireland, the Health Board in whose area the benefit is sought;
     in Italy, the provincial office of the 'Istituto nazionale per l'assicurazione contro le malattie ' (INAM, national sickness insurance institute);
     in Luxembourg, the ' Caisse nationale d'assurance-maladie des ouvriers' (national sickness insurance fund for manual workers);
     in the Netherlands, any sickness fund competent for the place of residence or stay;
     in the United Kingdom, the medical service (doctor, dentist, hospital, etc.) from which treatment is requested.
     In addition to this form E 1 19, you should have a copy of form E 303/3 on which point 7 will have been completed by the unemploy­
     ment insurance institution of the country where you are seeking employment.
b) In order to obtain cash benefits for yourself in case of incapacity for work or hospitalization, you should submit — except if you are in
     the Netherlands — the forms mentioned at point a) above and a certificate of incapacity for work issued by the doctor treating you :
     — to the insurance institution indicated under point a) above if you are in Belgium, Germany, France, Italy or Luxembourg;
     — to the local 'social- og sundhedsforvaltning ' (social and health authority) and, in the communes of Copenhagen, Odense, Ålborg
           and Århus, to the 'magistrat (municipal administration), if you are in Denmark;
     — to the local agent of the Department of Social Welfare, Dublin, or direct to the Department, if you are in Ireland;
     — to the Department of Health and Social Security, Overseas Group, Newcastle-upon-Tyne, or to the Ministry of Health and Social
           Services, Overseas Branch, Belfast, as appropriate, if you are in the United Kingdom.
                                                                         NOTES
(1 )   Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
       Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)    Complete only if the form is issued at the request of the institution of the place of residence or stay.
(3)    Postal code, town , street, number, country.
(4)    Put a cross in the square preceding the appropriate subject.
(5)    Complete this box only if the cash benefits have to be paid by the institution of the place of residence or stay.
(6)    Show the amount in the currency of the competent country.
(7)    If this form is issued by an institution in the Netherlands, the benefits in kind are payable by the ' Ziekenfondsraad ' ( sickness fund coun­
       cil ), Amstelveen ; the cash benefits are payable by the institution signing the form .
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                     Sea ' Instructions' on page 4
Social Security Regulations
                                                                                                 E 120                 (1 )
                 CERTIFICATE OF ENTITLEMENT TO BENEFITS IN KIND FOR PENSION
                                CLAIMANTS AND MEMBERS OF THEIR FAMILY
                                                  Reg. 1408/ 71 : Art. 26.1
                                                   Reg. 574/ 72 : Art. 28
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 of his place of residence. If the pension claimant resides in the United Kingdom,
both copies of the form should be sent direct to the Department of Health and Social Security, Overseas Group,
Newcastle-upon-Tyne. On receipt of the copies in question, the institution of the place of residence should
complete part B and send one of the copies to the institution mentioned in box 6. If necessary, the two copies should
first be sent to the institution that has to complete boxes 5 and 6.
A Notification of entitlement
~n        Institution of the place of residence ( 2)
  1.1     Name :
  1.2    Address ( 3 ) :
  1.3     Reference : your form E 107 of                                         (date)
  2       Pension claimant
  2.1    Surname                      Forenames                               Maiden name                Date of birth
  2.2    Address in the country of residence ( 3 ):
  2.3    Insurance 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
         (4) Q old age                       Q invalidity                      Q survival
         (4) Q accident at work              [J occupational disease.
 3.2     (5) []]] The investigation of this claim has shown that the person concerned is entitled to receive a pension
                   from us .
                                                                                                                            ©
 ---pagebreak---                                                                                                E 120
 4     Institution which completed box 3
 4.1  Name :
 4.2  Address ( 3 ) :
 4.3  Stamp
                                                                     4.4     Date :
                                                                     4.5     Signature
      To be completed by the institution to which the claim for a pension was submitted or by the sickness
 5     and maternity insurance institution of the country in which this claim was submitted
 5.1  The claimant indicated in box 2 and the members of his family are entitled to sickness and maternity
      insurance benefits in kind ( 6)
 5.2  from (date):                                     until this certificate is cancelled .
 6     Institution which completed box 5
 6.1  Name :
 6.2  Address ( 3 ):
 6.3  Stamp
                                                                     6.4     Date :
                                                                     6.5     Signature
B. Notification of registration or non - registration
  7     Competent institution
  7.1  Name :
  7.2 Address ( 3 ):
                                                                                                           ©
 ---pagebreak---                                                                                                  E 120
 8 | (7> □
 8.1    The claimant indicated in box 2 and the members of his family could not be registered because :
PH <7) □
 9.1    The claimant indicated in box 2 and the members of his family indicated below were registered on
                                   ( date).
  1 0| Registered members of the family
        Surname                    Forenames                               Maiden name        Date of birth
 10.1
 10.2
 10.3
 10.4
 10.5
 10.6
 10.7
 10.8
 11 j Institution of the place of residence
 11.1   Name :
 11.2 Address ( 3 ):
 1 1 .3 Stamp
                                                                    1 1 .4 Date :
                                                                    11.5 Signature
 ---pagebreak---                                                                                                                                   E 120
                                                                  INSTRUCTIONS
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 even if it does not contain any relevant information .
Information for the worker
a)    This certificate gives you and the members of your family the right to receive benefits in kind in case of sickness or maternity in your
     country of residence.
b) You should, as soon as possible, submit the two copies of this certificate in your possession to one of the following insurance institutions:
     in Belgium, the mutualité ' (local sickness insurance fund) of your choice;
     in Denmark, the competent 'amtskommune ' (local administration). In the commune of Copenhagen, the 'magistrat (municipal
     administration); in the commune of Frederiksberg, the 'kommunalbestyrelse ' (municipal administration);
     in Germany, the 'Allgemeine Ortskrankenkasse ' (AOK, local general sickness fund);
     in France, the 'Caisse primaire d'assurance-maladie ' (local sickness insurance fund);
     in Ireland, the Health Board in whose area the benefit is sought;
     in Italy, the provincial office of the 'Istituto nazionale per l'assicurazione contro le malattie ' (/NAM, national sickness insurance institute);
      in Luxembourg, the 'Caisse nationale d'assurance-maladie des ouvriers ' (national sickness insurance fund for manual workers);
     in the Netherlands, any sickness fund competent for the place of residence.
c)    You must inform the insurance institution to which you submit the form of any change of circumstances which might affect the right
     to benefits in kind, such as the grant of pension claimed or a change of your place of residence or stay or of that of a member of your
     family.
                                                                         NOTES
(1 )   Symbol of the country to which the institution completing part A of the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ;
        F = France ; Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)     Complete only if the form is issued at the request of the institution of the place of residence .
(3)     Postal code, town , street, number, country.
( 4)    Put a cross in the square preceding the appropriate subject.
(5)     Put a cross in this square, if applicable .
(6)     If the certificate is issued by an Italian insurance institution , the right to benefits for tuberculosis should be certified by the ' Istituto
        nazionale della previdenza sociale' ( INPS, national social welfare institute).
(7)    Complete box 8 or box 9, as appropriate, and put a cross in the corresponding square.
                                                                                                                                                     ©
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                    See Instructions' on page 4
Social Security Regulations
                                                                                              E 121                 (1
                         CERTIFICATE FOR THE REGISTRATION OF PENSIONERS
                                          AND THE KEEPING OF LISTS
                                               Reg. 1408/ 71 : Art. 28.1 . a
                                      Reg. 574/ 72: Art. 29. 1, 2 and 3 ; Art. 95.4
The institution which has to draw up this certificate in accordance with Art. 29.2 of Regulation 574/ 72 should com­
plete part A of the form and issue two copies to the pensioner or send them to the institution of the place of residence
if the form was requested by the latter institution. If the pensioner resides in the United Kingdom, the two copies
of the form should be sent direct to the Department of Health and Social Security, Overseas Group, Newcastle­
upon-Tyne. Where appropriate, the two copies should first be sent to the institution which has to complete boxes
5 and 6. The institution of the place of residence should, on receiving the two copies, complete part B and send one
copy to the institution shown in box 6.
A. Notification of entitlement
m        Institution of the place of residence ( 2 )
  1.1    Name :
  1.2    Address ( 3 ) :
  1.3    Reference : your form E 107 of                                          (date)
m        Pensioner
  2.1    Surname                     Forenames                                 Maiden name            Date of birth
   2 .?  Address in the country of residence (3 ):
   2.3   Date of transfer of residence, if applicable :
   2.4   Insurance number :
    3    To be completed by the institution responsible for payment of the pension
   3.1   The person concerned indicated above has been entitled to a pension for
         (4) Q old age                     Q invalidity                         Q survival
         (4) Q accident at work            |~] occupational disease
   3.2   since :
   3.3   Pension number :
                                                                                                                       ©
 ---pagebreak---                                                                                                    E 121
 4    Institution which completed box 3
 4.1  Name :
 4.2  Address (3 ):
 4.3  Stamp
                                                                       4.4    Date :
                                                                       4.5    Signature
      To be completed by the institution responsible for payment of the pension or by the sickness and
  ^   maternity insurance institution of the country responsible for payment of the pension
 5.1  The person concerned indicated in box 2 and the members of his family are entitled to sickness and maternity
      insurance benefits in kind from (date)
 5.2  The cost of the benefits to be provided in their country of residence - unless they reside in the competent
      country - will be borne by us
 5.3  from (date)                                   until this certificate is cancelled.
 5-4  (5 ) Q] With the issue of this certificate, form E 120 of
      ( date)                               is no longer valid .
  6 | Institution which completed box 5
 6.1  Name :
 6.2  Address ( 3 ):
 6.3  Stamp
                                                                       6.4    Date :
                                                                       6.5    Signature
B. Notification of registration or non-registration
  7    Institution indicated in box 6
  7.1  Name :
  7.2 Address ( 3 ):
                                                                                                                   (D
 ---pagebreak---                                                                                                  E 121
8 | («) □
8.1   The person concerned indicated in box 2 and members of his family could not be registered
8.2   (4) Q because the person concerned is already entitled to benefits in kind under the legislation of our
               country.
8.3   (4) \ ~\ Other reasons :
 9    < e) □
9.1   The person concerned indicated in box 2 and the members of his family have been registered .
9.2   Registered members of the family ( 7 ):
9.3   Surname                      Forenames                                Maiden name        Date of birth
9.4
9.5
9.6
9.7
9.8
9.9
9.10
9.11
9.1 2 The cost of these benefits should be borne by you ; the date from which the lump sum provided for in Art. 95
      of Regulation 574/72 should be calculated is :
10 j Institution of the place of residence
10.1  Name :
10.2 Address (3 ):
10.3 Stamp
                                                                     10.4 Date :
                                                                     10.5 Signature
 ---pagebreak---                                                                                                                                     E 121
                                                                  INSTRUCTIONS
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 even if it does not contain any relevant information .
Information for the pensioner
a)     You should, as soon as possible, send the two copies of this form to one of the following insurance institutions:
      in Belgium, the 'mutuality (local sickness insurance fund) of your choice;
      in Denmark, the competent 'amtskommune ' (local administration). In the commune of Copenhagen, the 'magistrat (municipal
      administration); in the commune of Frederiksberg, the 'kommunalbestyrelse ' (municipal administration);
      in Germany, the 'Allgemeine Ortskrankenkasse ' (AOK, local general sickness fund);
      in France, the 'Caisse primaire d'assurance-maladie ' (local sickness insurance fund);
      in Ireland, the Health Board in whose area the benefit is sought;
      in Italy, the provincial office of the 'Istituto nazionale per l'assicurazione contro le malattie ' (INAM, national sickness insurance institute);
      in Luxembourg, the 'Caisse nationale d'assurance-maladie des ouvriers ' (national sickness insurance fund for manual workers);
      in the Netherlands, any sickness fund competent for the place of residence.
b) You must inform the insurance institution to which you submit the form of any change of circumstances which might afffect the right
       to benefits in kind, such as suspension or withdrawal of pension, or change of your place of residence or of that of a member of your
       family.
                                                                          NOTES
 (1 )    Symbol of the country to which the institution completing part A of the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ;
         F = France ; Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
 (2)     Complete only if the form is drawn up at the request of the institution of the place of residence.
 (3)     Postal code, town, street, number, country.
 ( 4)    Put a cross in the square preceding the appropriate subject.
 (5 )    Put a cross in this square, if applicable.
 (6)     Complete box 8 or box 9, as applicable, and put a cross in the corresponding square.
 (7 )    To be completed by Netherlands institutions only.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                          See Instructions' on page 3
 Social Security Regulations
                                                                                                    E 122                 n
                CERTIFICATE FOR THE GRANT OF BENEFITS IN KIND TO MEMBERS
                                        OF THE FAMILY OF PENSIONERS
              Members of the family residing in another Member State than the pensioner
                                               Reg. 1408/ 71 : Art. 29.1 . a
                                                 Reg. 574/ 72: Art. 30. 1
The sickness insurance institution of the place of residence of the pensioner should complete part A of the form and
issue two copies to the pensioner, or send them to the institution of the place of residence of the msmbers of the
family if the form is drawn up at the request of the latter institution. If the members of the family reside in the United
Kingdom, the two copies of the form should be sent direct to the Department of Health and Social Security, Over­
seas Group, Newcastle-upon-Tyne. The institution of the place of residence should, on receiving the two copies
in question, complete part B and send one copy to the sickness insurance institution of the place of residence of the
pensioner. If the members of the family reside in several different countries, a separate certificate should be drawn up
for each of these countries.
A.     Notification of entitlement
ri I (2) Institution to which the form is addressed
  1.1    Name :
  1 .2  Address ( 3 ) :
  1.3    Reference : your form E 107 of (date)
   2 | Pensioner
  2.1    Surname                      Forenames                                   Maiden name               Date of birth
  2.2   Address ( 3 ) :
  2.3    Insurance number :
   3     Member of the family ( 4)
  3.1    Surname                       Forenames                                  Maiden name               Date of birth
  3.2   Address     (3 ) :
  4      The person concerned is entitled to receive sickness and maternity insurance benefits in kind for himself
         and for the members of his family.
  5      For the granting of these benefits to the members of the family, this certificate is valid
         (5) Q from                                               until receipt of notification of its cancellation
         ( 5) I I for 12 months from its date of issue ( 6).
                                                                                                                            CD
 ---pagebreak---                                                                                                 E 122
 6    Competent institution
 6.1  Name :
 6.2  Address ( 3 ):
 6.3  Stamp
                                                                 6.4     Date :
                                                                 6.5    Signature
B. Notification of registration
 7 I Competent institution
 7.1  Name :
 7.2  Address ( 3 ):
 8    ( 7 ) M The members of the family of the pensioner indicated in box 2 have not been registered . Reason :
 9     (7)     The following members of the family of the pensioner indicated in box 2 have been becanse :
 10    Registered members of the family
      Surname                    Forenames                               Maiden name          Date of birth
 10.1
 10.2
 10.3
 10.4
 10.5
 10.6
 10.7
 10.8
                                                                                                                ©
 ---pagebreak---                                                                                                                                   E 122
  11         Institution of the place of residence of the members of the family
  11.1       Name :
  11.2 Address ( 3 ):
  1 1 .3 Stamp
                                                                                           11.4    Date :
                                                                                           1 1 .5 Signature
                                                                  INSTRUCTIONS
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 even if it does not contain any relevant information .
Information for the pensioner
a)    This form gives the members of your family the right to receive sickness and maternity insurance benefits in kind in their country of
     residence under the legislation of that country, unless they are already entitled to such benefits under that legislation.
b) As soon as you have received the two copies of this form, you should send them to the members of your family who should present
      them immediately to a sickness and maternity insurance institution of their place of residence, i.e. :
     in Belgium, the 'mutualité ' (local sickness insurance fund) of their choice;
     in Denmark, the competent 'amtskommune ' (local administration). In the commune of Copenhagen, the 'magistrat (municipal
     administration); in the commune of Frederiksberg, the 'kommunalbestyrelse ' (municipal administration);
     in Germany, the 'Allgemeine Ortskrankenkasse ' (AOK, local general sickness fund);
     in France, the 'Caisse primaire d'assurance-maladie ' (local sickness insurance fund);
     in Ireland, the Health Board in whose area the benefit is sought;
     in Italy, the provincial office of the 'Istituto nazionale per l'assicurazione contro le malattie ' (INAM, national sickness insurance institute);
     in Luxembourg, the 'Caisse nationale d'assurance-maladie des ouvriers ' (national sickness insurance fund for manual workers);
     in the Netherlands, any sickness fund competent for the place of residence.
c)    This form is valid from the date and for the period indicated at point 5.
d) The members of your family must inform the insurance institution to which they have submitted the form of any change of circumstances
      which might affect the right to benefits in kind, in particular a change of their place of residence.
                                                                         NOTES
 (1)    Symbol of the country to which the institution completing part A of the form belongs : B = Belgium ; Dk = Denmark; D = Germany ;
        F = France ; Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
 (2)    Complete only if the form is drawn up at the request of the institution of the place of residence of the members of the family.
 (3)    Postal code, town , street, number, country.
 (4)    Complete only if the members of the family reside in the United Kingdom ; give details for one member of the family only.
 (5)    Put a cross in the square preceding the appropriate subject.
 (6)    If the form is issued by a French institution .
 (7)    Complete point 8 or 9, as appropriate, and put a cross in the corresponding square .
                                                                                                                                                     <D
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                           See ' Instructions overleaf
Social Security Regulations
                                                                                                      E 123                1
             CERTIFICATE OF ENTITLEMENT TO BENEFITS IN KIND UNDER INSURANCE
                    AGAINST ACCIDENTS AT WORK AND OCCUPATIONAL DISEASES
                                     Reg. 1408/ 71 : Art. 52.a ; Art. 55.1. a. i, b.i. and c.i
                               Reg. 574/ 72: Art. 60. 1 ; Art. 62.4 and 7 ; Art. 63. 1 and 3
If the form has been requested by the institution of the place of residence or stay of the person concerned by means
of form E 107r it should be sent to the said institution ; otherwise it should be issued to the worker. If the worker
goes to the United Kingdom, a copy of the form should also be sent to the Department of Health and Social Security,
Overseas Group, Newcastle-upon-Tyne.
  1       Institution of the place of residence or stay (2 )
   1.1   Name :
   1 .2  Address ( 3 ) :
   1.3    Reference : your form E 107 of ( date)
   2      Worker
    2.1   Surname                     Forenames                                     Maiden name                Date of birth
    2.2   Address in the competent country ( 3 ):
    2.3    Address in the country where the person concerned is going ( 3 ):
    2.4    Insurance number :
    3       On the grounds of
    3-1    ( 4) LJ ^e information supplied on your form E 107 of (date)
    3.2    (4) [_] the accident at work sustained on                                         (date)
                    which had the following consequences :
    3.3    (4) \_j the occupational disease diagnosed on                                               (date)
                    which had the following consequences :
    3-4    (4) LJ the authorization which we have granted to the person concerned to retain the right to benefits in kind
                    in                                          (country) where he is going
           (4) □ to take up his/her residence there                   Q to receive medical treatment
                                                                                                                             ©
 ---pagebreak---                                                                                                                                                                E 123
             the abovementioned worker may receive benefits in kind
     4       (4) LD for accident at work                                         Q for occupational disease
    4.1       (4)   Q     for a period laid down in the provisions of the legislation of his country of residence
    4.2       (4)   □     until
    4.3       (4)   Q     for a maximum of three months
    4.4       (4)   Q     for an unlimited period.
| 5 j The report of our examining doctor
    5-1      (4) Q is attached in a sealed envelope
    5.2      (4) Q has been sent on                                                                     to (5)
    5.3      (4) Q may be obtained from us on request
    5-4      (4) Q has not been drawn up.
    6 J Competent institution
    6.1      Name :
    6.2     Address (3 ):
    6.3     Stamp
                                                                                                               6.4       Date :
                                                                                                              6.5        Signature
                                                                              INSTRUCTIONS
                     Please complete this form in block letters, writing on the dotted lines only.
 Information for the insured person
 You should Present this certificate as soon as possible to the insurance institution of the country where you have gone, i.e.
in Belgium, the ' mutuality (local sickness insurance fund) of your choice;
in Denmark, the ' Sikringsstyrelse ' (national office for social security), Copenhagen;
in Germany, the 'Allgemeine Ortskrankenkasse ' (AOK, local general sickness fund);
'n France, the ' Caisse primaire d'assurance-maladie' (local sickness insurance fund);
in Ireland, the Health Board in whose area the benefit is sought;
in Italy, the provincial office of the 'Istituto nazionale per l'assicurazione contro gli infortuni sul lavoro ' (INAIL, national institute for insurance against accidents at work);
in Luxembourg, the 'Association d'assurance contre les accidents' (accident insurance association);
in the Netherlands, any sickness fund competent for the place of residence or, in case of temporary residence, the 'Algemeen Nederlands Onderling Ziekenfonds' (ANOZ
general sickness fund of the Netherlands), Utrecht. Assistance from a doctor, dentist or dispensing chemist may be sought without first contacting ANOZ;
in the United Kingdom, the medical service (doctor, dentist, hospital, etc.) from which treatment is requested.
                                                                                      NOTES
 (1 )  Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany; F = France; Irl = Irleand ; I = Italy ;
       L - Luxembourg ; N = Netherlands ; UK = United Kingdom.
 (2)   Complete only if the form is drawn up at the request of the institution of the place of residence or stay of the person concerned.
 (3)   Postal code, town , street, number, country.
 (4)   Put a cross in the square preceding the appropriate subject.
 (5)   Name and address of the institution to which the medical report has been sent.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                      See Instructions'overleaf
Social Security Regulations
                                                                                              E 124                 1
                                          CLAIM FOR DEATH GRANT
                                              Reg. 1408171 : Art 65
                                               Reg. 574/ 72: Art 78
 1     I the undersigned,
 1.1   Surname                     Forenames                                  Maiden name             Date of birth
 1.2   Insurance number ( 2 ):
 1.3   Institution with which I am insured ( 2 ) ( 3 ):
 1.4   Family relationship with the deceased :
 1.5   Address (4):
 2     hereby claim a grant by reason of the death of the undermentioned
        (5 ) Q] worker                                       I I pensioner
 3
        (5) Q] member of my family                           I I pension claimant
 3.1   Surname                     Forenames                                  Maiden name             Date of birth
 3.2   Insurance number ( 2 ):
 3.3   Date of death :
 3.4   Cause of death :
       (5 ) Q] illness                               I j accident              Q accident at work
        (5) Q occupational disease                                             I I other causes.
 3.5   Institution with which the deceased was insured ( 2 ) ( 3 ) :
 4      I the undersigned              (5) Q was              \_j was not a dependant of the deceased.
 5      The deceased person (5) Q was                   Q was not a dependant of mine.
 6     The cost of the funeral was ( 6)                                ; it has been paid
        by
 7      You will find attached the following documents :
                                                                         8      Date :
                                                                         8.1    Signature
                                                                                                                      ©
 ---pagebreak---                                                                                                                                                                E 124
                                                                            INSTRUCTIONS
                        Please complete this form in block letters, writing on the dotted lines only.
Information for the claimant
a) In order to receive a death grant you should, by means of this form, submit a claim :
     — either to the competent insurance institution,
     — or to the insurance institution of the place where you are, i.e. :
          in Belgium, a 'mutuality (local sickness insurance fund) of your choice;
          in Denmark, the 'Sikringsstyrelse' (national office for social security), Copenhagen;
          in Germany, the 'Allgemeine Ortskrankenkasse' (AOK, local general sickness fund);
          in France, the ' Caisse primaire d'assurance-maladie ' (social sickness insurance fund);
          in Ireland, the Department of Social Welfare, Dublin;
          in Italy, the provincial office of the INAM, the INPS or the INAIL, as appropriate;
          in Luxembourg, the ' Caisse nationale d'assurance-maladie des ouvriers' (national sickness insurance fund for manual workers);
          in the United Kingdom, the Department of Health and Social Security, Overseas Group, Newcastle-upon-Tyne, or the Ministry of Health and Social Services,
          Overseas Branch, Belfast, as appropriate.
b) Together with your claim you should send the following documents:
     in Belgium, an extract of the death certificate, issued by the municipal administration;
     the receipted bills relating to funeral expenses;
     in Denmark, the death certificate ;
     the receipted bills relating to funeral expenses;
     in Germany, the death certificate;
     in France,
     — in every case, the 'bulletin de dices' (death certificate) of the insured person;
     — in addition, as appropriate,
          — if the insured person was your husband or wife, the 'fiche familiale d'état- civil ' (family card of the Registry of births, deaths, and marriages) ;
          — if you are his/her descendant (son, daughter, grandson, etc.), the 'fiche familiale d'état-civil ' (family card of the Registry of births, deaths and marriages), showing
              your family relationship to the deceased;
          — if you are his/her ascendant (father, mother, grandfather, etc.), his/her 'fiche individuelle d'état-civil ' (individual card of the Registry of births, deaths and mar­
              riages);
          — if you were his/her dependant in any other way, a statutory declaration testifying that you were factually, wholly and constantly supported by the deceased;
     in Ireland, the death certificate;
     the marriage certificate, if appropiate ;
     the undertakers' account or estimate or the receipt for funeral expenses if paid by you;
     in Italy, the death certificate;
     the document of insurance registration;
     if appropriate, a declaration of family status;
     in Luxembourg, the death certificate ;
     the receipted bills relating to funeral expenses;
     if appropriate, a declaration from the municipal administration testifying cohabitation as husband and wife;
     in the United Kingdom, the death certificate;
     if appropriate, the marriage certificate ;
     the undertaker's account or estimate for funeral expenses.
                                                                                    NOTES
0)     Symbol of the country of residence of the claimant of the grant : B = Belgium ; Dk = Denmark; D = Germany; F = France ; Irl = Ireland ; I = Italy ; L = Luxembourg ;
       N = Netherlands ; UK = United Kingdom .
(2)    Indicate only if it concerns a worker, pensioner, or pension claimant.
(3 )   Give name and address .
( 4)   Postal code, town , street, number, country.
(5)    Put a cross in the square preceding the appropriate subject.
(6)    Indicate the amount in the currency of the country of residence of the claimant.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                        See Instructions' overleaf
Social Security Regulations
                                                                                                 E 125                 n
                           INDIVIDUAL RECORD OF ACTUAL EXPENDITURE
                                Reg. 1408/ 71 : Art. 36.1 and 2 ; Art. 63.1 ; Art. 87.1
                                   Reg. 574/ 72 : Art. 93.1, 2, 4 and 5 ; Art. 105.1
A separate form should be completed for each recipient. Italian institutions should also complete Annex 1 or Annex 2
as appropriate.
   1   Invoice No                    (2)          (3 ) \_\ 1 st half year P] 2nd half year of the financial year 19.
  2     Competent institution to which the form is addressed
  2.1  Name :
  2.2  Address (4):
   3    Insured person
  3.1  Surname                      Forenames                                  Maiden name               Date of birth
  3.2   Insurance number :
  4      Member of the family ( 5 )
  4.1  Surname                      Forenames                                  Maiden name               Date of birth
  5     The person indicated     (3) [_J in box 3          Q in box 4 has received benefits
        under Article
  5.1   ( 3) □ 19.1       LJ 22.1        □ 25.1 , 3          n 26 n 29.1 N 31 □ 52 □ 55.1
                and 2        and 3           and 4
        of Regulation 14087/71
       on the basis of the following forms which were sent to us :
  5.2   (3 ) □ form E                     of                              □ form E 1 1 7 of
                                                                 (date)                                                 (date)
                                                                                                                            ©
 ---pagebreak---                                                                                                                        E 125
    6        EXPENDITURE INCURRED                                                                                      6.1 Amount ( 6)
   6.2      For benefits in kind provided                               from                   to
   6.3      Medical treatment
   6.4      Dental treatment
   6.5       Medicaments
    6.6      Hospitalization                                            from                   to
                                                                        from                   to
   6.7      Other benefits ( 7 )
                                       6.8  Total benefits in kind
    6.9      Medical examinations ( 8 )
   6.10 For cash benefits provided                                      from                   to
                                       6.11 TOTAL EXPENDITURE
    7        Creditor institution
   7.1      Name :
   7.2      Address (4) :
   7.3      Stamp
                                                                                      7.4     Date :
                                                                                      7.5     Signature
   8         Reserved for the institution of the competent country
                                                               INSTRUCTIONS
                   Please complete this form in block letters, writing on the dotted lines only.
                                                                     NOTES
H      Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
       Irl = Ireland ; I = Italy; L = Luxembourg ; N = Netherlands .
(2)    To be indicated if the creditor institution needs this information .
(3)    Put a cross in the square preceding the appropriate subject.
(4)    Postal code, town , street, number, country.
(5 )   Complete only when the account refers to a member of the family of the insured person .
(6)    Indicate the amount in national currency.
(7)    Indicate the kind of benefits : confinement, dentures, orthopaedic protheses, spa treatment, ambulance, etc.
(8)    Indicate the kind of medical examinations carried out.
                                                                                                                                       ©
 ---pagebreak--- To be completed by Italian institutions only                                                          E 125 Annex 1
Details of expenditure for benefits in kind provided for sickness or maternity
                                                                                                                     Amount in lire
1         Treatment by general practitioners
1.1       Examinations at surgery :                         ( number)                     each lire
1.2       Home visits                                       ( number)                     each lire
1 .3      Additional benefits :                              ( number)                    each lire
            1.4    Total treatment by general practitioners
2         Treatment by specialists
2.1       (1 )                                                                            each lire
2.2       (1 )                                                                            each lire
2.3       V)                                                                              each lire
            2.4    Total treatment by specialists
            3      Total treatment by general practitioners and specialists
4         Dental treatment :                                                          ( number of benefits)
5         Medicaments :                                                              ( number of prescriptions)
6         Hospitalization
6.1       Number of days spent in hospital                                                each lire
6.2       Medical fees                                                                    each lire
            6.3    Total hospitalization
7         Other benefits ( 2 )
            7.1    Total other benefits
            8      GRAND TOTAL
9         Stamp
                                                      10       Date :
                                                      11       Signature
( 1 ) Indicate the kind of benefit : examination, operation , X-ray, etc.
 ( 2 ) Indicate the kind of benefit : confinement, dentures, orthopaedic prostheses, spa treatment, ambulance, etc .
                                                                                                                                    ©
 ---pagebreak--- To be completed by Italian institutions only
                                                                                                    E 125 Annex 2
Details of expenditure for accidents at work and occupational diseases
                                                                                                                       Amount in lire
  1     Benefits in kind
  2     Medical treatment
  3     Medicaments
  4     Hospitalization for treatment :
  4.1   from                   to                            days each lire
  4.2   from                   to                           days each lire
  4.3   from                    to                           days each lire
  5     Orthopaedic appliances ( 1 )
  6     Physiotherapy ( 1 )
  7     Other benefits ( 2 )
             8    Total benefits in kind
  9     Medical examinations
10      Doctor's fees
11      Specialist's fees :
11.1     (3)
11.2 ( 3 )
12       Examinations by specialists :
12.1     Number of X-ray photographs
12.2 Tomography
12.3 Electrocardiogram
12.4 Electroencephalogram
12.5 Laboratory tests
12.6 Examination of respiratory function
12.7 Other examinations and tests ( 1 )
13       Hospitalization for observation                                 from                  to
                          days each lire
           14     Total medical examinations and tests
( 1 ) Specify the kind of benefit.
( 2 ) Specify the kind of benefit : reimbursement of travel expenses, compensation for loss of wages or salary, ambulance, etc .
( 3 ) Specify specialty.
                                                                                                                                      ©
 ---pagebreak---                                                             E 125 Annex 2
                                                                       Amount in lire
15   Cash benefits
16   Daily allowances for the insured person :
16.1 while under out-patient treatment,             from to
16.2 while undergoing hospital in-patient treatment from to
17   Daily allowances for members of the family,    from to
      18      Total cash benefits
      19     TOTAL EXPENDITURE
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                          See Instructions overleaf
 Social Security Regulations
                                                                                                   E126                 (1 )
                                RATES FOR REFUND OF BENEFITS IN KIND
                                   Reg. 1408/ 71 : Art. 22.1 . a. i ; Art. 22.3 ; Art. 31 . a
                                                  Reg. 574/ 72 : Art. 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 benefits to the person concerned in the country
of stay. The institution of the place of stay, after completing part B of the form, should return one copy to the com­
petent institution.
A. Request
 ~1 | Institution to which the form is addressed (2)
  1.1    Name :
  1.2   Address (3 ):
  2
         (4) Q Worker                                        [_] Member of the family of a worker
         (4) r~] Pensioner                                    [H Member of the family of a pensioner
  2.1    Surname                     Forenames                                      Maiden name            Date of birth
  3      The abovementioned person concerned,
  3.1    during a stay in                                                      ( country)
  3.2    at                                                               (town ),
  3.3    himself paid for the benefits which he required .
  3.4    The person        (4) Q] a widower / widow Q an invalid ( 5 )
         concerned is
  3.5    and earns an income of                         ( 5)
  4      Please indicate on the receipts attached, for each benefit separately, the amount to be refunded to the person
         concerned according to the rates administered by the institution of the place of stay.
  5      Attached :                         receipts.
  6 | Competent institution
  6.1    Name :
  6.2   Address (3 ):
  6.3   Stamp
                                                                             6.4    Date :
                                                                             6.5    Signature
                                                                                                                             ©
 ---pagebreak---                                                                                                                                      E 126
B. Reply
I 7 I Competent institution
   7.1      Name :
   7.2      Address ( 3 ):
8         Attached :                                             receipts indicating the requested rates.
   9        Remarks :
    10       Institution of the place of stay
   10.1     Name :
   10.2 Address ( 3 ):
   10.3 Stamp
                                                                                              10.4  Date :
                                                                                              10.5  Signature
                                                                   INSTRUCTIONS
                   Please complete this form in block letters, writing on the dotted lines only.
                                                                         NOTES
 (1 )  Symbol of the country to which institution completing part A of the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ;
       F = France ; Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands .
 (2)   If it is not known which institution would have had to provide the benefits in kind, the form may be sent to the liaison body of the
       country of stay, i.e.
       — in Belgium, the ' Institut national d'assurance maladie-invalidité ' ( INAMI , national sickness and invalidity insurance institute),
             Brussels ;
       —     in Denmark, the ' Sikringsstyrelsen ' ( national office for social security), Copenhagen ;
       —    in Germany, the ' Bundesverband der Ortskrankenkassen ' ( national federation of local sickness funds), Bonn - Bad Godesberg ;
       —    in France, the ' Centre de sécurité sociale des travailleurs migrants', ( centre for the social security of migrant workers ), Paris ;
       —    in Ireland, the Department of Health, Dublin ;
       —    in Italy, the ' Istituto nazionale per l'assicurazione contro le malattie, Direzione generale' ( directorate-general of the national sickness
            insurance institute ), Rome ;
       — in Luxembourg, the ' Ministère du travail et de la sécurité sociale ' ( ministry of labour and social security ), Luxembourg ;
       — in the Netherlands, the 'Algemeen Nederlands Onderling Ziekenfonds ' ( ANOZ, general sickness fund of the Netherlands), Utrecht.
 (3 )  Postal code, town , street, number, country.
 (4)   Put a cross in the square preceding the appropriate subject .
 (5)   Complete only if the request is sent to a Belgian institution .
                                                                                                                                                       ©
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                          See ' instructions' overleaf
Social Security Regulations
                                                                                                     E 127                 (1 )
                     INDIVIDUAL RECORD OF MONTHLY LUMP-SUM PAYMENTS
                                              Reg. 1408171 : Art. 36.1 and 2
                                               Reg. 574/ 72: Art. 94 ; Art. 95
  1
 Record No                                  3f year                              19      ( 2)
 2     Competent in <stitution
 ? 1   Name :
 2.2   Address ( 3 ) :
       The right to benefits in kind has been acquired for the
 3
        (4) [~] worker named below                                Q pensioner named below
 3.1   Name                          Forenames                                  Maiden name                 Date of birth
 3.2   Insurance number allocated by the competent institution :
 4     Address of the worker s family or address of the pensioner and his family ( 3 )
 5     The right to benefits 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 certified by your form
       E                   of                                (date).
 6     For the period during which this right existed
       (from                                 to                             ),
 6.1   the number of monthly lump-sum payments,
       (4) Q per family or per pensioner and family Q per family member                Q per individual,
       was
 7 I    Creditor institution
 7.1   Name :
 7.2   Address (3 ):
 7.3   Stamp
                                                                         7.4    Date :
                                                                         7.5    Signature
                                                                                                                                ©
 ---pagebreak---                                                                                                                      E 127
  8       To be completed by the competent institution
                                                              INSTRUCTIONS
       Please complete three copies of this form in block letters, writing on the dotted lines only.
The institution of 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 No 574/ 72.
                                                                     NOTES
(1 ) Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
     Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)  The year to be indicated here is that in which the benefits were provided .
(3)   Postal code, town , street, number, country.
(4)   Put a cross in the square preceding the appropriate subject.
                                                                                                                                      ©
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                        See Instructions overleaf
Social Security Regulations
                                                                                                 E 201                m
          CERTIFICATE CONCERNING THE AGGREGATION OF PERIODS OF INSURANCE
                                          OR PERIODS OF RESIDENCE
                                           Reg. 1408/ 71 : Art. 9.2 ; Art. 15.3
                                                  Reg. 574172: Art. 6.2
This certificate should be drawn up at the request of the person concerned by the institution or institutions of the
Member States where he/she was insured. He/she should send it to the institution of the Member State in question
with a view to his/her admission to voluntary or optional continued insurance for invalidity, old age and death (pension.)
 1      Worker
 1.1    Surname                                Forenames                                       Maiden name
 1.2    Place of birth                     Date of birth                  Sex                  Nationality ( 2 )
 1.3    Address ( 3 ):
 1.4    Insurance number :
 2      Last employment entailing compulsory insurance (4)
 2.1    Type of occupation ( manual , clerical , miner, etc.):
 2.2    Name of employer or firm :
 2.3    Address ( 3 ):
 3      The worker named in box 1                     ( 5 ) □ is                was                       insured by us
                                                                           type of insurance
          from/to                periods ( 6 )          as (4)    7                                   for the risks of ( 9 )
                                                                                   ( 8)
               I
               I
               I
 4      The worker named in box 1 completed the following periods of residence ( 10 )
                                                                                 Duration
             from                     to
                                                            Years               Months                       Days
                                                                                                                             ©
 ---pagebreak---                                                                                                                                E 201
  5
  5.1       The person concerned                    (5 ) \_\ has                  \_j has not
            submitted an application in another Member State for registration for voluntary or optional continued
            insurance .
            If he/she has, state :
  5.2       the country :
  5.3       the risk ( 9 ):
   6 | Institution issuing the certificate
  6.1       Name :
  6.2       Address ( 3 ) :
  6.3       Stamp
                                                                                          6.4      Date :
                                                                                          6.5      Signature
                                                                   INSTRUCTIONS
                   Please complete this form in block letters, writing on the dotted lines only.
                                                                         NOTES
(1 )   Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
       Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)    Where applicable, indicate the date of naturalization .
(3)    Postal code, town , street, number, country.
(4)    If the certificate is issued by a Belgian , French , Irish or United Kingdom institution, the information given is based on particulars sup­
       plied by the worker himself.
(5)    Put a cross in the square preceding the appropriate subject.
(6)    Indicate the number of quarters, months, weeks, days, in accordance with the provisions of national laws.
(7)    Complete only if the form is being sent to a German or Italian institution .
(8 )   Indicate the type of insurance by using the following symbols :
       A = compulsory
        B = voluntary
       C = optional continued .
(9)     Indicate the risks covered by using the following symbols :
       D = invalidity
       E = old age
       F   = death .
( 10 ) Complete only if the certificate is issued by a Danish institution .
                                                                                                                                                 ©
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                    See ' Instructions' on page 5
 Social Security Regulations
                                                                                                E 202                 n
            Country              Insurance number ( 2 )       Institution concerned ( where applicable, liaison body)
  1)
  2)
  3)
 4)
  5)
                        INVESTIGATION OF A CLAIM FOR AN OLD-AGE PENSION
                                              Reg. 1408/ 71 : Art. 44 to 50
                    Reg. 574172: Art. 36 to 38 ; Art. 41 to 43 ; Art. 45 to 47 ; Art. 49 ; Art. 111
The investigating institution should complete this form and send one copy to each of the institutions with which
the worker has been insured (institutions concerned) or to the liaison body.
  1     Institution to which the form is addressed ( institution concerned or liaison body, as applicable )
  1.1   Name :
  1 .2  Address ( 3 ) :
A. Information concerning the insured person
  2
  2.1   Surname                          Forenames                                          Maiden name
  2.2   Place of birth                   Date of birth              Sex                     Nationality ( 4)
  2.3   Civil status :           (5) (_] single                 married                ! widow/widower
                                 ( 5 ) [J divorced          Q separated
  2.4   Address on the date of submission of the claim ( 3 ) ( 6):
    2.5 Insurance number with the investigating institution :
    2.6 File reference of the investigating institution :
                                                                                                                        ©
 ---pagebreak---                                                                                                    E 202
3.1   (5) [_] The insured person is still pursuing a professional or trade activity
3.2   (5) Q The insured person ceased to pursue a professional or trade activity on
3.3   ( 5) r~] The insured person intends to retire from gainful employment on
3.4   ( 5 ) [J The insured person is engaged in gainful employment (8)
3.5   (5) Q The insured person intends to engage in gainful employment (9).
3.6   Amount of annual earnings and, where applicable, of any other income                                    ( 10)
3.7   Nature of other income :                                                                                ( 10)
R
 4.1  The claimant
       (5) QJ draws                      Q does not draw a pension
       (5) Q has been                    Q] has not been in receipt of a pension .
       If in the affirmative, indicate :
 4.2   Type of pension :
 4.3   Pension number :
 4.4    Institution responsible for pension payment :
 4.5    Date on which pension became or will become payable :
 4.6   Where applicable, date when pension        payment ceased or will cease :
 5      The claimant            (5) [_] has received            Q] has not received
        unemployment benefits since submitting his claim .
  6      Information to be supplied only if the form is to be sent to French institutions
  6.1   The claimant          ( 5 ) \_j declares that he is unfit for work
                              (5) Q does not declare that he is unfit for work.
  6.2  The claiment           (5) Q declares he needs constant attendance for the performance of one of the
                                        ordinary activities of everyday life
                              (5 ) Q does not declare that he needs constant attendance for the performance of one
                                        of the ordinary activities of everyday life .
  7 j Information to be supplied only if the form is to be sent to French or Italian institutions
  7.1   The claimant          (5) Q has been receiving an increase for spouse since                        (date)
                              ( 5 ) P] does not receive an increase for spouse.
                                                                                                                    ©
 ---pagebreak---                                                                                                        E 202
 B. Information concerning the members of the insured person 's family
| 8 J Spouse
  8.1   Surname                           Forenames                        Maiden name           Sex
  8.2   Date of birth :                                                    Place of birth :
  8.3   Address ( 3 ):
  8.4   Date of marriage :
  8.5   The spouse            (5 ) [H pursues           Q does not pursue a professional or trade activity.
  8.6   If in the affirmative, state amount of ( 11 ):
        (5) Q weekly earnings                           Q annual earnings
  8.7   The spouse aged between 60 and 65 declares to be
        (5) Q fit for work                              Q unfit for work ( 12)
  8.8   The spouse            ( 5 ) Q receives          Q does not receive a pension .
        If in the affirmative, indicate :
  8.9   Type of pension :
  8.1 0 Institution responsible for pension payment :
  8.11 Amount                 ( 5 ) Q] monthly          Q quarterly               Q annually :
  8.12 The spouse              (5 ) Q receives          Q does not receive other benefits ( 13), namely for :
        ( 5 ) Q unem -              Q sickness          [j invalidity             Q other.
                   ployment
  8.13  Other known resources :
         Children . ( Complete only if the claimant is not entitled to supplements in respect of children under the
  ^      legislation of the country where he resides).
  9.1   Surname                      Forenames                           Date of birth      Relationship
        1
        2
        3
        4
  9.2   Address ( 3 ) ( 14):
  9.3    Remarks ( 15 ):
                                                                                                                    CD
 ---pagebreak---                                                                                                        E 202
C. Miscellaneous information
 10    (5 ) [J Date of submission of claim :
       (5) F] Date from which the pension was payable if it was awarded automatically:
 11    The claimant                            (5) [J has requested             Q has not requested
       deferment of the award of an old-age pension to which he would be entitled . If in the affirmative, indicate
       the country :
 12    The investigating institution           (5) Q can                        Q] cannot
       make provisional payments of benefit under Article 45.1 of Regulation 574/72 .
 12.1  If in the negative, the institutions concerned are requested to investigate the possibility of making provisional
       payments of benefit under Article 45.2 of Regulation 574/72 .
 13     (3) O There are grounds                Q] there are no grounds            for making deductions to compen -.
       sate for overpayment in accordance with Article 111 of Regulation 574/72.
 14    Attached is :                           (5) □ E 205         □ E 206           □ E 207
 15 Investigating institution
  15.1 Name:                                                                                                             I
  15.2 Address ( 3 ):
  15.3 Stamp
                                                                       15.4   Date :
                                                                       15.5 Signature
                                                                                                                       ©
 ---pagebreak---                                                                                                                           E 202
                                                                 INSTRUCTIONS
Please complete this form in block letters, writing on the dotted lines only. It consists of five pages,
              none of which may be left out even if it does not contain any relevant information .
                                                                       NOTES
(1 )   Symbol of the country to which the investigating institution belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
       Irl = Ireland ; I = Italy; L = Luxembourg ; N = Netherlands; UK = United Kingdom .
(2 )   If the form is being sent to a Danish institution , indicate the CPR number and, where applicable, the ATP number.
(3)    Postal code, town, street, number, country.
( 4)   Where applicable, indicate the date of naturalization .
(5 )   Put a cross in the square preceding the appropriate subject.
(6)    If the form is being sent to a Danish institution, give the claimant's last address in Denmark in the box below :
            Address ( 3 ):
(7)    Complete only if the form is being sent to a United Kingdom institution .
(8)    Complete only if the form is being sent to an Irish or United Kingdom institution .
(9)    Complete only if the form is being sent to an Irish institution .
( 10 ) Complete only if the form is being sent to a Danish institution .
( 11 ) Complete only if the form is being sent to a French, Italian, Luxembourg or United Kingdom institution .
( 12 ) Complete only if the form is being sent to a French institution .
( 13 ) Complete only if the form is being sent to a Belgian , French or United Kingdom institution .
( 14 ) Indicate the common address. If one of the children lives at a different address, indicate in the box below :
            Surname and forenames :
            Address ( 3 ):
( 15 ) Indicate if the child is married , invalid, deceased ( date of death ), apprenticed , or continuing studies .
                                                                                                                                      ©
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                  See  Instructions' on page 5
Social Security Regulations
                                                                                                E 203                1
              Country             Insurance number ( 2)       Institution concerned (or liaison body, if applicable )
 1)                                                       L.                                                   . . .
 2)
 3)
 4)
 5)
                       INVESTIGATION OF A CLAIM FOR A SURVIVOR 'S PENSION
                                             Reg. 1408/ 71 : Art 44 to 50
                      Reg. 574172: Art 36 to 38 ; Art 41 to 43 ; Art 45 to 47 ; Art. 49 ; Art 111
The investigating institution should complete the form and send one copy to each of the institutions with which
the worker has been insured (institutions concerned) or to the liaison body.
  1 | Institution to which the form is addressed (institution concerned or liaison body, as applicable)
  1.1   Name :
  1.2   Address ( 3 ):
A. Information concerning the deceased insured person
  2
  2.1   Surname                               Forenames                              Maiden name
  2.2   Place of birth                  Date of birth                   Sex                  Nationality (4)
  2.3   Civil status at date of death :                           ( 5) Q single              [[[] married
                               (5) Q widow/widower                      Q divorced           Q] separated .
  2.4   Address at date of death ( 3 ) ( 6):
    2.5 Insurance number with the investigating institution :
    2.6 File reference of the investigating institution :
 3      At the date of death , the deceased insured person
         ( 5 ) □ was still pursuing             []] no longer pursued a professional or trade activity.
                                                                                                                       ©
 ---pagebreak---                                                                                                            E 203
Z!
 4.1   Date and place of death :
 4.2   The death                            ( 5) Q is assumed                Q is not assumed
                                           to have been the result of an accident at work or an occupational disease.
 4.3   The death                            ( 5) Q is assumed                Q] is not assumed
                                           to have been caused by a third party.
 4.4   In the case of a missing person : ( 5) Q date last heard of:
                                            (5) □ date of death officially presumed :
  5
 5.1   The deceased insured person         ( 5) \_\ was    Qj was not receiving a pension at
                                                               the date of his/ her marriage.
 5.2   The deceased insured person         (5 ) [J was     [J was not receiving a pension
                                                               at the date of his/ her death .
       If in the affirmative, indicate :
 5.3   Type of pension :
 5.4   Pension number :
 5.5   Institution responsible for payment of pension :
 5.6   Date from which the pension was due :
 5.7   Date when payment ceased, where applicable :
 6     The deceased insured person (5) Q had requested                     Q had not requested
       deferment of the award of an old-age pension to which he would have been entitled .
       ( If in the affirmative, indicate the country :                                   ).
B. Information concerning the claimants
  7 j Widow, widower, or other claimants, excluding children (7)
 7.1   Surname                                   Forenames                            Maiden name
 7.2   Place of birth                     Date of birth                  Sex                   Nationality
 7.3  Address (3 ) (8 ):
 7.4   Date of marriage :
 7.5  Where applicable, date of divorce :
 7.6  Where applicable, date of remarriage :
 7.7   Name and forenames of new spouse :
 7.8   Relationship (for claimants other than widow or widower):
                                                                                                                      ©
 ---pagebreak---                                                                                                     E 203
 8
 8.1   The person named in box 7
 8.2   (5) Q is engaged in                          Q] is not engaged in paid employment
 8.3   (5 ) Q is                                   □ is not                self-employed.
 8.4   If in the affirmative, state amount of annual income :                                               (9)
 8.5   The person named in box 7
 8.6   (5) Q was                                   Q was not a dependant of the deceased insured person
 8.7   (5) Q] is                                    □ is not
                ( 5) Q permanently unfit for work
                ( 5 ) Q temporarily unfit for work, namely for more than three months ( 10)
 8.8   (5 ) Q needs                                 Q] does not need constant attendance.
 8.9   The person named in box 7
       (5 ) Q] receives                             Q does not receive a pension .
       If in the affirmative, indicate :
 8.10 Type of pension :
 8.11  Pension number :
 8.12 Institution responsibleforpaymentof pension :
 8.13 Date from which pension was due :
 8.14 Date when payment ceased, whereapplicable :
 8.1 5 If the widow named in box 7 is pregnant, give the expected date of her confinement :
 i                                                                                                        ( 11 )
 9     Other known resources (amount and type) :
~io~|   Children Γ 2)
 10.1  Surname                  Forenames                            Date of birth        Relationship
       1
       2
       3
       4
 10.2  Address ( 3) ( 13 ):
 10.3   Remarks ( 14):
                                                                                                                 (D
 ---pagebreak---                                                                                                     E 203
 11   The children residing in the country of the investigating institution
      (5)     ] are entitled        [H are not entitled to a benefit under Article 78 of Regulation 1408/71 .
C. Miscellaneous information
 12   (5 ) Lj Date of submission of claim :
      ( 5 ) n Date from which the pension was due if it was awarded automatically :
 13   The investigating institution
      ( 5) fn can            ] cannot make provisional payment of benefits under Article 45.1 of Regulation 574/72,
 13.1 If it cannot, the institutions concerned are requested to investigate the possibility of making provisional
      payment of benefits under Article 45.2 of Regulation 574/72 .
 14   ( 5 ) LJ There are grounds       [ | there are no grounds      for making deductions to compensate for
                                             overpayment in accordance with Article 111 of Regulation 574/72 .
 15   Attached forms :                 ( 5 ) □ E 205             □ E 206                 □ E 207 .
 16   Investigating institution
 16.1 Name :
 16.2 Address ( 3 ):
 16.3 Stamp
                                                                      16.4  Date :
                                                                      16.5  Signature
                                                                                                                    ©
 ---pagebreak---                                                                                                                               E 203
                                                                 INSTRUCTIONS
Please complete this form in block letters, writing on the dotted lines only. It consists of five pages,
              none of which may be left out even if it does not contain any relevant information .
                                                                        NOTES
(1 )   Symbol of the country to which the investigating institution belongs : B = Belgium ; Dk = Denmark; D = Germany ; F = France ; Irl =
       Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)    If the form is to be sent to a Danish institution, indicate the CPR number and, where applicable, the ATP number of the deceased
       insured person .
(3)    Postal code, town , street, number, country.
( 4)   If applicable, indicate the date of naturalization .
(5)    Put a cross in the square preceding the appropriate subject.
(6)    If the form is to be sent to a Danish institution, indicate in the box below the deceased insured person 's last address in Denmark :
           Address ( 3 ):
(7)    If there are several persons to be indicated in box 7, insert additional copies of pages 2 and 3 as necessary.
(8 )   If the form is to be sent to a Danish institution , indicate the claimant's address in Denmark.
(9)    Complete only if the form is to be sent to Danish or French institutions.
( 10 ) Complete only if the form is to be sent to Netherlands institutions.
( 11 ) Complete only if the form is to be sent to United Kingdom institutions.
( 12 ) Complete only if the form is to be sent to Danish , French , Irish , Netherlands or United Kingdom institutions.
( 13 ) Indicate the common address . If one of the children lives at a different address, indicate in the box below :
           Surname and forenames :
           Address ( 3 ):
( 14 ) Indicate if the child is married , invalid, deceased ( date of death ), apprenticed, or continuing studies.
                                                                                                                                             ©
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                     See ' Instructions! on page 6
Social Security Regulations
                                                                                                   E 204               n
                                                                                Institution concerned
            Country              Insurance number ( 2 )
                                                                         ( or liaison body, if applicable)
 1)
 2 ).
 3)
 4)
 5)
                       INVESTIGATION OF A CLAIM FOR AN INVALIDITY PENSION
                                             Reg. 1408/ 71 : Art. 44 to 50
                    Reg. 574/ 72: Art. 36 to 38 ; Art. 41 to 43 ; Art. 45 to 47 ; Art. 49 ; Art. 111
The investigating institution should complete this form and send one copy to each of the institutions with which
the worker has been insured (institutions concerned) or to the liaison body.
  1 j Institution to which the form is addressed (institution concerned or liaison body, as applicable)
  1.1   Name :
  1.2   Address ( 3 ):
A. Information concerning the insured person
3
  2.1   Surname                         Forenames                                                Maiden name
  2.2   Place of birth                  Date of birth             Sex                            Nationality (4)
  2.3   Civil status :           (5 ) \_j single           Q married                    Q widow/widower
                                 (5 ) Q divorced           Q separated.
  2.4   Address at the date of the claim ( 3 ) ( 6 ):
    2.5 Insurance number with the investigating institution :
    2.6 File reference of the investigating institution :
                                                                                                                         ©
 ---pagebreak---                                                                                                 E 204
3   Date which has been determined as the commencement of invalidity :
3.1 Date of commencement of incapacity for work followed by invalidity :
3.2 The person concerned
    ( 5 ) Q is still engaged in                           Q is no longer engaged in
          (5) O paid employment                               Q self-employment.
3.3 If he is engaged in paid employment ( 7 ), indicate :
    Amount of wage or salary :                        Weekly hours of work :
3.4 Date of cessation of normal professional or trade activity :
3.5 Type of activity :
3.6 If he is self-employed, indicate the amount of professional income ( 8 ):
3.7 Other known resources (amount and nature) (9 ):
3.8 The invalidity
    (5 ) r~l is assumed                j~] is not assumed        to have been caused by a third party.
4   Since the commencement of his incapacity for work, the person concerned
    ( 5 ) Q has followed occupational rehabilitation courses
    ( 5 ) \~\ has not followed occupational rehabilitation courses.
    If he has, indicate :
4.1 for what new occupation :
4.2 the employer for whom he worked in this new occupation :
    Name of employer or firm :
    Address ( 3 ):
4.3 the date of commencement and of the end of this employment :
4.4 The person concerned         (5) Q has been receiving     Q does not receive an increase for spouse.
    If in the affirmative, indicate since when :
                                                                                                         ©
 ---pagebreak---                                                                                                  E 204
m
5.1   Before the commencement of invalidity benefit, the person concerned
         (5) Q was                                                  Q was not receiving
                 (5) Q an invalidity pension                           Q an old-age pension
                 (5) Q a benefit for accident at work or occupational disease.
5.2 If in the affirmative, indicate :
      the period during which these benefits were or will be paid :
      institution responsible for payment :
5.3   Since the commencement of his incapacity, the person concerned
       (5) Q has claimed                                            Q has not claimed
       (5) Q is entitled to receive                                 Q is not entitled to receive
                 ( 5) Q cash sickness insurance benefits
                 ( 5) Q an old-age pension
                 (5) Q a survivor's pension
                 ( 5) Q benefits for accident at work or occupational disease
                 (5) Q unemployment benefits.
5.4    If in the affirmative, indicate :
      the period during which these benefits were or will be paid :
      institution responsiblefor payment :
5.5   Since the commencement of invalidity benefit, the person concerned
       (5) Q has      been receiving                                Q has not received
                 (5)   Q cash sickness insurance benefits
                 (5)  Q an old-age pension
                 (5 ) Q unemployment benefits.
5.6   If in the affirmative, indicate :
      the period during which these benefits were or will be paid :
      institution responsiblefor payment :
 ---pagebreak---                                                                                                            E 204
B. Information concerning the members of the insured person's family
 6 I Spouse
 6.1   Surname                    Forenames                                 Maiden name               Sex
 6.2   Date of birth :
 6.3   Date of marriage :
 6.4  The spouse                           ( 5 ) j I is                 j j is not pursuing a professional or trade activity.
 6.5   If in the affirmative, indicate amount of annual income ( 7 ):
 6.6   The spouse                          ( 5) Q receives              [_]  does not receive                    a pension .
 6.7   Ifjn the affirmative, indicate :
       type of pension :
       institution responsible for payment :
       amount :              ( 5) I I monthly               | | quarterly              | | annually
 6.8   The spouse                (5 ) [_| has been receiving Q does not receive other social benefits ( 10), namely :
                                           ( 5 ) Q] for unemployment Q for sickness
                                           (5 ) \^] for invalidity       Q other.
 6.9   Other known resources :
        Children (To be completed only if the claimant is not entitled to supplements in respect of children under
 ^      the legislation of his country of residence)
 7.1    Surname                    Forenames                                Date of birth        Relationship
        1
        2                                                                                                             ;
        3
        4
  7.2   Address (3 ) ( 11 ):
  7.3   Remarks ( 12 ):
                                                                                                                              ©
 ---pagebreak---                                                                                                         E 204
  8     Dependent ascendants ( 13 )
 8.1   Surname                   Forenames                             Date of birth        Relationship
 8.2   Address ( 3 ) ( 11 ):
 8.3   Remarks :
C. Miscellaneous information
 9     ( 5 ) LJ Date of submission of claim :
       ( 5 ) n ^ ate       commencement of pension if awarded automatically :
 10    If the person concerned can obtain another pension , indicate :
       type of this pension :                                       ,
       institution responsible for payment :
 11    The investigating institution
       ( 5 ) Q] can          Q cannot make provisional payment of benefits under Article 45.1 of Regulation
                                No 574/ 72 .
 12    If in the negative, the institutions concerned are requested to investigate the possibility of making provisional
       payment of benefits under Article 45.2 of Regulation 574/ 72 .
 13    ( 5 ) Q There are         Q There are no grounds for making deductions to compensate for overpayment in
                 grounds             accordance with Article 1 1 1 of Regulation No 574/ 72 .
 14    Attached forms :                        ( 5) □ E 205 □ E 206 n E 207 □ E 213 □ E 214 ( 14)
 1 5 j Investigating institution
 15.1  Name :
 15.2 Address ( 3 ):
 15.3 Stamp
                                                                       15.4   Date :
                                                                       15.5   Signature
                                                                                                                      ©
 ---pagebreak---                                                                                                                                E 204
                                                                  INSTRUCTIONS
Please complete this form in block letters, writing on the dotted lines only. It consists of six pages ,
                none of which may be left out even if it does not contain any relevant information .
                                                                         NOTES
  ( 1 ) Symbol of the country to which the investigating institution belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
         Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
  ( 2 ) If the form is to be sent to a Danish institution , indicate CPR number.
   ( 3 ) Postal code, town , street, number, country.
   ( 4 ) If applicable, indicate the date of naturalization .
  ( 5 ) Put a cross in the square preceding the appropriate subject .
  ( 6 ) If the form is to be sent to a Danish institution , indicate the claimant's last address in Denmark in the box below :
        I Address (3):                                                                             :                                            I
  ( 7 ) Complete only if the form is to be sent to Danish , French , Irish , Luxembourg , Netherlands or United Kingdom institutions.
  ( 8 ) Complete only if the form is to be sent to Belgian , Danish , Irish , Luxembourg or Netherlands institutions .
  ( 9 ) Complete only if the form is to be sent to Danish institutions.
( 10 ) Complete only if the form is to be sent to Belgian , Irish or United Kingdom institutions .
 ( 11 ) Indicate the common address . If one of the children or one of the ascendants lives at a different address, indicate in the box below :
             Surname and forenames :
             Address ( 3 ):
( 12 ) Indicate if the child is married, invalid , deceased ( date of death ), apprenticed , or continuing studies .
( 13 ) Complete only if the form is to be sent to Belgian , German or United Kingdom institutions .
( 14 ) If form E 204 is issued by a German or Netherlands institution or to be sent to a German or Netherlands institution , form E 213 and
         form E 214 should be attached .
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                        See ' Instructions' on page 3
 Social Security Regulations
                                                                                                    E 205           B     V)
                    CERTIFICATE CONCERNING INSURANCE RECORD IN BELGIUM
                                  Reg. 1408/ 71 : Art. 38 ; Art. 45 ; Art. 48 ; Art. 57.3.C
                                    Reg. 574172: Art. 42.1 ; Art. 43.1 to 3 ; Art. 69
To be drawn up by the investigating institution for insurance periods completed under the legislation which it ad­
ministers ; to be attached to forms E 202, E 203 or E 204, as applicable. Each institution concerned should draw up
a form for the periods completed under the legislation which it administers and send it to the investigating institution.
  1 j Institution to which the form is addressed (institution concerned or investigating institution, as applicable)
  1.1   Name :
  1 .2  Address ( 2 ) :
 2 | File references
  2.1   of investigating institution :                                :
 2.2    of institution concerned :
 3      Worker
 3.1    Surname                              Forenames                                   Maiden name
 3.2    Place of birth                  Date of birth                     Sex                  Nationality
 3.3    Address ( 2 ):
 3.4    Insurance number :
 4      Person who has entitlement ( 3 )
 4.1    Surname                              Forenames                                  Maiden name
 4.2    Place of birth                  Date of birth                     Sex                  Nationality
 4.3    Address ( 2 ):
                                                                                                                             ©
 ---pagebreak---                                                                                          E 205       B
5
                                                               Periods
  Periods during which insurance periods and     Insurance  treated as
    periods treated as such were completed        periods    insurance    Insurance
                                                                           scheme          Occupation (5 )
                                                            periods (4)
    Year |         from               to           (Years)    ( Years )
5.1    Total length of period of insurance under Belgian social security schemes for employed persons :
5.2    Remarks :
                                                                                                           L2J
 ---pagebreak---                                                                                                       E 205 B
   6        The insured person showing proof that he has completed an insurance period of less than one year
            (6 ) Q may receive                                       Q may not receive
            a pension under national legislation (Art. 48.1 of Reg . 1408/71 ).
   7        Institution completing the form
   7.1     Name :
   7.2     Address ( 2 ) :
   7.3     Stamp
                                                                                        7.4 Date :
                                                                                        7.5 Signature
                                                               INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                                      NOTES
(1 )   Symbol of the country to which the institution completing the form belongs (B = Belgium ).
(2)    Postal code, town , street, number, country.
(3)    To be completed if applicable.
(4)    Specify at point 5.2 the type of periods that are treated as insurance periods .
(5)    For workers who have been employed in mines or similar undertakings, attach form E 206 .
(6)    Put a cross in the square preceding the appropriate subject.
                                                                                                              (D
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                       See ' Instructions' on page 3
 Social Security Regulations
                                                                                                   E 205          DK     (1
                  CERTIFICATE CONCERNING PERIODS OF INSURANCE AND PERIODS
                                          OF RESIDENCE IN DENMARK
                                 Reg. 1408/ 71 : Art. 38 ; Art. 45 ; Art. 48 ; Art. 57.3.C
                                    Reg. 574172 : Art. 42.1 ; Art. 43.1 to 3 ; Art. 69
To be drawn up by the investigating institution for insurance periods completed under the legislation which it ad­
ministers ; to be attached to forms E 202, E 203 or E 204, as applicable. Each institution concerned should draw up
a form for the periods completed under the legislation which it administers and send it to the investigating institution.
  1     Institution to which the form is addressed ( institution concerned or investigating institution , as applicable)
  1.1   Name :
  1.2   Address ( 2 ) :
  2     File references
  2.1   of investigating institution :
  2.2   of institution concerned :
  3 j Worker
  3.1   Surname                               Forenames                                 Maiden name
  3.2   Place of birth                   Date of birth                   Sex                   Nationality
  3.3   Address ( 2 ):
  3.4   CPR number:                                                      ATP number:
  4      Person who has entitlement ( 3 )
  4.1   Surname                               Forenames                                 Maiden name
  4.2   Place of birth                   Date of birth                    Sex                   Nationality
  4.3   Address ( 2 ):
  4.4    CPR number :
 ---pagebreak---                                                                                               E 205      DK
 5j
   Periods during which periods of                     Periods
residence and periods treated as such     Periods of treated as            Periods in which insurance periods
                                                                   were completed under the law on supplementary
    were completed under the law          residence  periods of
                                                                                     pensions (ATP )
          on social pensions                          residence
  Year         from            to
                                           Number
                                           of years
                                                        Number
                                                        of years
                                                                    Year I       from     I      to         Number
                                                                                                            of vears
 5.1    Total length of period of insurance under Danish social security schemes for employed persons :
 5.2    Remarks :
 ---pagebreak---                                                                                                    E 205 DK
  6       The insured person showing proof that he has completed an insurance period of less than one year
          (4) Q] may receive                                   Q may not receive
          a pension under national legislation (Art. 48.1 of Reg . 1408/71 ).
  7       Institution completing the form
  7.1     Name :
  7.2     Address ( 2 ):
  7.3     Stamp
                                                                                 7.4    Date :
                                                                                 7.5    Signature
                                                           INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                                 NOTES
(1)   Symbol of the country to which the institution completing the form belongs ( Dk = Denmark ).
(2)   Postal code, town , street, number, country .
(3)   To be completed if applicable .
(4)   Put a cross in the square preceding the appropriate subject .
                                                                                                             (D
 ---pagebreak---  EUROPEAN COMMUNITIES                                                                       See 'Instructions' on page 3
 Social Security Regulations
                                                                                                  E 205            D     r
                      CERTIFICATE CONCERNING INSURANCE RECORD IN GERMANY
                                  Reg. 1408/ 71 : Art. 38 ; Art. 45 ; Art. 48 ; Art. 57.3.C
                                    Reg. 574/ 72: Art. 42.1 ; Art. 43.1 to 3 ; Art. 69
 To be drawn up by the investigating institution for insurance periods completed under the legislation which it ad­
ministers ; to be attached to forms E 202, E 203 or E 204, as applicable. Each institution concerned should draw up
a form for the periods completed under the legislation which it administers and send it to the investigating institution.
  1 | Institution to which the form is addressed (institution concerned or investigating institution, as applicable)
  1.1   Name :
  1.2   Address ( 2 ) :
  2 J File references
■ 2.1   of investigating institution :
  2.2   of institution concerned :
  3 | Worker
  3.1   Surname                              Forenames                                   Maiden name
  3.2   Place of birth                  Date of birth                     Sex                  Nationality
  3.3   Address ( 2 ):
  3.4   Insurance number :
  4 j Person who has entitlement (3)
  4.1   Surname                              Forenames                                   Maiden name
  4.2   Place of birth                  Date of birth                     Sex                  Nationality
  4.3   Address ( 2 ):
 ---pagebreak---                                                                                           E 205     D
5I
                                                                Periods treated
Periods during which insurance periods and       Insurance
                                                                 as insurance
  periods treated as such were completed         periods (4)      periods (5)   Insurance
                                                                                 scheme
                                                                                              Occupation (6)
 Year           from                to        Weeks    Months  Weeks     Months
 5.1    Total length of period of insurance under German social security schemes for employed persons :
 5.2    Remarks :
 ---pagebreak---                                                                                                                 E 205          D
    6        The insured person showing proof that he has completed an insurance period of less than one year
             ( 7 ) Q may receive                                    Q] may not receive
             a pension under national legislation (Art. 48.1 of Reg . 1408/ 71 ).
    7 j Institution completing the form
    7.1      Name :
    7.2      Address ( 2 ):
    7.3      Stamp
                                                                                       7.4      Date :
                                                                                       7.5      Signature
                                                              INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                                     NOTES
(1 )    Symbol of the country to which the institution completing the form belongs (D = Germany).
(2)     Postal code, town , street, number, country.
(3)     To be completed if applicable .
( 4) Write ' P' after number of weeks or months of periods of compulsory insurance (' Pflichtversicherung ') to distinguish them from periods
        of voluntary insurance .
( 5 ) Write ' E' after number of weeks or months of substitute periods (' Ersatzzeiten ') to distinguish them from interrupted periods. At point
        5.2 the type of periods that are treated as insurance periods should be specified .
(6)     For workers who have been employed in mines or similar undertakings, attach form E 206.
(7)     Put a cross in the square preceding the appropriate subject.
                                                                                                                                             (D
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                        See ' Instructions' on page 3
 Social Security Regulations
                                                                                                    E 205           F     (1
                        CERTIFICATE CONCERNING INSURANCE RECORD IN FRANCE
                                  Reg. 1408/ 71 : Art. 38 ; Art. 45 ; Art. 48 ; Art. 57.3.C
                                     Reg. 574172 : Art. 42.1 ; Art. 43.1 to 3 ; Art. 69
To be drawn up by the investigating institution for insurance periods completed under the legislation which it ad­
ministers ; to be attached to forms E 202, E 203 or E 204, as applicable. Each institution concerned should draw up
a form for the periods completed under the legislation which it administers and send it to the investigating institution.
  1      Institution to which the form is addressed ( institution concerned or investigating institution , as applicable )
  1.1   Name :
  1.2   Address ( 2 ) :
  2 j   File references
  2.1   of investigating institution :
  2.2   of institution concerned :
  3 | Worker
  3.1   Surname                                Forenames                                 Maiden name
  3.2   Place of birth                   Date of birth                    Sex                  Nationality
  3.3   Address ( 2 ):
  3.4   Insurance number :
  4     Person who has entitlement ( 3 )
  4.1   Surname                                Forenames                                 Maiden name
  4.2   Place of birth                    Date of birth                   Sex                   Nationality
  4.3   Address ( 2 ):
 ---pagebreak---                                                                                          E 205         F
U
                                                                Periods
  Periods during which insurance periods and     Insurance   treated as
     periods treated as such were completed      periods (4)  insurance   Insurance
                                                                           scheme         Occupation (6 )
                                                             periods (5 )
    Year I          from               to         Quarters     Quarters
5.1    Total length of period of insurance under French social security schemes for employed persons :
5.2     Remarks :
 ---pagebreak---                                                                                                             E 205 F
  6       The insured person showing proof that he has completed an insurance period of less than one year
           (7) (Z] may receive                                     [J may not receive
           a pension under national legislation (Art. 48.1 of Reg . 1408/ 71 ).
  7        Institution completing the form
  7.1     Name :
  7.2     Address ( 2 ):
  7.3     Stamp
                                                                                      7.4    Date :
                                                                                      7.5    Signature
                                                              INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                                     NOTES
C1 )  Symbol of the country to which the institution completing the form belongs (F = France ).
(2)   Postal code, town , street, number, country.
(3)   To be completed if applicable.
(4)   Write 'V' after periods of voluntary insurance to distinguish them from periods of compulsory insurance.
(5)   Specify at point 5.2 the type of periods that are treated as insurance periods.
(6)    For workers who have been employed in mines or similar undertakings, attach form E 206 .
(7)   Put a cross in the square preceding the appropriate subject.
                                                                                                                    <D
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                          See ' Instructions' on page 3
 Social Security Regulations
                                                                                                      E 205           RL    (1
                        CERTIFICATE CONCERNING INSURANCE RECORD IN IRELAND
                                  Reg. 1408/ 71 : Art. 38 ; Art. 45 ; Art. 48 ; Art. 57. 3. c
                                    Reg. 574/ 72 : Art. 42.1 ; Art. 43.1 to 3 ; Art. 69
To be drawn up by the investigating institution for insurance periods completed under the legislation which it ad­
ministers ; to be attached to forms E 202, E 203 or E 204, as applicable. Each institution concerned should draw up
a form for the periods completed under the legislation which it administers and send it to the investigating institution.
  1 j Institution to which the form is addressed (institution concerned or investigating institution, as applicable)
  1.1    Name :
  1 .2  Address ( 2 ) :
 2 | File references
 2.1    of investigating institution :
 2.2    of institution concerned :
 3      Worker
 3.1    Surname                              Forenames                                   Maiden name
 3.2    Place of birth                  Date of birth                    Sex                     Nationality
 3.3    Address ( 2 ):
 3.4    Insurance number :
 4 j Person who has entitlement (3)
 4.1    Surname                              Forenames                                   Maiden name
 4.2    Place of birth                  Date of birth                    Sex                     Nationality
 4.3   Address ( 2 ):
 ---pagebreak---                                                                                                E 205       IRL
Il
                                                                              Reason for
                                                                    Periods
  Periods during which insurance periods and        Insurance    treated as     treating
                                                                                  these
     periods treated as such were completed         periods (4 )  insurance
                                                                                                Occupation (6) (7)
                                                                    periods    periods as
                                                                               insurance
    Year j           from                to       | Weeks [ Weeks              periods ( 5)
 5.1     Total length of period of insurance under the Irish social security scheme for employed persons :
 5.2     Remarks :
 ---pagebreak---                                                                                                     E 205 IRL
     6     The insured person showing proof that he has completed an insurance period of less than one year
           ( 8) Q] may receive                               Q may not receive
           a pension under national legislation (Art. 48.1 of Reg . 1408/ 71 ).
     7     Institution completing the form
     7.1   Name :
     7.2   Address ( 2 ):
     7.3   Stamp
                                                                                 7.4    Date :
                                                                                 7.5    Signature
                                                        INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                              NOTES
( 1 ) Symbol of the country to which the institution completing the form belongs ( Irl = Ireland ).
(2) Postal code , town , street, number, country .
(3) To be completed if applicable .
(4) Write 'V ' after number of weeks to indicate voluntary insurance , if applicable.
(5) State whether periods of sickness, unemployment, etc .
(6) For workers who have been employed in mines or similar undertakings, attach form E 206 .
(7 ) This information can only be given from statements made by the worker .
(8) Put a cross in the square preceding the appropriate subject .
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                       See ' Instructions on page 3
 Social Security Regulations
                                                                                                   E 205           I    (1 )
                        CERTIFICATE CONCERNING INSURANCE RECORD IN ITALY
                                 Reg. 1408/ 71 : Art. 38 ; Art. 45 ; Art. 48 ; Art. 57.3.C
                                    Reg. 574/ 72: Art. 42.1 ; Art. 43.1 to 3 ; Art. 69
To be drawn up by the investigating institution for insurance periods completed under the legislation which it ad­
ministers ; to be attached to forms E 202, E 203 or E 204, as applicable. Each institution concerned should draw up
a form for the periods completed under the legislation which it administers and send it to the investigating institution.
  1     Institution to which the form is addressed ( institution concerned or investigating institution , as applicable)
  1.1   Name :
  1.2   Address ( 2 ) :
  2     File references
  2.1   of investigating institution :
  2.2   of institution concerned :
  3     Worker
  3.1   Surname                               Forenames                                 Maiden name
  3.2   Place of birth                   Date of birth                   Sex                   Nationality
  3.3   Address ( 2 ):
  3.4   Insurance number :
  4      Person who has entitlement ( 3 )
  4.1   Surname                               Forenames                                 Maiden name
  4.2   Place of birth                   Date of birth                    Sex                   Nationality
  4.3   Address ( 2 ):
 ---pagebreak---                                                                                           E 205      I
5
                                                                Periods treated
Periods during which insurance periods and     Insurance
                                                                 as insurance
  periods treated as such were completed -     periods (4)                      Insurance
                                                                  periods (5)                  Occupation (6)
                                                                                 scheme
  Year          from              to        Weeks     Months    Weeks    Months
5.1    Total length of period of insurance under Italian social security schemes for employed persons and for
       self-employed persons treated as employed persons :
5.2    Remarks :
 ---pagebreak---                                                                                                           E 205           I
  6        The insured person showing proof that he has completed an insurance period of less than one year
           ( 7) Q may receive                                    Q may not receive
           a pension under national legislation (Art. 48.1 of Reg . 1408/71 ).
  7        Institution completing the form
  7.1      Name :
  7.2     Address ( 2 ):
   7.3     Stamp
                                                                                     7.4    Date
                                                                                     7.5    Signature
                                                             INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                                    NOTES
C)     Symbol of the country to which the institution completing the form belongs (I = Italy ).
(2)    Postal code, town , street, number, country .
(3)    To be completed if applicable .
( 4) Write ' P' after number of weeks or months of periods of compulsory insurance to distinguish them from periods of voluntary insurance.
(5)    Specify at point 5.2 the type of periods that are treated as insurance periods .
(6)    For workers who have been employed in mines or similar undertakings, attach form E 206 .
(7)    Put a cross in the square preceding the appropriate subject.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                        See 'Instructions' on page 3
 Social Security Regulations
                                                                                                   E 205           L     D
                   CERTIFICATE CONCERNING INSURANCE RECORD IN LUXEMBOURG
                                  Reg. 1408/ 71 : Art. 38 ; Art. 45 ; Art. 48 ; Art. 57.3.C
                                     Reg. 574/ 72 : Art. 42.1 ; Art. 43.1 to 3 ; Art. 69
To be drawn up by the investigating institution for insurance periods completed under the legislation which it ad­
ministers ; to be attached to forms E 202, E 203 or E 204, as applicable. Each institution concerned should draw up
a form for the periods completed under the legislation which it administers and send it to the investigating institution.
  1 I    Institution to which the form is addressed ( institution concerned or investigating institution, as applicable)
  1.1   Name :
  1.2   Address ( 2 ):
  2      File references
  2.1   of investigating institution :
  2.2   of institution concerned :
  3     Worker
  3.1   Surname                               Forenames                                  Maiden name
  3.2   Place of birth                   Date of birth                    Sex                  Nationality
  3.3   Address ( 2 ):
 3.4    Insurance number :
 4 I    Person who has entitlement (3)
 4.1    Surname                               Forenames                                  Maiden name
 4.2    Place of birth                   Date of birth                    Sex                  Nationality
 4.3    Address ( 2 ):
 ---pagebreak---                                                                                             E 205     L
Ll
                                                                Periods treated
  Periods during which insurance periods and      Insurance
                                                                 as insurance
   periods treated as such were completed           periods
                                                                   periods (4)    Insurance
                                                                                   scheme
                                                                                                Occupation ( 5)
   Year           from               to         Days j Months   Days     Months
   5.1    Total length of period of insurance under Luxembourg social security schemes for employed persons :
   5.2    Remarks :
i
 ---pagebreak---                                                                                                      E 205 L
   6       The insured person showing proof that he has completed an insurance period of less than one year
           (6 ) [J may receive                                    Q] may not receive
           a pension under national legislation (Art. 48.1 of Reg . 1408/ 71 ).
   7       Institution completing the form
   7.1     Name :
   7.2     Address ( 2 ):
   7.3     Stamp
                                                                                     7.4  Date :
                                                                                     7.5  Signature
                                                             INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                                   NOTES
(1 )   Symbol of the country to which the institution completing the form belongs (L = Luxembourg ).
(2)    Postal code, town , street, number, country.
(3)    To be completed if applicable .
(4)    Specify at point 5.2 the type of periods that are treated as insurance periods.
(5)    For workers who have been employed in mines or similar undertakings, attach form E 206 .
(6)    Put a cross in the square preceding the appropriate subject.
                                                                                                             @
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                        See ' Instructions' on page 3
 Social Security Regulations
                                                                                                    E 205           N     (1 )
                CERTIFICATE CONCERNING INSURANCE RECORD IN THE NETHERLANDS
                                  Reg. 1408/ 71 : Art. 38 ; Art. 45 ; Art. 48 ; Art. 57.3.C
                                     Reg. 574172 : Art. 42.1 ; Art. 43.1 to 3 ; Art. 69
To be drawn up by the investigating institution for insurance periods completed under the legislation which it ad­
ministers ; to be attached to forms E 202, E 203 or E 204, as applicable. Each institution concerned should draw up
a form for the periods completed under the legislation which it administers and send it to the investigating institution.
  1      Institution to which the form is addressed ( institution concerned or investigating institution , as applicable )
  1.1   Name :
  1.2   Address ( 2 ) :
  2     File references
  2.1   of investigating institution :
  2.2   of institution concerned :
  3     Worker
  3.1   Surname                                Forenames                                 Maiden name
  3.2   Place of birth                   Date of birth                    Sex                   Nationality
  3.3   Address ( 2 ):
  3.4   Insurance number :
  4     Person who has entitlement ( 3 )
  4.1   Surname                                Forenames                                 Maiden name
  4.2   Place of birth                    Date of birth                   Sex                   Nationality
  4.3   Address ( 2 ):
 ---pagebreak---                                                                                        E 205         N
  5
     Insurance periods         Insurance periods                 Number of
. under AOW/AWW (4)              under WAO (4)
                                                                                             Type (5)
      from         to          from          to        Years      Months        Days
  5.1     Total length of period of insurance in the Netherlands under AOW, AWW and WAO (6):
                                      years,                           months ,                        days .
 ---pagebreak---                                                                                                                  E 205          N
   6          The insured person showing proof that he has completed an insurance period of less than one year
              ( 7) Q may receive                                     Q may not receive
              a pension under national legislation (Art. 48.1 of Reg . 1408/71 ).
   7          Institution completing the form
   7.1        Name :
   7.2       Address ( 2 ):
   7.3       Stamp
                                                                                         7.4       Date :
                                                                                         7.5       Signature
                                                                INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                                      NOTES
C)      Symbol of the country to which the institution completing the forrp belongs (N = Netherlands).
(2)     Postal code, town , street, number, country .
(3)    To be completed if applicable .
( 4)   AOW = law on general old-age insurance .
       AWW = law on general widows' and orphans ' insurance .
       WAO = law on insurance against protracted incapacity for work .
(5)    To indicate periods of insurance under AOW and AWW, use the following symbols :
       P     = compulsory insurance ;
       F     = voluntary insurance ;
       G     = periods treated as equivalent.
(6)    Delete whichever is not applicable . As, under the Netherlands insurance scheme , the insured are not registered , it is possible that
      the list at point 5 includes periods during which the person concerned was only presumed to have been insured in the Netherlands .
       If it is found that, in the insurance periods in the Netherlands as indicated in that list, the person concerned was in fact insured under
       the legislation of your country, you may, without first consulting us, subtract these periods from the total length of insurance periods
       in the Netherlands indicated at point 5.1 .
(7)    Put a cross in the square preceding the appropriate subject­
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                        See ' Instructions' on psge 3
 Social Security Regulations
                                                                                                    E 205          UK     (1 )
              CERTIFICATE CONCERNING INSURANCE RECORD IN THE UNITED KINGDOM
                                  Reg. 1408/ 71 : Art. 38 ; Art. 45 ; Art. 48 ; Art. 57.3.C
                                     Reg. 574172: Art. 42.1 ; Art. 43.1 to 3 ; Art. 69
To be drawn up by the investigating institution for insurance periods completed under the legislation which it ad­
ministers ; to be attached to forms E 202, E 203 or E 204, as applicable. Each institution concerned should draw up
a form for the periods completed under the legislation which it administers and send it to the investigating institution.
  1      Institution to which the form is addressed ( institution concerned or investigating institution , as applicable)
  1.1   Name :
  1 .2  Address ( 2 ) :
  2 | File references
  2.1   of investigating institution :
  2.2   of institution concerned :
 3      Worker
 3.1    Surname                               Forenames                                 Maiden name
 3.2    Place of birth                   Date of birth                    Sex                  Nationality
 3.3    Address ( 2 ):
 3.4    Insurance number :
 4      Person who has entitlement ( 3 )
 4.1    Surname                               Forenames                                 Maiden name
 4.2    Place of birth                   Date of birth                    Sex                  Nationality
 4.3    Address ( 2 ):
 ---pagebreak---                                                                                           E 205       UK
5
                                                                Periods Reason for
  Periods during which insurance periods and     Insurance   treated as  treating
                                                                           these
    periods treated as such were completed       periods (4)  insurance
                                                                                           Occupation (6) (7 )
                                                                periods periods as
                                                                        insurance
   Year            from       J       to           Weeks        Weeks   periods (5)
5.1     Total length of period of insurance under the United Kingdom social security scheme for employed persons :
5.2     Remarks :
 ---pagebreak---                                                                                                           E 205 UK
   6       The insured person showing proof that he has completed an insurance period of less than one year
            (8 ) Q may receive                                    Q] may not receive
            a pension under national legislation (Art. 48.1 of Reg . 1408/71 ).
   7        Institution completing the form
   7.1     Name :
   7.2     Address ( 2 ):
   7.3     Stamp
                                                                                    7.4   Date :
                                                                                    7.5   Signature
                                                             INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                                   NOTES
(1 )   Symbol of the country to which the institution completing the form belongs ( UK = United Kingdom ).
(2)    Postal code, town, street, number, country.
(3)    To be completed if applicable .
(4)    Write ' V ' after number of weeks to indicate voluntary insurance.
( 5)   State whether periods of sickness, unemployment, etc .
(6)    For workers who have been employed in mines or similar undertakings, attach form E 206 .
(7)    This information can only be given from statements made by the worker.
(8)    Put a cross in the square preceding the appropriate subject.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                      See Instructions an page 3
Social Security Regulations
                                                                                                  E 206              1
                 CERTIFICATE CONCERNING PERIODS OF EMPLOYMENT IN MINES
                                          AND SIMILAR UNDERTAKINGS
                                  Reg. 1408/ 71 : Art. 38 ; Art. 45 ; Art. 48 ; Art. 57.3.C
                                       Reg. 574/ 72: Art. 42.1 ; Art. 43.1 to 3 ; Art. 69
To be drawn up by the investigating institution for insurance periods completed under the legislation which it ad­
ministers ; to be attached to forms E 202, E 203 or E 204, as applicable. Each institution concerned should draw up
a form for the periods completed under the legislation which it administers and send it to the investigating institution.
  1     Institution to which the form is addressed ( institution concerned or investigating institution , as applicable)
  1.1   Name :
  1.2   Address ( 2 ):
  2     File references
  2.1   of investigating institution :
  2.2   of institution concerned :
  3     Worker
  3.1   Surname                               Forenames                                  Maiden name
  3.2   Place of birth                        Date of birth                Sex                  Nationality
  3.3   Address ( 2 ):
  3.4   Insurance number :
  4 j Person who has entitlement (3)
  4.1   Surname                               Forenames                                  Maiden name
  4.2   Place of birth                         Date of birth               Sex                  Nationality
  4.3   Address ( 2 ) :
 ---pagebreak---                                                                                         E 206
5
                               Periods of employment             Length of each period
                                 or periods treated
                 Type of work          as such             overall              underground work
Undertakings (4)
                 performed (5)
                                 from          to    Years Months    Days     Years    Months Days
  5.1                                      Total
 ---pagebreak---                                                                                                                        E 206
   6       The periods of employment shown at point 5 were interrupted as follows ( 6):
                  Periods of interruption                            Reason for interruption ( sickness, leave, military service,
              from                 I           to                    active   service,     unemployment,     medical     treatment,
     Day/ Month/Year               |    Day/ Month/Year                             retraining , unpaid leave, etc .)
   7       Institution completing the form
  7.1      Name :
  7.2      Address ( 2 ):
  7.3      Stamp
                                                                                      7.4    Date :
                                                                                      7.5    Signature
                                                               INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                                      NOTES
(1 )  Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
      Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)   Postal code, town , street, number, country.
(3)   To be completed if applicable.
(4)   Indicate the undertakings in which the person concerned was employed and the substance extracted or processed .
(5)   Specify type of work and indicate whether performed at the surface or underground , or whether it concerns periods treated as periods
      of employment
(6)   Complete only if the form is to be sent to German institutions.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                       See Instructions' on page 3
  Social Security Regulations
                                                                                                  E 207                n
                  INFORMATION CONCERNING THE WORKER'S INSURANCE HISTORY
                                 Reg. 1408/ 71 : Art. 38 ; Art. 45 ; Art. 48 ; Art. 57.3.C
                                            Reg. 574172: Art. 42.1 ; Art. 69
To be completed where necessary by the investigating institution and to be attached to forms E 202, E 203 and E 204
except if these forms are sent to a United Kingdom institution.
The information in box 3 has been obtained from the person concerned and will be sent to the institution concerned
for its record.
    1    Worker
    1.1  Surname                                 Forenames                                      Maiden name
    1.2  Place of birth                  Date of birth                   Sex                   Nationality
    1.3  Address (2 ):
    1.4  Insurance number :
 ( Information relating to each period : see page 2)
    2 j Investigating institution
    2.1  Name :
    2.2  Address ( 2):
    2.3  Stamp
                                                                         2.4    Date :
                                                                         2.5    Signature
 ---pagebreak---                                                                                                        E 207
                                                   a) Insurance institution or scheme       Place of residence
Name of employer and place of   Place and country
                                                   b) Insurance number (5)                    during period
      registered office       of actual employment                                           of employment
                                                   c) Type of insurance (6)
              4                         5                                   6                        7
                                                   a)                                 ,
                                                   b)
                                                   c)
                                                   a)
                                                   b)
                                                   c)
                                                   a)
                                                   b)
                                                   c)
                                                   a)
                                                   b)
                                                   c)                                     -
                                                   a)
                                                   b)
                                                   c)
                                                   a>                   :
                                                   b)
                                                   c)                                   :
                                                   a)
                                                   b)
                                                   c)
                                                   a)                     '
                                                   b)
                                                   c)
 ---pagebreak---                                                                                                                           E 207
                                                               INSTRUCTIONS
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 even if it does not contain any relevant information . If the space
provided on page 2 is not sufficient to indicate all stages of the insurance history of the person
concerned, insert one or more identical pages, changing the numbers at the extreme left-hand side
                                                ( replacing 1 , 2, 3 ... by 9, 10, 11 . . . ).
                                                                     NOTES
(1)  Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
     Irl = Ireland ; I = Italy; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)  Postal code, town , street, number, country.
(3)  If the form is to be sent to a Danish or Netherlands institution , indicate all periods of residence completed by the worker in Denmark
     or in the Netherlands respectively.
( 4) Indicate the type of work performed ( employed or self-employed ), e.g. mechanic, shop assistant, self-employed farmer. Where
     applicable : military service ( country ), school or vocational training, periods without paid employment (e.g. housewife, unemployed ,
     sickness, etc .).
(5)   If the form is to be sent to a Danish institution, indicate CPR number and , where applicable, ATP number.
( 6)  Specify whether compulsory insurance, voluntary insurance, optional continued insurance or period uninsured .
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                      See Instructions' on page 3
Social Security Regulations
                                                                                                E 208                 C)
                                   DETERMINATION OF RIGHTS TO PENSION
to (2 ) [] an old-age pension Q] invalidity pension                       Q] survivor's pension
                                                     in ( 3 )
                                       Reg. 1408/ 71 : Art. 46.1 and 2 ; Art. 49.2 and 3
                                           Reg. 574172: Art. 43.2 and 3 ; Art. 46
 To be sent by the institution concerned to the investigating institution.
   1       Investigating institution to which the form is addressed
   1.1     Name :
   1.2     Address ( 4):
    2       File references
    2.1    of investigating institution :
    2.2     of institution concerned :
     3      Insured person
     3.1    Surname                         Forenames                                           Maiden name
  j 3.2 Date of birth                       Sex                                    Insurance number
     3.3    Address (4) :
     4       Person who has entitlement ( 5 )
     4.1    Surname                         Forenames                                           Maiden name
     4.2     Date of birth                                                                      Sex
     4.3    Address (4) :
     4.4     Relationship to the deceased insured person
   5     Date of pension claim :
 ---pagebreak---                                                                                                    E 208
6    If the claim is rejected ( 6 )
Reason :
7    If a pension is awarded ( 6 )
7.1  Annual amount ( 7 ) of the national pension referred to in Art. 46.1 (first subparagraph ) of Regulation
     1408/71 which the person concerned may claim for periods of insurance ( compulsory, voluntary or
     optional continued ) and periods treated as such completed in the country concerned , even if some of these
     periods overlap with periods completed in another country :
7.2  Actual annual amount ( 7 ) of the theoretical pension referred to in Art. 46.2 of Regulation 1408/71 which
     would be payable if all insurance periods and periods treated as such, determined in accordance with the
     rules laid down in Art. 15 of Regulation 574/72, had been completed in the country concerned :
7.3  Actual annual amount ( 7 ) of the proportional pension referred to in Art. 46 . 2 . b, c and d of Regulation
     1408/71 , calculated by taking into consideration periods completed in the country concerned, excluding
     periods of voluntary or optional continued insurance overlapping with periods of insurance completed in
     another country :
7.4  Actual annual amount ( 7 ) of the proportional pension referred to in Art. 46.2 . b, c and d of Regulation
     1408/71 , calculated by taking into consideration periods completed in the country concerned, including
      periods of voluntary or optional continued insurance overlapping with periods of insurance completed in
     another country :
7.5  Date from which benefits are payable :
8     Institution concerned
8.1  Name :
8.2  Address ( 4) :
8.3  Stamp
                                                                    8.4   Date :
                                                                    8.5   Signature
 ---pagebreak---                                                                                                                    E 208
                                                             INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                                    NOTES
(1)  Symbol of the country to which the institution concerned belongs : B = Belgium ; Dk = Denmark; D = Germany ; F = France ;
     Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)  Put a cross in the square preceding the appropriate subject.
(3 ) Indicate the country.
( 4) Postal code, town, street, number, country.
(5)  To be completed only in the case of a claim for a survivor's pension .
(6)  Complete box 6 or 7 as applicable.
(7)  The annual amount is equal to the total of the amounts to be paid in the course of one year, calculated on the basis of the rate of
     benefit applicable at the date of commencement of the pension .
 ---pagebreak---  EUROPEAN COMMUNITIES                                                                See ' Instructions' on page 3
  Social Security Regulations
                                                                                               E 209               1)
                                      DETERMINATION OF PENSION AMOUNTS
        (2) D old-age pension             [] invalidity pension      [] survivor's pension
        REGARDING THE POSSIBLE APPLICATION OF ARTICLE 46.3 OF REGULATION 1408/71
 The investigating institution should complete this form and send a copy to each of the institutions concerned.
   1        Institution concerned to which the form is addressed
   1.1     Name :
   1 .2    Address ( 3 ) :
   2        File references
  2.1      of investigating institution :
  2.2      of institution concerned :
   3 I      Insured person
  3.1      Surname                         Forenames                                        Maiden name
  3.2      Place of birth                  Date of birth             Sex                    Nationality
   4        Person who has entitlement (4)
  4.1      Surname                        Forenames                                         Maiden name
  4.2      Date of birth :                                                         Sex :
  4.3      Address ( 3 ):
  4.4      Relationship to the deceased insured person :
( Determination of amounts : see page 2 )
  5        Investigating institution
  5.1      Name :
  5.2      Address ( 3 ):
  5.3      Stamp
                                                                     5.4    Date :
                                                                     5.5    Signature
 ---pagebreak---                                                                                                                                                                             E 209
currency of the country of the                                            Annual amount in the currency of the country of the
nt institution ( 5 )                                                                      investigating institution
                                                                                                                                                            Annual amount in the currency
                                                                                 Highest amount in columns 3 or 4 (7)                                       of the country of the, competent
                                                                                                                                           Product of                  institution ( 5 )
 nal pension          Proportional pension (6)    Theoretical pension                                                                 multiplication of the      ( Pension after application
 6.1 first sub­         (Art. 46.2.b of Reg.        (Art. 46.2.a of Reg .                                                             amounts in col . 6 by  of Art. 46.3 of Reg . 1408/71 ) (S)
graph of Reg .                1408/71 )                   1408/ 71 )           Amounts in col . 3                                     reduction coefficient
1408/71 )                                                                                                 Amounts in col . 4
                                                                               (Art. 46.1 first sub­      (Art. 46.2.b of Reg.           (see box 7 ) (8 )
                                                                                paragraph of Reg .              1408/71 )
                                                                                     1408/71 )
    3                            4                           5                           6                           7                          8                              9
                                                                 Total       A                           B
                                      Repeat of total B from col. 7          B
                                                                                                                  8        Parities (10)
                                                                                                                    Currency of the country of the                 Currency ofthe country ofthe
             Total pensions due from all countries (C = A + B)               C                                      competent institution                          investigating institution
                                                                                                                    DM. 100      x
                          Highest theoretical pension from col . 5           D                                      Bfrs. 100    x
                                                                                                                    FF. 100      x
                                               Difference (C-D = E)          E                                      Lit. 100     x
                                                                                                                    Lfrs. 100    x
Art. 46.3 of Reg . 1 408/7 1 (Coefficient used for
                                                                                                                    Fl . 100     x
                     A                                                                                              Dkr. 100     x
                     E                                                                                              UK. £ 100 x
                     F                                                                                              Ir. £  100 x
 ---pagebreak---                                                                                                                         E 209
                                                              INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                                     NOTES
(1 )  Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
      Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)   Put a cross in the square preceding the appropriate subject.
(3)   Postal code, town , street, number, country.
(4)   To be completed only in the case of a claim for a survivor's pension .
(5)   State which currency.
( 6)  Calculated without reference to periods of voluntary or optional continued insurance coinciding with periods of compulsory insurance
      completed in another country.
(7)    If the amount in column 3 is the same as that in column 4 this amount should be indicated in column 7 .
(8)   Complete only if the amounts at A and E in column 6 are positive.
(9)   To the amount in column 7 should be added, where applicable, the increase of pension provided for in Art. 46.1 of Reg . 574/ 72,
      corresponding to periods of voluntary or optional continued insurance coinciding with periods of insurance completed in another
      country.
( 10) See Reg . 574/72 , Art. 107 .
                                                                                                                                        <D
 ---pagebreak---                                                                                    See Instructions on page 3
EUROPEAN COMMUNITIES
 Social Security Regulations
                                                                                           E 210              (1 )
                 NOTIFICATION OF DECISION CONCERNING A CLAIM FOR PENSION
for (2)     Q] old age                   [] invalidity               Q] survivor
                                               (award or rejection )
                                                Reg. 574/ 72: Art. 48
Each of the institutions concerned should complete this form m duplicate, sending them to the investigating insti­
tution and attaching two copies of the formal decision. If there is more than one institution concerned, one extra
copy should be added for each additional institution concerned.
  1     Investigating institution to which the form is addressed
  1.1   Name :
  1 .2  Address (3 ) :
  2     File references
  2.1   of investigating institution :
  2.2   of institution concerned :
   3    Insured person
  3.1   Surname                        Forenames                                         Maiden name
                                                                                                       v
  3.2   Place of birth                 Date of birth                  Sex                Nationality
  3.3   Address ( 3 ):
  3.4   Insurance number :
  4     Person who has entitlement ( 4)
  4.1   Surname                        Forenames                                         Maiden name
  4.2   Place of birth                 Date of birth                  Sex                Nationality
  4.3   Relationship to deceased insured person :
  4.4   Address ( 3 ):
 ---pagebreak---                                                                                   I E 210
 5 j The claim is rejected (5)
Reason :
 6 j A pension is awarded (5)
6.1  Annual amount :
6.2  Where appropriate, deduction under the provisions on the prevention of
     overlapping (Art. 12 of Reg . 1408/71 and Art. 7 of Reg . 574/72 ):
     Reason :
6.3  Amount due :
6.4  Payable from (date):
 7   A Danish pension is awarded ( 6 )
7.1  Annual amount under the legislation on social pensions :
7.2  Annual amount under the legislation on supplementary pensions for employed
     persons (ATP ):
7.3  Total annual amount :
7.4  Where appropriate, deduction under the provisions on the prevention of over­
     lapping (Art. 12 of Reg . 1408/71 and Art. 7 of Reg . 574/72 ):
     Reason :
7.5  Amount due (social pension ):
7.6  Amount due (ATP pension ):
7.7  Date from which social pension is payable :
7.8  Date from which ATP pension is payable :
8    Legal remedies and periods allowed for appeals : see form E 212
9 I   Institution concerned
9.1  Name :
9.2  Address ( 3 ):
9.3  Stamp
                                                                9.4   Date :
                                                                9.5   Signature
 ---pagebreak---                                                                                                                     E 210
                                                          INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                                  NOTES
(1 ) Symbol of country to which the institution concerned belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ; Irl = Ireland ;
     I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)  Put a cross in the square preceding the appropriate subject.
(3)  Postal code, town , street, number, country.
(4)  To be completed only in the case of a claim for a survivor's pension .
(5)  Complete box 5 or box 6 , as appropriate .
( 6) To be completed only by Danish institutions.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                  See ' Instructions' overleaf
 Social Security Regulations
                                                                                             E 211 I             i (n
                                          SUMMARY OF DECISIONS
                                                Reg. 574/ 72: Art. 48
The investigating institution should complete this form and send a copy to the claimant in his own language, attach­
ing a copy of each of the decisions of award or rejection (form E 210) together with a notice of legal remedies and
periods allowed for appeals (form E 212) and a copy of the formal decisions. The investigating institution should
also send a copy of form E 211 to each of the institutions concerned, attaching a copy of the decisions of the other
institutions (form E 210).
  1      Claimant
  1.1    Surname                       Forenames                                             Maiden name
  1.2    Place of birth                Date of birth                  Sex                    Nationality
  1 .3   Address ( 2 ) :
  2      Your claim for a pension for
  2.1    (3) Q old age                  Q invalidity                                     Q survivor
  2.2    has been examined by the following institutions :
  3H     Institutions concerned
         Country                                   Institution                               File reference
  3.1
  3.2
  3.3
  3.4
  3.5
  4      These institutions have taken the following decisions (see forms E 210 attached ):
   5     Your claim has been rejected
  5.1    as regards (4):
         Reason :
  5.2    as regards (4):
         Reason :
 ---pagebreak---                                                                                                                         E 21 1
  6 I A pension has been awarded to you
           as regards ( 4)                              Annual amount in currency of country              Payable from ( date):
                                                        responsible for payment ( 5 ) ( 6 )
  6.1
  6.2
  6.3
  6.4
  6.5
  7        If you wish to appeal against the decisions given in your case by one or more of these institutions, you may
           do so in accordance with the procedures and within the time-limits indicated on form E 212 .
   8       Investigating institution
  8.1      Name :
  8.2      Address ( 2 ):
  8.3      Stamp
                                                                                      8.4     Date :
                                                                                      8.5     Signature
                                                              INSTRUCTIONS
                 Please complete this form in block letters, writing on the dotted lines only.
                                                                     NOTES
(1 )  Symbol of the country to which the investigating institution belongs : B = Belgium ; Dk = Denmark; D = Germany ; F = France ;
      Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)   Postal code, town, street, number, country.
(3)   Put a cross in the square preceding the appropriate subject.
( 4)  Indicate country and where necessary the scheme concerned .
(5)   Where rates of pensions are upgraded by virtue of national legislation, the amount indicated above will be changed without notification
      of the new amount .
( 6)  It is possible that this amount is reduced by taxes and contributions payable by the pensioner.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                         Sea  Instructions' overleaf
Social Security Regulations
                                                                                                    E 212                (i )
                        LEGAL REMEDIES AND PERIODS ALLOWED FOR APPEALS
                                                     Reg. 574/ 72: Art. 48
A — If you do not agree with the decision or decisions taken , you may appeal . For this purpose you should , for each
      contested decision :
      1.  State clearly in a letter the grounds of your appeal .
      2.  State the references on the notification relating to the contested decision . Attach a copy of this decision ( 2 ).
      3.  Sign the letter. If you cannot sign , make a cross and have the letter of appeal signed by two persons of
          age, giving their surnames, forenames and addresses (3 ).
B — 1.    An appeal against a Belgian decision should, within one month from the date of receiving notification
          of it, either be sent by registered letter, or delivered to the office of the clerk of the labour court in the area
          of jurisdiction where you reside, if you are resident in Belgium ( labour court of :
          or in the area of jurisdiction of your last domicile or residence in Belgium, if you are resident abroad .
      2 . An appeal against a Danish decision relating to a pension under the legislation on social pensions should
          be sent, within a period of four weeks from the date of receiving notification of it, to ' Den sociale Ankesty­
          relse' (social appeals board ), Copenhagen .
          An appeal against a Danish decision relating to entitlement to a pension under the legislation on sup­
          plementary pensions for employed persons (ATP) should be lodged , within a period of four weeks of
          receipt of its notification , with the 'Ankenaevnet for Arbejdsmarkedets Tillaegspension ' (ATP appeals
          board ), Ministry of Labour, Copenhagen .
      3 . An appeal against a German decision taken by an institution for pension insurance for manual or clerical
          workers should be lodged within a period of one month if that decision was notified in the territory of the
          Federal Republic of Germany, including West Berlin ; the appeal should be lodged within a period of three
          months from its notification if it was notified outside the territory of the Federal Republic of Germany,
          including West Berlin .
          An appeal against a decision taken by an institution for pension insurance for miners should be lodged within
          a period of one month from the notification of that decision .
          The letters of appeal should be sent in duplicate :
          — either to the German institution whose address appears on the German decision (E 210, column 8 );
          — or to the ' Sozialgericht' (social court) of :
          — or to a consular authority of the Federal Republic of Germany ;
          — or, if it concerns insurance for seamen , also to a German 'Seemannsamt' (seamen 's registration office ) in
               the country concerned .
      4.  An appeal against a French decision should be sent, within a period of two months from the date of
          receiving notification of it, to ' Mr. le President de la Commission de recours gracieux de la Caisse de security
          sociale', whose address is given on the French notification .
      5.  An appeal against an Irish decision should be sent to the Secretary, Department of Social Welfare, Dublin ,
          within a period of 21 days from the date of its notification .
      6 . An appeal against an Italian decision of the INPS should be sent to the ' Comitato provinciale' attached to
          the provincial office of the INPS in :
          not later than 90 days from receipt of the Summary of Decisions (form E 21 1 ).
          If no decision has been received from the ' Comitato provinciale' at the end of the period of 90 days, the
          appeal must be regarded as rejected ; in that case, the person concerned may, within 90 days from the end
          of the period in which the first appeal should have been decided , send a second appeal to :
                                                                                                                              ©
 ---pagebreak---                                                                                                                          E 212
              The above appeal procedures apply to claims for pensions which have been decided by the IN PS in the
              framework of general compulsory invalidity, old-age and survivor's insurance . Appeals against decisions
             taken in the framework of special schemes of the IN PS or of other institutions are subject to different
              procedures of which the insured person will be notified separately.
        7 . An appeal against a Luxembourg decision should be sent in duplicate to the ' Conseil arbitral des assurances
              sociales' in Luxembourg , within a period of 40 days from the date of receiving notification of it.
        8 . An appeal against a Netherlands decision should be sent in duplicate to :
              within one month from the date when you could reasonably have taken note of that decision .
        9 . An appeal against a decision of a United Kingdom institution should be sent, within a period of 21 days
               from the date of its notification , to the Department of Health and Social Security, Overseas Group, Newcastle­
               upon-Tyne, or to the Ministry of Health and Social Services, Overseas Branch , Belfast, as appropriate.
N.B.
These time-limits run from the date of notification ; it should be noted, however, that under Article 86 of Regulation
1408/71 appeals submitted within the time-limits prescribed by the legislation of a Member State are admissible if
they are submitted within the same time-limit to the corresponding court or authority of another Member State.
                                                             INSTRUCTIONS
                    Please complete this form in block letters, writing on the dotted lines only.
                                                                   NOTES
 (1 ) Symbol of the country to which the investigating institution belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ; Irl = Ire
      land ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
 (2)  Except as regards Germany, Belgium and the United Kingdom .
 (3)  Postal code, town , street, number, country.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                     See ' Instructions' on page 8
 Social Security Regulations
                                                                                                   E 213               (1 )
                                          DETAILED MEDICAL REPORT
                                        Reg. 1408/ 71 : Art. 39 to 41 and Art. 87
If this form is intended for a German or Netherlands institution or if it is drawn up by a German or Netherlands doctor
or at the request of an institution of another Member State, form E 214 concerning assessment of functional abilities
and limitations should be attached.
  1       Institution to which the report is addressed
  1.1     Name :
  1.2    Address ( 2 ):
  2       Person examined
  2.1    Surname                           Forenames                                 Maiden name
  2.2     Place of birth         Date of birth                            Sex               Nationality
  2.3    Address ( 2) :
  2.4    Last occupation :
  2.5     (3 ) Q Insurance number :                                Q Pension number :
  2.6     File number :
  2.7     Date of submission of pension claim :
  2.8     Date of submission of request for review on grounds of aggravation :
  3       Doctor who drew up the report
  3.1    Surname :                                                 Forenames : ...
  3.2    Address ( 2 ):
  3.3     Examining doctor of :
 ---pagebreak---                                                                                                     E 213
PART I — QUESTIONNAIRE COMMON TO ALL CASES
A. Medical history
     1. Personal and family history :
     2. Present illness ( complaints of person concerned, beginning of illness, development, treatment given to date ):
 B. Objective examination
     1. General condition
         Height :                                              Weight :
         General appearance (senile, calm , agitated , etc .):
         Constitution ( strong , average, weak ):
         Posture :                                             Carriage :
         Movements :
         Musculature :
         Colour of mucous membranes :
         Nutritional condition :
         Face ( pale, cyanotic ):
         Condition of mouth and teeth :
     2.  Sense organs
         Hearing :
         Vision :
         Smell :
 ---pagebreak---                                                                                                        E 213
   3.    Respiratory system
         Upper respiratory tracts, lungs, chest measurement, appearance of thorax, macroscopic and microscopic
         examination of sputum, test for Koch's bacillus, X-ray examination, etc ):
         Report on radiographic examination, with date (where applicable, attach form E 214 ) ( 4):
         Other information :
   4. Circulatory system
         ( Heart, aorta , blood vessels, enlargement of heart, auscultation, pulse, blood pressure, dyspnoea, oedema,
         condition of peripheral blood vessels, varicose veins, radiological (X-ray) evidence, etc .):
          Test of               Blood
                                           Respiration     Pulse                     Other observations
   cardiocirculatory           pressure
                                            per minute  per minute                     after exertion
         function               ( R.R. )
— after prolonged                                                     — Dyspnoea ?
    rest                                                                  (3) □ Yes          □ No
— after                                                                   If yes, how long ?
    leg-bends in :
             sees .
                                                                      — Labial cyanosis ?
   — immediately                                                          (3) □ Yes          □ No
   — after 2 m ins.
                                                                      — Extrasystoles ?
   — after 4 mins .
   — after 6 mins .                                                       ( 3) □ Yes         □ No
                                                                      — If there were already extrasystoles at rest,
    Other disturbances of rhythm after exertion ?
                                                                          do they become more frequent ?
                                                                          (3) □ Yes          □ No
                                                                          or less frequent ?
 • Special observations :                                                 (3) □ Yes          □ No
                                                                          or disappear completely ?
                                                                          (3) □ Yes          □ No
 ---pagebreak---                                                                                                   E 213
    Report on electro-cardiographic examination, with date :
    Report on electro-oscillographic examination, with date :
5.  Digestive system
    (Abdominal wall, hernias, palpation of abdomen, scars from surgical operations, liver, spleen , ganglions, etc.) :
    Report on X-ray examinations, with date :
6.  Locomotor system
    ( Bones, muscles, structure and mobility of joints and vertebral column, Lasègue sign, comparative measure­
    ments of limbs ; degree of any functional diminution of joint movements):
7 . Genito-urinary system
     Result of urine tests and other necessary tests ( azotemy, pyelography, gynaecological examination , etc.),
    with date :
 ---pagebreak---                                                                                                            E 213
    8.  Central nervous system
        ( pupillary and peripheral reflexes, palsies, paralysis, significant disorders of sensation , psychic peculiarities):
        Report on electro-diagnosis or electro-encephalography :
    9.  Other organs and systems :
   10.  Blood tests, with date ; haemoglobin rate and erythrocyte count, etc.:
   11 . Results of other tests, with dates (sedimentation, reaction to diagnosis for syphilis, etc.):
        Other specific examinations                   (3) Q] are necessary                 Q are not necessary
        In the affirmative, which ?
        Date of request for examinations :
C. Diagnosis and interpretation
    1.  Diagnosis, with reasons and assessment :
    2. The condition of the person concerned               (3) Q is                         CH 's not    stabilized
    3.  Date of commencement of incapacity for work ( 5 ):
 ---pagebreak---                                                                                                  E 213
 4.   Date of commencement of present invalidity ( 6):
 5. The person concerned         (3) Q is                    | | is not capable of performing an occupation
                                                                   other than that last performed .
 6. Occupational                 (3) Q is                    | | is not possible.
      rehabilitation
  7 . The person concerned       ( 3) Q is                    | | is not absolutely incapable of moving about.
  8. The person concerned        (3) Q is                      | | is not in hospital .
      If so, probable length of stay in hospital :
      If known , date of discharge from hospital :
  9.  Constant attendance from a third person
                                  (3) Q] is essential           Q is not essential
      for him to be able to perform normal everyday activities.
1 0. The invalidity is            (3) Q] temporary              Q permanent.
11.    Date of probable end of this temporary invalidity :
1 2. Since the granting of pension, the condition of the person concerned
       (3) Q] has improved             Q has remained thesame        Q] has deteriorated.
       Remarks :
13. The person concerned           (3) Q should                 Q need not be re-examined .
       If he should , indicate the date :
 ---pagebreak---                                                                                                     E 213
 PART II — QUESTIONNAIRE RESERVED FOR CERTAIN CASES
 1. Subject to the opinion of the competent administration and in the light of the opinion of the practitioner who is
    completing this form, compensation for the patient's injury or disease                »
     (3) Q] can                    Q cannot
    be regarded as coming within the legislation on accidents at work and occupational diseases .
    If the person concerned previously benefited from legislation on accidents at work, occupational diseases,
    military pensions, pensions for civilian war victims, indicate :
    — nature of this injury of disease :
    — degree of invalidity proposed :
2.  In case of accident, state expected date of
    consolidation of injuries :
3. Treatment necessary :
    The person concerned           (3) Q agrees                     Q does not agree to such treatment.
4.  The continuation of medical treatment
    (3) □ is                       Q is not likely to bring about an improvement in the patient's condition
    (3) Q is                       Q is not likely to effect recovery.
5 . Degree of invalidity for mine work (only if a miner is concerned ) ( 7 ):
    underground work :                                                     surface work
    (Where appropriate, attach form E 214).
6. The person concerned            (3) Q needs                      Q does not need
                                            (3) Q to cease mine work
                                            ( 3 ) Q] to change his occupation .
    Remarks :
 ---pagebreak---                                                                                                                              E 213
PART III — CONCLUSIONS
 1         Date on which the person concerned ceased work :
 2         The invalidity for the last occupation is
           ( 3 ) Q] total                                                           Q partial
           If partial, indicate the degree :
 3         Degree of invalidity for any other work with reference to the aptitudes of the person concerned ( 8 ):
 4         Category of invalidity ( 9 ) : ....
   5
  5.1      Date :
  5.2      Doctor's signature :
   6        Institution which called for the examination
  6.1      Name :
  6.2      Address ( 2 ):
  6.3      Stamp
                                                                                        6.4    Date :
                                                                                        6.5    Signature
                                                              INSTRUCTIONS
Please complete this form in block letters, writing on the dotted lines only. It consists of eight pages,
              none of which may be left out even if it does not contain any relevant information .
                                                                      NOTES
(1 )  Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
      Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)   Postal code, town , street, number, country.
(3)   Put a cross in the square preceding the appropriate subject.
(4)   The information in these sections is essential when the claim for invalidity pension is wholly or partly based on a disease of the
      respiratory system .
(5)   If the report is to be sent to or drawn up by a Netherlands institution , indicate the first day of the current period of absence through
      sickness .
(6)   If the report is to be sent to a Netherlands institution, indicate the first day on which invalidity benefit was granted .
(7 )  Does not concern the Netherlands, Ireland or the United Kingdom .
(8)   Does not concern the Netherlands.
(9)   Complete only if the medical examination was carried out in view of the decision to be taken on a pension claim .
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                See ' Instructions' on page 4
  Social Security Regulations
                                                                                              E 21 4              (1
                   MEDICAL REPORT CONCERNING ASSESSMENT OF FUNCTIONAL
                                      ABILITIES AND LIMITATIONS
                                   Reg. 1408/ 71 : Art. 39 to 41 and Art. 87
To be attached to form E 213 when the latter is drawn up by a doctor of a German or Netherlands institution or is
intended for a German or Netherlands institution, or when an institution of another Member State requests it
  1 I Institution to which the report is addressed
  1.1    Name :
  1 .2  Address ( 2) :
  2      Person examined
  2.1   Surname                      Forenames                                             Maiden name
  2.2    Place of birth              Date of birth                  Sex                    Nationality
  2.3   Address ( 2 ) :
  2.4    Last occupation :
  2.5   (3) Q] Insurance number:                              Q] Pension number:
  3      Doctor who drew up the report
  3.1   Surname :                                         Forenames : ....
  3.2   Address ( 2 ):
  3.3   Examining doctor of :
 4      Attached forms :              (3 ) Q] E 204        Q E 213 .
 ---pagebreak---                                                                                                                                 E 214
                            Questions                                            Answers (3)                                Instructions
                                                                  Occasionally    Frequently   Full-time   Part-time
                                                            Yes                                                        No
5      Can the insured person :
5.1    perform heavy work ?
5.2    perform fairly heavy work ?
5.3    perform light work ?
5.4    work mainly standing or walking ?                                                                                         hours per day
5.5    work mainly seated ?                                                                                                      hours per day
5.6    work alternately standing, seated and walking ?                                                                           hours per day
5.7    work stooping ?
5.8    work crouching ?
5.9    work kneeling ?
5.10 work lying down ?
5.11   work with arms raised ?
5.12 work in a dry atmosphere ?
5.13   work in a humid atmosphere ?
5.14 work in a cold atmosphere ?
5.15 work in a hot atmosphere ?
5.16   work in a very hot atmosphere ?
5.17   work in water ?
5.18 be exposed to sudden changes of temperature ?
5.19   work outdoors ?
5.20   work indoors ?
5.21   work in confined spaces ( pipes, places which have
       to be entered by crawling, etc .) ?
5.22   climb staircases ?
5.23   use ladders ?
5.24   climb on roofs ?
     lift and carry loads occasionally or repeatedly
     ( loading and unloading, etc.):
5.25 heavy weights ( over 25 kg )?
5.26 medium weights ( 10-25 kg )?
5.27 light weights ( 5-10 kg )?
5.28 very light weights ( under 5 kg )?
 ---pagebreak---                                                                                                                                                 E 214
                         Questions                                                             Answers ( 3 )                              Instructions
                                                                                Occasionally    Frequently   Full-time   Part-time
                                                                          Yes                                                        No
5.29 Does the insured person have to use a particular
     technique for lifting and carrying loads ( e.g . back
     straight and knees bent ?
5.30 Is he allergic to certain substances ?                                                                                               If yes, say which sub­
                                                                                                                                          stances and what
                                                                                                                                          precautions are to be
                                                                                                                                          taken .
5.31   Does he need special accessories for work
       ( e.g . adjustable, polyfunctional chair, etc .)?                                                                                  If yes, give details.
5.32   Can he use public transport ?
       What distance, approximately, can he travel :
5.33   on foot ?                                                                                                                              ... km
5.34   by bicycle ?                                                                                                                           ... km
5.35   by light-weight motorcycle ?                                                                                                           ... km
5.36   by car ?                                                                                                                                ... km
5.37   by wheelchair ?
5.38   by small motorized invalid car ?                                                                                                        ... km
5.39   Can he work with other people ?
5.40   Can he use machinery or apparatus presenting some
       hazard ?
5.41   Can he undertake management, supervisory or
       organizational tasks, as he would if the business
       belongs to him ?
5.42 Should one take account of any psychological
       peculiarities for certain jobs ?                                                                                                   If yes, say which, and
                                                                                                                                          for what jobs.
5.43 Are there any reservations concerning working
       tempo ?                                                                                                                            If yes, say for what
                                                                                                                                          reason .
5.44 Taking account of the replies to the above questions,
     and even assuming appropriate working conditions,
     should one expect prolonged or frequent absences
     due to physical or mental deficiencies ?
  6
        Date :                                     Doctor's signature :
 ---pagebreak---                                                                                                                       E 214
  7        Institution which called for the examination
  7.1      Name :
  7.2      Address ( 2 ):
  7.3      Stamp
                                                                                     7.4   Date :
                                                                                     7.5   Signature
                                                               INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                                      NOTES
C)    Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
      Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)   Postal code, town , street, number, country.
(3)   Put a cross in the appropriate square or squares.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                        See  Instructions' on page 3
Social Security Regulations
                                                                                                     E 301               (1
                   CERTIFICATE CONCERNING THE PERIODS TO BE TAKEN INTO
                     ACCOUNT FOR THE GRANT OF UNEMPLOYMENT BENEFITS
                            Reg. 1408/ 71 : Art. 67 ; Art. 68 ; Art. 71 .1 . a.ii ; Art. 71.1.b.ii
                                      Reg. 574/ 72: Art. 80 ; Art. 81 ; Art. 84.2
To be issued by the competent unemployment institution or the institution designated by the competent authority
of the country where the unemployed person was previously insured.
  1 j Worker
 1.1    Surname                        Forenames                                                   Maiden name
 1.2    Date of birth                  Place of birth                                              Nationality
 2      The worker named above completed the following periods in the course of
 2.1    (3) Q the year (2)             Q the two years (2)                       Q the three years (2)
                 preceding the end of his last employment.
 3      Periods of insurance and periods treated as such ( 4 ) :
 3.1    Periods of insurance ( 5 ):
                                                 from                 to
 3.2    Periods treated as periods of insurance ( 6 ):
                                                 from                to                  Reason for treating as such ( 7 )
 4.     Periods of employment and periods treated as such ( 4) :
 4.1    Periods of employment ( 5 ) (8 ):
                                                 from                to                            Occupation (9 )
 4.2    Periods treated as periods of employment ( 6 ) ( 8 ):
                                                 from                to                  Reason for treating as such ( 7 )
 ---pagebreak---                                                                                                  E 301
5   Periods of insurance and periods of employment ( 1 °) :
                                          from                  to
5.1 Periods treated as periods of insurance or of employment ( 11 ) :
                                          from                  to            Reason for treating as such ( 7 )
6   Periods of insurance and periods treated as such ( 8 ) :
6-1 (3 ) I I less than 52 weeks, namely:
                                          from                 to
6.2 (3) Q 52 weeks or more. Last day of employment:
7   Details of last employment engaged in :
                                           Nature of work carried out ( e.g .
                                                                                     Approximate average
               Branch of activity           ' bricklayer' not ' building
                                                                                    weekly wage ( 12 )
                                                       worker')
7.1 Reason for ceasing ( 13 ):
8   The person concerned
8.1 (3) Q has received or is due to receive wages for the period following the cessation of work, up to :
8.2 (3) Q has received or is due to receive, on cessation of work, compensation or other similar
             payment, amounting to :
8.3 (3) Q has received or is due to receive payment in lieu of annual leave, amounting
    to                                for                                                          days ( 14)
8-4 (3) Q] has waived the following rights which he enjoys under his contract of employment ( 15):
             Reason :
 ---pagebreak---                                                                                                                                 E 301
  9         Since the commencement of the first period shown above, the person concerned received unemployment
            benefits ( 16 ):
                                                                  from                     to
  10        The person concerned is not entitled to benefits under Article 69 of Regulation 1408/71
  10.1 (3) Q] because he has no entitlement under the legislation administered by the institution issuing this
                        certificate
  10.2 (3) Q] because he did not remain available to employment services of the competent country for four weeks
                        after becoming unemployed, and he was not authorized to leave before the end of this period .
  11        The person concerned is not entitled to receive benefits under Article 1 7.1 . a . i or Article 71 .1 . b.i of Regulation
            1408/71 from the institution issuing this certificate .
  12 J Institution issuing the certificate
   12.1     Name :
   12.2 Address ( 17 ) :
  12.3 Stamp
                                                                                            12.4 Date :
                                                                                            12.5 Signature
                                                                    INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                                          NOTES
0)     Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
       Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)    One year if the certificate is to be sent to a French , Luxembourg or Netherlands institution ; two years if it is to be sent to an Italian
       institution ; three years if it is to be sent to a Belgian , Danish, German , Irish or United Kingdom institution .
(3 )   Put a cross in the square preceding the appropriate subject.
(4)    If separate details of the items asked for at points 3.1 and 3.2, 4.1 and 4.2 are not available, show the total at point 3.1 or 4.1 , as
       the case may be .
(5)    To be completed if the certificate is to be sent to a Belgian, Danish , German , French, Irish, Netherlands or United Kingdom institution .
(6)    To be completed if the certificate is to be sent to a Belgian , Danish , German or Netherlands institution .
(7)    E.g . sickness, maternity, accident at work, military service, vocational training, recorded unemployment.
(8)    To be completed if the certificate is to be sent to an Italian institution .
(9)    To be completed if the certificate is to be sent to a French or Italian institution .
( 10 ) To be completed if the certificate is to be sent to a Luxembourg institution .
( 11 ) To be completed if the certificate is to be sent to a French or Luxembourg institution .
( 12 ) To be completed, if possible, if the certificate is to be sent to a German , French or Netherlands institution .
( 13 ) E.g . expiry of contract of employment, resignation , dismissal, dismissal without notice as a result of
( 14 ) To be completed if the certificate is being sent to a Belgian , Danish , French , Italian or Netherlands institution .
( 15 ) To be completed if the certificate is to be sent to a Belgian , Danish, Italian or Netherlands institution .
( 16 ) To be completed if the certificate is to be sent to a French , German or Italian institution . If the certificate is to be sent to an Italian
       institution , it is necessary to show all the periods for which the person concerned received unemployment benefits in the course of
       the year preceding the issue of the certificate.
( 17 ) Postal code, town , street, number, country.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                     See  Instructions  overleaf
Social Security Regulations
                                                                                                E 302                1
          CERTIFICATE RELATING TO MEMBERS OF THE FAMILY OF AN UNEMPLOYED
                             PERSON WHO MUST BE TAKEN INTO ACCOUNT FOR
                                           THE CALCULATION OF BENEFITS
                                                      Reg. 1408/ 71 : Art. 68.2
                                                        Reg. 574/ 72: Art. 82
To be issued by the designated institution of the country of residence of the members of the family.
  1      Unemployed person
 1.1     Surname                               Forenames                                     Maiden name
 1 .2    Date of birth                         Place of birth                                Nationality
  2      Members of the family
   Order                                                                                                    Place of
                   Surname                       Forenames         Date of birth Relationship
 number                                                                                                    residence
     1
     2
      3
     4
      5
      6
      7
      8
         Where appropriate, income of members of the family ( nature and monthly amount, including social
   3
          benefits) ( 2 )
 Number                     Members
                                                               Nature of income                     Amount
     (3)                  of the family
  4       Until he became unemployed , the unemployed person maintained the members of his family shown at the
          order numbers :
                                        ( 2 ).
 ---pagebreak---                                                                                                                         E 302
   4.1       The member of the family shown at order number
                                               is unable, due to physical or mental disability, to provide for his own keep by
             working (4).
   4.2       The family supplements for the members of the family shown at order numbers
             have been paid to another person at the same time as unemployment benefits for the period
             from                                                    to
   4.3       Information required only by German or United Kingdom institutions :
             With the exception of the period of employment in
             ( 5 ) Q Germany                                         | | the United Kingdom,the unemployed person and his/herspouse
             ( 5) Q have been living underthe same roof Q] have not been living under the same roof.
   4.4       This certificate is valid for twelve months from the date of issue.
    5        Institution issuing the certificate
   5.1       Name :
   5.2      Address (6 ) :
   5.3      Stamp
                                                                                           5.4 Date :
                                                                                          5.5  Signature
    6        Statement of the unemployed person ( 7 )
   6.1      The unemployed person named in box 1 declares that the members of his family shown at numbers
                                              of box 2
            (5) Q are                                                     Q are not
            taken into consideration for the calculation of unemployment benefits due to another person under United
            Kingdom legislation .
                                                                                         6.2   Date :
                                                                                         6.3   Signature of the unemployed person
                                                                INSTRUCTIONS
                     Please complete this form in block letters, writing on the dotted lines only.
                                                                       NOTES
(1 )   Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
       Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)    This information is superfluous if the form is to be sent to a German institution .
(3)    For each member of the family mentioned in this box, retain the order number shown in box 2 .
(4)    Complete only if the form is to be sent to a Belgian , French or United Kingdom institution .
( 5)   Put a cross in the square preceding the appropriate subject.
(6)    Postal code, town , street, number, country.
(7)    To be completed by the unemployed person only if the certificate was issued by a United Kingdom institution .
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                                            See Instructions ' overleaf
Social Security Regulations
                                                                                                                   E 303/0                   n
                                   CERTIFICATE CONCERNING THE RETENTION OF THE
                                               RIGHT TO UNEMPLOYMENT BENEFITS
                                                                Reg. 1408/ 71 : Art. 69
                                                    Reg. 574/ 72 : Art. 26.2; Art. 83.1 to 3; Art. 97
 1     I   Unemployed person                                                                      Insurance number :.
 1.1     Surname                                 Forenames                                                          Maiden name
 1.2     Date of birth                           Place of birth                                                     Nationality
 2       Under the provisions of Article 69 of Regulation 1408/71 , the unemployed person named above is entitled to unemployment benefits .
 3       He can receive benefits from                              (date )                         , provided that he has registered as being in
         search of employment at the latest by                                                      with the employment services ( 2 ) of the country ;
         where he is looking for work.
  4      The unemployed person is entitled to benefits for a period of                                       days,
         provided that the period does not extend beyond ( date )
 4.1     The benefits are granted for every day of the week, except
         ( 3 ) □ Monday              □ Tuesday           □ Wednesday □ Thursday             □ Friday            □ Saturday        □ Sunday.
 4.2     Daily amount of unemployment benefits :
                                        net, which includes an increase for dependants of :                                        net
         and from                                  date :                      ,
                                       net, which includes an increase for dependants of :                                         net.
  5      The payment of benefits must be suspended in the following circumstances ( Regulation 574/ 72 , Art . 83.1 and Art. 83.3 ):
  5.1    — when the unemployed person has taken up ' permanent' gainful employment ( 4 ) or becomes self-employed ;
  5.2    — when the unemployed person is receiving occasional earnings from an activity other than those shown at 5.1 above ( in
               this case, the payment of benefits must be suspended for the number of days during which the person concerned is receiving
               these occasional earnings );
  5.3    — when the unemployed person refuses an offer of employment or refuses to attend for an interview with the employment services,
  5.4    — when the unemployed person refuses an offer of vocational retraining or fails to participate therein ( 5 );
  5.5    — when the unemployed person does not submit or no longer submits to control procedures and checks ;
  5.6    — when the unemployed person is suffering from permanent incapacity for work ( 6 );
  5.7    — when the unemployed person is suffering from temporary incapacity for work ( in this case, the payment of benefits is suspended
                until re-registration );
    5.8     — when the unemployed person is not or is no longer available to the employment services ;
   5.9    — when the number of the members of the family giving entitlement to increase for dependants decreases, or when one of these
               members receives an income referred to on form E 302 ( in this case, the benefit is to be paid with deduction of thefamily increase )
   6 I       Institution completing the form
   6.1    Name :
   6.2    Address ( 7 )
   6.3    Stamp
                                                                                       6.4   Date :
                                                                                      6.5   Signature
 ---pagebreak---                                                                                INSTRUCTIONS
The competent institution of the last country of employment should complete the relevant sections of the series of forms E 303 /0 to E 303 /4 ; it should keep E 303 /0 and
send the rest of the series to the unemployed person , including E 303 / 5 , or , if appropriate, send it to the competent unemployment institution of the place where the un­
employed person is seeking employment.
                                         Please complete this form in block letters, writing on the dotted lines only.
                                                                                       NOTES
(') Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany; F = France ; Irl = Ireland ; I = Italy ; L = Luxem­
      bourg ; N = Netherlands ; UK = United Kingdom .
( 2) In Italy and the Netherlands, the unemployed person must in addition submit a claim for benefits to the competent unemployment insurance institution through
      the employment office.
( 3 ) Put a cross in the square preceding the appropriate subject .
( 4) Under Italian legislation , permanent employment ('occupazione non occasionale') is any employment of more than five days ; under Belgian and Netherlands
       legislation, permanent employment ('volledige tewerkstelling ') is any employment of at least one normal working day.
( 5 ) This situation does not entail suspension of benefits if the certificate was issued by a Danish institution .
( 6 ) Or when the unemployed person is receiving an old-age or invalidity pension , if the certificate is drawn up by a German or Luxembourg institution .
( 7 ) Postal code, town , street, number, country.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                                             See Instructions' overleaf
 Social Security Regulations
                                                                                                                    E 303/1                   r
                                   CERTIFICATE CONCERNING THE RETENTION OF THE
                                                RIGHT TO UNEMPLOYMENT BENEFITS
                                                                 Reg. 1408/ 71 : Art. 69
                                                     Reg. 574/ 72: Art. 26.2; Art. 83. 1 to 3; Art. 97
This copy should be sent to the unemployment insurance institution of the place where the unemployed person is seeking employment.
It must be used as the basis for payment of unemployment benefits (Reg. 574j 72: Art. 83.1).
   1    I   Unemployed person                                                                      Insurance number :.
   1.1    Surname                                 Forenames                                                          Maiden name
   1.2    Date of birth                           Place of birth                                                     Nationality
   2      Under the provisions of Article 69 of Regulation 1 408/71 , the unemployed person named above is entitled to unemployment benefits .
   3      He can receive benefits from                             ( date )                         , provided that he has registered as being in
          search of employment at the latest by                                                      with the employment services ( 2 ) of the country ;
          where he is looking for work.
   4      The unemployed person is entitled to benefits for a period of                                       days,
          provided that the period does not extend beyond ( date )
   4.1    The benefits are granted for every day of the week, except
          ( 3 ) □ Monday             □ Tuesday            □ Wednesday □ Thursday             □ Friday            □ Saturday       □ Sunday.
   4.2    Daily amount of unemployment benefits :
                                         net, which includes an increase for dependants of :                                       net
          and from                                  date :                     ,
                                        net, which includes an increase for dependants of :                                        net.
   5      The payment of benefits must be suspended in the following circumstances ( Regulation 574/72, Art. 83.1 and Art. 83.3 ):
   5.1    — when the unemployed person has taken up ' permanent' gainful employment ( 4 ) or becomes self-employed ;
   5.2    — when the unemployed person is receiving occasional earnings from an activity other than those shown at 5.1 above ( in
                this case, the payment of benefits must be suspended for the number of days during which the person concerned is receiving
                these occasional earnings );
   5.3    — when the unemployed person refuses an offer of employment or refuses to attend for an interview with the employment services ;
   5.4    — when the unemployed person refuses an offer of vocational retraining or fails to participate therein ( 5 );
   5.5    — when the unemployed person does not submit or no longer submits to control procedures and checks ;
   5.6    — when the unemployed person is suffering from permanent incapacity for work ( 6 );
   5.7    — when the unemployed person is suffering from temporary incapacity for work ( in this case, the payment of benefits is suspende^
                until re-registration );
    5.8   — when the unemployed person is not or is no longer available to the employment services ;
    5.9   — when the number of the members of the family giving entitlement to increase for dependants decreases, or when one of these
                members receives an income referred to on form E 302 ( in this case, the benefit is to be paid with deduction of thefamily increase )
    6 |      Institution completing the form
   6.1     Name :
   6.2    Address ( 7 )
   6.3    Stamp
                                                                                      6.4    Date :
                                                                                      6.5    Signature
 ---pagebreak---                                                                                INSTRUCTIONS
The competent institution of the last country of employment should complete the relevant sections of the series of forms E 303 /0 to E 303/4 ; it should keep E 303 /0 and
send the rest of the series to the unemployed person , including E 303/5, or, if appropriate, send it to the competent unemployment institution of the place where the un­
employed person is seeking employment.
                                         Please complete this form in block letters, writing on the dotted lines only.
                                                                                     NOTES
(') Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany; F = France ; Irl = Ireland ; I = Italy ; L = Luxem­
      bourg ; N = Netherlands ; UK = United Kingdom .
( 2 ) In Italy and the Netherlands, the unemployed person must in addition submit a claim for benefits to the competent unemployment insurance institution through
      the employment office.
( 3 ) Put a cross in the square preceding the appropriate subject .
( 4) Under Italian legislation , permanent employment ('occupazione non occasionale') is any employment of more than five days ; under Belgian and Netherlands
        legislation , permanent employment ('volledige tewerkstelling ') is any employment of at least one normal working day.
( 5 ) This situation does not entail suspension of benefits if the certificate was issued by a Danish institution .
( 6 ) Or when the unemployed person is receiving an old-age or invalidity pension, if the certificate is drawn up by a German or Luxembourg institution .
( 7 ) Postal code, town , street, number, country .
                                                                                                                                                                            ©
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                                            See  Instructions' overleaf
Social Security Regulations
                                                                                                                   E 303/2                    r
                                 CERTIFICATE CONCERNING THE RETENTION OF THE
                                                 RIGHT TO UNEMPLOYMENT BENEFITS
                                                                  Reg. 1408/ 71 : Art. 69
                                                      Reg. 574/ 72: Art. 26.2; Art. 83. 1 to 3; Art. 97
This copy must be returned to the competent institution to inform it of the registration of the unemployed person and of the commence­
ment of paymeht of benefits (Reg. 574/ 72 : Art. 83.3).
 1         Unemployed person                                                                       Insurance number : .
 .1    Surname                                     Forenames                                                        Maiden name
 1.2     Date of birth                             Place of birth                                                   Nationality
 2      Under the provisions of Article 69 of Regulation 1 408 / 71 , the unemployed person named above is entitled to unemployment benefits.
 3      He can receive benefits from                                ( date )                         provided that he has registered as being in
        search of employed at the latest by                                                          with the employment services ( 2 ) of the country
        where he is looking for work.
 4      The unemployed person is entitled to benefits for a period of                                          days,
        provided that the period does not extend beyond ( date )
 4.1    The benefits are granted for every day of the week, except
        ( 3 ) □ Monday            □ Tuesday                 □ Wednesday      □ Thursday       □ Friday          □ Saturday        □ Sunday.
 4.2    Daily amount of unemployment benefits :
                                     net, which includes an increase for dependants of :                                            net
        and from date                            ( date ) :                      ,
                                     net, which includes an increase for dependants of :                                           net.
 5      The payment      of benefits must be suspended in the following circumstances ( Regulation 574/72 , Art . 83.1 and Art . 83.3 ):
 5.1    — when the       unemployed person has taken up ' permanent' gainful employment ( 4 ) or becomes self-employed ;
 5.2    — when the        unemployed person is receiving occasional earnings from an activity other than those shown at 5.1 above ( in
              this case, the payment of benefits must be suspended for the number of days during which the person concerned is receiving
              these occasional earnings);
 5.3    —     when the unemployed person refuses an offer of employment or refuses to attend for an interview with the employment services ;
 5.4    —     when the unemployed person refuses an offer of vocational retraining or fails to participate therein ( 5 );
  5.5   —     when the unemployed person does not submit or no longer submits to control procedures and checks ;
 5.6    —     when the unemployed person is suffering from permanent incapacity for work ( 6 );
 5.7    —     when the unemployed person is suffering from temporary incapacity for work ( in this case, the payment of benefits is suspended
              until re-registration );
 5.8    — when the unemployed person is not or is no longer available to the employment services ;
 5.9    — when the number of the members of the family giving entitlement to increase for dependants decreases, or when one of these
              members receives an income referred to on form E 302 ( in this case, the benefit is to be paid with deduction of the family increase ).
  6        Institution completing the form
  6.1     Name :
  6.2    Adress ( 7 ):
To be completed by the institution of the country where the unemployed person is seeking employment.
  1     We certify
  7.1   that the unemployed person named above registered as being in search of employment on
                                       ( date )
  7.2   and has been receiving unemployment benefits since
                                       ( date ).
  8 J      Institution of the country where the unemployed person is seeking employment
  8.1    Name :
  8.2    Address ( 7 ):
  8.3    Stamp
                                                                                        8.4   Date :
                                                                                        8.5   Signature
 ---pagebreak---                                                                                 INSTRUCTIONS
The competent institution of the last country of employment should complete the relevant sections of the series of forms E 303 /0 to E 303 /4 ; it should keep E 303 /0 and
send the rest of the series to the unemployed person , including E 303 / 5, or, if appropriate, send it to the competent unemployment institution of the place where the un­
employed person is seeking employment.
                                         Please complete this form in block letters, writing on the dotted lines only .
                                                                                     NOTES
(') Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ; Irl = Ireland ; I = Italy ; L = Luxem­
      bourg ; N = Netherlands ; UK = United Kingdom .
( 2 ) In Italy and the Netherlands, the unemployed person must in addition submit a claim for benefits to the competent unemployment insurance institution through
      the employment office.
( 3 ) Put a cross in the square preceding the appropriate subject.
( 4 ) Under Italian legislation , permanent employment ('occupazione non occasionale') is any employment of more than five days ; under Belgian and Netherlands
       legislation , permanent employment ('volledige tewerkstelling ') is any employment of at least one normal working day .
( 5 ) This situation does not entail suspension of benefits if the certificate was issued by a Danish institution .
( 6 ) Or when the unemployed person is receiving an old-age or invalidity pension, if the certificate is drawn up by a German or Luxembourg institution .
( 7 ) Postal code, town , street, number, country.
                                                                                                                                                                             <D
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                                            See ' Instructions' overleaf
Social Security Regulations                                                                                      i              j   I      I
                                                                                                                   E 303/3                   r
                                CERTIFICATE CONCERNING THE RETENTION OF THE
                                              RIGHT TO UNEMPLOYMENT BENEFITS
                                                                Reg. 1408/ 71 : Art. 69
                                                    Reg. 574/ 72: Art. 26.2; Art. 83.1 to 3; Art. 97
This copy should be sent to the sickness insurance institution of the place where the unemployed person is seeking employment (Reg.
574/ 72: Art. 26.2).
  1       Unemployed person                                                                      Insurance number :..
  1.1   Surname                                  Forenames                                                          Maiden name
  1.2    Date of birth                           Place of birth                                                     Nationality
  2     Under the provisions of Article 69 of Regulation 1408/71 , the unemployed person named above is entitled to unemployment benefits .
  3     He can receive benefits from                              (date )                        , provided that he has registered as being in
        search of employment at the latest by                                                      with the employment services ( 2 ) of the country
        where he is looking for work.
  4     The unemployed person is entitled to benefits for a period of                                      days,
        provided that the period does not extend beyond (date )
  4.1   The benefits are granted for every day of the week, except
       (3)    □ Monday           □ Tuesday              □ Wednesday       □ Thursday       □ Friday            □ Saturday          □ Sunday.
  4.2   Daily amount of unemployment benefits :
                                    net, which includes an increase for dependants of :                                               net
        and from                               ( date )                       ,
                                     net, which includes an increase for dependants of :                                           net.
  5     The payment of benefits must be suspended in the following circumstances ( Regulation 574/ 72, Art. 83.1 and Art. 83.3 ):
  5.1   — when the unemployed person has taken up ' permanent' gainful employment ( 4) or becomes self-employed ;
  5.2   — when the unemployed person is receiving occasional earnings from an activity other than those shown at 5.1 above ( in
            this case, the payment of benefits must be suspended for the number of days during which the person concerned is receiving
            these occasional earnings );
  5.3   — when the unemployed person refuses an offer of employment or refuses to attend for an interview with the employment services ;
  5.4   — when the unemployed person refuses an offer of vocational retraining or fails to participate therein ( 5 );
  5.5   — when the unemployed person does not submit or no longer submits to control procedures and checks ;
  5.6   — when the unemployed person is suffering from permanent incapacity for work ( 6 );
  5.7   — when the unemployed person is suffering from temporary incapacity for work ( in this case, the payment of benefits is suspended
            until re-registration );
  5.8   — when the unemployed person is not or is no longer available to the employment services ;
  5.9   — when the number of the members of the family giving entitlement to increase for dependants decreases, or when one of these
            members receives an income referred to on form E 302 ( in this case, benefit is to be paid with deduction of the family increase ).
  6 |     Institution completing the form
  6.1   Name :
  6.2   Address ( 7 ):
To be completed by the institution of the country where the unemployed person is seeking employment and to be attached to form E 119
 7     We certify
 7.1   that the unemployed person named above registered as being in search of employment on
                                      ( date)
 7.2   and has been receiving unemployment benefits since
                                     ( date )
 8 I     Institution of the country where the unemployed person is seeking employment
 8.1   Name :
 8.2   Address ( 7 ):
 8.3   Stamp
                                                                                    8.4   Date :
                                                                                    8.5   Signature
 ---pagebreak---                                                                                 INSTRUCTIONS
 The competent institution of the last country of employment should complete the relevant sections of the series of forms E 303/0 to E 303/4 ; it should keep E 303/0 and
 send the rest of the series to the unemployed person , including E 303 /5 , or, if appropriate, send it to the competent unemployment institution of the place where the un­
 employed person is seeking employment.
                                         Please complete this form in block letters, writing on the dotted lines only.
                                                                                      NOTES
 ( n ) Symbol of the country to which the institution completing theform belongs : B = Belgium ; Dk = Denmark; D = Germany; F = France; Irl = Ireland ; I = Italy; L — Luxem­
       bourg ; N = Netherlands; UK = United Kingdom .
( 2) In Italy and the Netherlands, the unemployed person must in addition submit a claim for benefits to the competent unemployment insurance institution through
       the employment office.
( 3 ) Put a cross in the square preceding the appropriate subject ,
(4) Under Italian legislation, permanent employment ('occupazione non occasionale') is any employment of more than five days; under Belgian and Netherlands
        legislation, permanent employment ('volledige tewerkstelling ') is any employment of at least one normal working day.
( 5 ) This situation does not entail suspension of benefits if the certificate was issued by a Danish institution .
( 6 ) Or when the unemployed person is receiving an old-age or invalidity pension , if the certificate is drawn up by a German or Luxembourg institution .
( 7 ) Postal code, town , street, number, country.
                                                                                                                                                                          ©
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                                               See ' Instructions overleaf
Social Security Regulations
                                                                                                                     E 303/4                   C)
                                   CERTIFICATE CONCERNING THE RETENTION OF THE
                                                RIGHT TO UNEMPLOYMENT BENEFITS
                                                                  Reg. 1408/ 71 : Art. 69
                                                      Reg. 574/ 72: Art. 26.2; Art. 83.1 to 3; Art. 97
This copy must be returned to the competent institution, to serve as the basis for refund of unemployment benefits paid on behalf
of that institution (Reg. 574/ 72 : Art. 97).
  1 j      Unemployed person                                                                       Insurance number :..
  1.1    Surname                                   Forenames                                                          Maiden name
  2.1     Date of birth                            Place of birth                                                     Nationality
  2      Under the provisions of Article 69 of Regulation 1 408/71 , the unemployed person named above is entitled to unemployment benefits .
  3      He can receive benefits from                               ( date )                         , provided that he has registered as being in
         search of employment at the latest by                                                        with the employment services ( 2 ) of the country
         where he is looking for work.
  4      The unemployed person is entitled to benefits for a period of                                       days,
         provided that the period does not extend beyond ( date )
  4.1    The benefits are granted for every day of the week, except
         ( 3 ) □ Monday              □ Tuesday             □ Wednesday □ Thursday            □ Friday           □ Saturday           □ Sunday.
  4.2    Daily amount of unemployment benefits :
                                        net, of which there is an increase for dependants of :                                         net
         and , from                             ( date):                        ,
                                        net, of which there is an increase for dependants of :                                        net.
  5      The payment of benefits must be suspended in the following circumstances ( Regulation 574/ 72, Art. 83.1 and Art . 83.3 ):
  5.1    — when the unemployed person has taken up ' permanent' gainful employment ( 4 ) or becomes self-employed ;
  5.2    — when the unemployed person is receiving occasional earnings from an activity other than those shown at 5.1 above ( in
               this case, the payment of benefits must be suspended for the number of days during which the person concerned is receiving
               these occasional earnings );
  5.3    —     when the unemployed person refuses an offer of employment or refuses to attend for an interview with the employment services ;
  5.4    —     when the unemployed person refuses an offer of vocational retraining or fails to participate therein ( 5 );
  5.5    —     when the unemployed person does not submit or no longer submits to control procedures and checks ;
  5.6    —     when the unemployed person is suffering from permanent incapacity for work ( 6 );
  5.7    —     when the unemployed person is suffering from temporary incapacity for work ( in this case, the payment of benefits is suspended
                until re-registration );
   5.8   — when the unemployed person is not or is no longer available to the employment services ;
   5.9   — when the number of the members of the family giving entitlement to increase for dependants decreases, or when one of these
               members receives an income referred to on form E 302 ( in this case, the benefit is to be paid with deduction of the family increase).
  6 |       Institution completing the form
  6.1     Name :
  6.2     Address ( 7 ):
To be completed by the institution of the country where the unemployed person is seeking employment.
   7      The following sums have been paid to the unemployed person in accordance with the above certificate :
                 from              to                    Amount                            Reason for suspension or
                                                                                            cessation of payments
   8        Institution of the country where the unemployed person is seeking employment
   8.1    Name :
   8.2    Address ( 7 ):
   8.3    Stamp
                                                                                        8.4   Date :
                                                                                        8.5   Signature
 ---pagebreak---                                                                                 INSTRUCTIONS
The competent institution of the last country of employment should complete the relevant sections of the series of forms E 303 /0 to E 303 /4 ; it should keep E 303 /0 and
send the rest of the series to the unemployed person , including E 303 / 5 , or, if appropriate , send it to the competent unemployment institution of the place where the un­
employed person is seeking employment .
                                        Please complete this form in block letters, writing on the dotted lines only.
                                                                                      NOTES
( 1 ) Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ; Irl = Ireland ; I = Italy; L = Luxem­
      bourg ; N = Netherlands ; UK = United Kingdom .
( 2 ) In Italy and the Netherlands, the unemployed person must in addition submit a claim for benefits to the competent unemployment insurance institution through
      the employment office.
( 3 ) Put a cross in the square preceding the appropriate subject.
(4 ) Under Italian legislation , permanent employment ('occupazione non occasionale ') is any employment of more than five days ; under Belgian and Netherlands
      legislation , permanent employment ('volledige tewerkstelling ') is any employment of at least one normal working day .
( 5 ) This situation does not entail suspension of benefits if the certificate was issued by a Danish institution .
( 6 ) Or when the unemployed person is receiving an old-age or invalidity pension , if the certificate is drawn up by a German or Luxembourg institution .
( 7 ) Postal code, town , street, number, country .
                                                                                                                                                                              ©
 ---pagebreak--- EUROPEAN COMMUNITIES
  Social Security Regulations                                                                                                       E 303/5
                                                   Information for the unemployed person
                              who intends to go to another Member State to seek employment
Before leaving,
you must do whatever is required to be sure of receiving , if need be, sickness and maternity insurance benefits for
yourself and for the members of your family, even while you are looking for work .
Accordingly, you should go to the sickness fund with which you are or were last insured . On presentation of form
E 303 which has been issued to you by the unemployment insurance institution , the sickness fund will give you a
certificate 'E 119 '. In the case of sickness or maternity, you should present this certificate to the sickness fund of
the country where you are seeking employment.
As soon as you arrive
in the place where you are going to look for employment, you should go to the employment office ( 1 ); in Italy and
the Netherlands, you must also go to the unemployment insurance office ( 1 ). You should hand in all the copies of
form E 303 that are in your possession .
Please note the ultimate date, indicated on form E 303, by which you must attend if you still wish to receive unem­
ployment benefits from the moment when you ceased to be registered as seeking employment in the country you
are leaving .
While you are looking for work,
you are subject to the supervision of the employment services and unemployment insurance bodies just like the other
unemployed persons in the area . You must inform the institution to which you gave form E 303 of any change of
circumstances that may affect your entitlement to unemployment benefits ; the same applies if you become unfit for
work.
If this change in circumstances could entitle you to increased benefits ( e.g. when you get married or in case of the
birth of a child ), you may also directly inform the institution which issued you with form E 303, attaching the appro­
priate documents as proof.
If your search for a job outside your last country of employment lasts for more than three months, you will lose, at
the end of this period , any remaining rights to unemployment benefits in this last country of employment. However,
the office which issued you with form E 303 may authorize exceptions.
 ( 1 ) These offices are the following :
        in Belgium : the local offices of the ' Office national de l'emploi ' ( national employment office );
       in Denmark : the local 'Arbejdsformidlingskontor' ( labour exchange office );
        in Germany : the 'Arbeitsamt' ( employment office );
        in France : the 'Agence de l'emploi ' ( local employment office );
        in Ireland : the nearest local office of the Department of Social Welfare ;
        in Italy : the ' Ufficio provinciale del lavoro' ( provincial employment office ) and the provincial office of the ' Istituto nazionale della previ­
        denza sociale ' ( INPS, national social welfare institute );
        in Luxembourg : the ' Office national du travail ' ( national labour office );
        in the Netherlands : the ' Gewestelijk Arbeidsbureau ' ( regional employment office ) and the ' Nieuwe Algemene Bedrijfsvereniging '
        ( new general professional and trade association );
        in the United Kingdom : the local employment exchange .
                                                                                                                                                         ©
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                    See Instructions' on page 3
 Social Security Regulations
                                                                                               E 401                (1 )
           CERTIFICATE CONCERNING THE COMPOSITION OF THE FAMILY FOR THE
                         PURPOSE OF THE GRANTING OF FAMILY BENEFITS
                                          Reg. 1408/ 71 : Art. 73.1 ; Art. 74.1
                                            Reg. 574/ 72: Art. 86.2 ; Art. 88
To be attached to a claim sent to the institution competent for the grant of family benefits.
  1     Worker
  1.1   Surname                        Forenames                                              Maiden name
  1.2   Place of birth                 Date of birth                        Sex               Nationality
  1.3   Civil status :           (2) Q single                   married               Q widow/widower
                                 (2) Q divorced            Q separated
  1.4   Address ( 3 ):
  2     Spouse
  2.1   Surname                         Forenames                                             Maiden name
  2.2   Place of birth                  Date of birth                     Sex                  Nationality
  2.3   Occupation :
  2.4   Address ( 3 ):
  3     Members of the family other than the spouse
                                                 Date of       Relation­            Place of
       Surname             Forenames              birth        ship ( 4 )          residence              Occupation
 1.
 2
 3
 4
 5.
 6.
 7
 8
 9
10 .
 3.1    Remarks :
 ---pagebreak---                                                                                                         E 401
4      Information to be supplied only if the form is to be sent to a Danish institution
4.1    Person exercising the authority of father :
4.2    The maintenance of the children          (2) Q is                Q is not paid for from public funds
4.3    The mother of the children              (2) Q is                 EH 's not dead.
       If she is, please indicate date of death :
4.4    The mother or father of the children               (2) Q draws              Q does not draw
       an old-age or invalidity pension .
        Information to be supplied only if the form is to be sent to a United Kingdom institution if the worker is
0
        neither the father nor the mother of the children
    Number                                                         Number
                               Place of birth                                               Place of birth
   in box 3                                                       in box 3
®       Certificate of the population registry or the authority or administration competent in matters of civil status ( 5)
The accuracy of the information given above has been verified from the official documents in our possession .
6.1     Nameandaddressoftheregistry, authority oradministration ( 3 ) :
6.2    Stamp
                                                                           6.3    Date :
                                                                           6.4    Signature
 7 J Name and address of the institution competent for the granting of family benefits
 7.1    Name :
 7.2   Address ( 3 ):
 7.3    File reference number :
 ---pagebreak---                                                                                                                                 E 401
                                                                     INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                                            NOTES
(1 ) Symbol of the country to which the institution completing the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ; F = France ;
     Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)  Put a cross in the square preceding the appropriate subject.
(3)  Postal code, town , street, number, country.
(4)  Show the relationship of each member of the family to the worker, using the following symbols :
     A = legitimate child
     B = legitimized child
     C = adopted child
     D = natural child ( if the form is completed for a male worker, the natural children must be mentioned only if the paternity orthe worker's
            obligation to maintain them has been officially recognized )
     E = child of a spouse belonging to the worker's household
     F = grandchildren, brothers and sisters whom the person concerned has taken into his household
     G = other children belonging permanently to the household on the same footing as the worker's children (foster children ).
            Other relationships ( e.g. grandfather ) must be written in full . If a child is married , show this at point 3.1 .
C5 ) In France, the ' mairie ' ( registrar's office ) or the ' caisse d'allocations familiales' (fund for family allowances ) ;
     in Ireland, the Department of Social Welfare, Dublin ;
     in the United Kingdom , the Department of Health and Social Security, Overseas Group, Newcastle-upon-Tyne, or the Ministry of
     Health and Social Services, Overseas Branch , Belfast, as appropriate.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                   See ' Instructions' overleaf
Social Security Regulations
                                                                                              E 402                 1
                  CERTIFICATE OF CONTINUATION OF STUDIES FOR THE PURPOSE
                                  OF THE GRANTING OF FAMILY BENEFITS
                                      Reg. 1408/ 71 : Art. 73.1 and Art. 74.1
                                         Reg. 574/ 72 : Art. 86 and Art. 88
A. Request for certificate
To be completed by the institution competent for the granting of family benefits. If the form is addressed to a Belgian
institution, a form 'E 402 Annex' should be attached.
         Worker applying for family benefits or person claiming them on other grounds
  1
  1.1    Surname                       Forenames                                           Maiden name
  1.2    Place of birth                Date of birth                Sex                    Nationality
  1.3    Address (2 ):
  2 j Pupil or student
  2.1    Surname                       Forenames                                            Maiden name
  2.2     Place of birth                      Date of birth                           Sex
  2.3    Address ( 2 ):
  3 J Institution competent for the granting of family benefits
  3.1     Name :
  3.2    Address ( 2 ):
  3.3     File reference number :
   3.4    Stamp
                                                                     3.5    Date :
                                                                     3.6    Signature
 ---pagebreak---                                                                                                                             E 402
 B. Certificate
 To be completed by the establishment (school, university or establishment of higher education) and sent to the
institution named in box 3.
   4
   4.1      The pupil named in box 2 is attending the school shown in box 5
            since
   4.2      His/her education will probably last until
   4.3      The number of hours of the course is                                          a week.
            These hours are spread over                                                   half-days.
   4.4      Type of school ( 3 ):
   4.5      The student named in box 2 has been registered at the
            (4) Q establishment of higher education                   Q] university shown in box 5
            since
   4.6      His/ her studies at this establishment or university will probably last
            until
   5 J School, university or establishment of higher education
   5.1      Name :
   5.2     Address ( 2 ):
   5.3      Stamp
                                                                                       5.4     Date :
                                                                                       5.5    Signature
                                                                INSTRUCTIONS
                    Please complete this form in block letters, writing on the dotted lines only.
                                                                     NOTES
(1 )   Symbol of the country to which the institution completing part A of the form belongs : B = Belgium ; Dk = Denmark; D = Germany ;
       F = France ; Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)    Postal code, town , street, number, country.
(3)    Please indicate whether it is a publicly maintained school, ' public school ', or state-controlled school . To be completed only if the
       institution shown in box 3 is a United Kingdom institution .
(4)    Put a cross in the square preceding the appropriate subject.
 ---pagebreak---                                                                                                                  (1 )
                                                                                        E 402 Annex
To be completed if the claim for family benefits has to be made to a Belgian institution.
 1     Education given at the establishment (other than establishments of higher or university education )
 1.1   Over how many half-days and how many hours a week are the lessons spread ?
                                                half-days                                             hours .
 1 .2  The lessons        (4) Q are                                  Q are not         given before 6 p.m.
 1 .3  The pupil          (4) Q] does                                Q does not        attend lessons regularly.
       If he does not, show the number of days of absence and the reason :
 1 .4  The lessons mentioned at 1 above
       a) (4) Q] include                              Q do not include
             hours of practical training outside the establishment, required for obtaining an official diploma
       b) (4) Q include                               Q do not include
             hours of practical lessons which take place in the establishment
       c) (4) Q] include                              Q do not include
             hours devoted to study in the establishment.
             If they do, show the number of hours a week :
 1.5   Type of education provided :
       (4) O general education                        Q] technical or vocational training Q] art education
       (4) Q courses treated as equivalent to university education .
 1.6   The curriculum
       (4) □ 's                                       □ is not approved by the State
       (4) Q] corresponds                             Q does not correspond to a curriculum approved by the State.
 1.7   Show the periods of holidays :
       — Christmas holiday :      from                               to
       — Easter holiday :         from                               to
       — Summer holiday :         from                               to
 ---pagebreak---                                                                                               (1 )
                                                                           E 402 Annex
2 J Education given in the establishment of higher or university education
21  (4) Q It involves               Q It does not involve a full-time curriculum.
2.2 The course followed         (4) Q leads                 Q does not lead to a university
    degree or a diploma .
2.3 The student                (4) [J has bean preparing \_j has not been preparing a thesis.
    If he/she has, indicate :
    — since when ?
    — when must he/she submit the thesis ?
2.4 Show the periods of holidays :
    — Christmas holiday :     from                           to
    — Easter holiday :        from                           to
    — Summer holiday :        from                           to
3   School , university or establishment of higher education
3.1 Name :
3.2 Address ( 2 ):
3.3 Stamp
                                                                3.4   Date :
                                                                3.5   Signature
                                     FOR INSTRUCTIONS AND NOTES
                                         see page 2 of form E 402
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                See ' Instructions' on page 3
Social Security Regulations
                                                                                            E 403                 r
                   CERTIFICATE OF APPRENTICESHIP FOR THE PURPOSE OF THE
                                    GRANTING OF FAMILY BENEFITS
                                     Reg. 1408/ 71 : Art. 73.1 and Art. 74.1
                                        Reg. 574/ 72: Art. 86 and Art. 88
A. Request for certificate
To be completed by the institution competent for the granting of family benefits.
  1 | Worker applying for family benefits or person claiming them on other grounds
 1.1   Surname                        Forenames                                            Maiden name
 1 .2  Place of birth                 Date of birth                 Sex                    Nationality
 1.3   Address ( 2 ):
  2 I Apprentice
  2.1   Surname                       Forenames                                            Maiden name
  2.2   Place of birth                        Date of birth                       Sex
  2.3   Address ( 2 ):
   3    Institution competent for the granting of family benefits
  3.1   Name :
  3.2   Address ( 2 ):
  3.3   Stamp
                                                                     3.4   Date :
                                                                     3.5   Signature
 ---pagebreak---                                                                                                     E 403
B. Certificate
To be completed by the person, undertaking or institution responsible for the apprenticeship and to be sent to the
body responsible for supervision of the apprenticeship, which must forward the completed form to the institution
mentioned in box 3.
 4      Information concerning the apprenticeship
 4.1   The person named in box 2 has been apprenticed to us
       from
       to receive training for the trade of
 4.2   The apprenticeship will probably last until
 4.3   The apprentice
       ( 3 ) Q is receiving :
             ( 3) Q] an apprenticeship allowance or wage
                       (3) Q weekly                         Q monthly            amounting to
             (3) Q other benefits (4), namely :
                       (3) Q] accommodation       Q] full board                          Q partial board
                       (3) Q tips                 Q         meals a day                  Q] other (5)
       from                                 to                              amounting to
       (3 ) Q is not receiving
             (3) Q an apprenticeship allowance or wage                Q other benefits.
 4.4   Work-place :
 4.5    Name of the person , undertaking or institution responsible for the apprenticeship :
 4.6   Address ( 2 ) :
 4.7    Stamp
                                                                      4.8    Date :
                                                                      4.9    Signature
  5      Endorsement of the body responsible for supervision of the apprenticeship ( 6)
  5.1    Name :
  5.2   Address ( 2 ):
  5.3    Stamp
                                                                       5.4   Date :
                                                                       5.5   Signature
 ---pagebreak---                                                                                                                          E 403
                                                               INSTRUCTIONS
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 even if it does not contain any relevant information .
                                                                     NOTES
(1 ) Symbol of the country to which the institution completing part A of the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ;
     F = France ; Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)  Postal code, town , street, number, country.
(3)  Put a cross in the square preceding the appropriate subject.
(4)  When the form is being sent to a United Kingdom institution , give details of the amount of these benefits in the box below :
        accommodation :                                                     other benefits :
        full board :
        partial board :
        tips :
        meals :
(5 ) If applicable, give details of these other benefits in the box below :
(6)  This box should be completed by the following :
     in Ireland, the Department of Social Welfare, Dublin , in the case of apprenticeships that are not supervised by the Industrial Training
     Authority;
     in the United Kingdom, the Department of Health and Social Security, Overseas Group, Newcastle-upon-Tyne, or the Ministry of
     Health and Social Services, Overseas Branch , Belfast, as appropriate.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                  See ' Instructions overleaf
Social Security Regulations
                                                                                             E 404                1)
                   MEDICAL CERTIFICATE FOR THE PURPOSE OF THE GRANTING
                                            OF FAMILY BENEFITS
                                    Reg. 1408/ 71 : Art. 73.1 and 3 ; Art. 74.1
                                           Reg. 574/ 72: Art. 86 ; Art. 88
A. Request for certificate
To be completed by the institution competent for the granting of family benefits.
 1     Worker applying for family benefits or person claiming them on other grounds
 1.1   Surname                       Forenames                                            Maiden name
 1.2   Place of birth                Date of birth                   Sex                  Nationality
 1 .3  Address ( 2 ) :
 2     Person to whom the medical certificate relates
 2.1   Surname                                Forenames                            Maiden name
 2.2   Place of birth                         Date of birth                        Sex
 2.3   Address ( 2 ):
 3     Institution competent for the granting of family benefits
 3.1   Name :
 3.2   Address ( 2 ):
 3.3   Stamp
                                                                     3.4   Date :
                                                                     3.5   Signature
 ---pagebreak---                                                                                                                        E 404
B. Certificate
To be completed by the doctor designated by the liaison body (3) of the country of residence of the person examined
and to be sent to the institution mentioned in box 3.
   4
  4.1      a ) The physical or mental faculties of the person examined
               (4) Q are diminished                        Q are not diminished.
               If they are, indicate percentage of diminishment :                                                %
           b) The person examined                            (4) Q is capable of earning his/her living
                                                           (4) Q is incapable of earning his/her living due to physical or mental
                                                                     deficiency.
           c) The person examined                          (4) Q is                 Q is not a housewife.
               If she is, indicate whether                 (4) Q] she is            Q] she is not in a fit condition to look after her
                                                                                         home .
           d ) Observations :
           e) Description of the condition of the person examined :
  4.2        Date of commencement ©f disablement or illness ( be as precise as possible) :
  4.3      Probable duration :
   4.4     a ) A further examination                        (4) Q is necessary              Q] is not necessary.
           b) If it is, indicate date of the examination :
   5
   5.1     Surname and forenames of the doctor :
   5.2     Address ( 2 ):
                                                                                        5.3     Date :
                                                                                        5.4     Signature
                                                                  INSTRUCTIONS
                   Please complete this form in block letters, writing on the dotted lines only.
                                                                       NOTES
(1 )   Symbol of the country to which the institution completing part A of the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ;
       F = France ; Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)    Postal code, town , street, number, country.
(3)    Or the doctor of the fund designated by the liaison body.
( 4)   Put a cross in the square preceding the appropriate subject.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                    See Instructions overleaf
 Social Security Regulations
                                                                                              E 405               (1 )
PAYMENT OF FAMILY BENEFITS OR FAMILY ALLOWANCES IN THE CASE OF SUCCESSIVE
EMPLOYMENT IN SEVERAL MEMBER STATES, BETWEEN THE DATES ON WHICH PAYMENT
                       IS DUE ACCORDING TO THE LEGISLATION OF THESE STATES
                                               Reg. 1408/ 71 : Art. 12 ; Art. 72
                                          Reg. 574172: Art. 10.2 ; Art. 85.2 and 3
This certificate should be issued to the person concerned at his request. If appropriate, the competent institution
should request it from the institution with which the worker was previously registered.
A. To be completed by the institution competent for the granting of family benefits or family allowances with
      which the worker is reaistered.
   1     Worker
  1.1    Surname                           Forenames                                        Maiden name
  1.2    Place of birth                    Date of birth                  Sex               Nationality
  1 .3   Civil status               ( 2) Q single             Q married                     Q widow/widower
                                    ( 2) Q divorced           Q separated .
  1.4    Address ( 3 ):
   2 J Person who should receive the family benefits or family allowances
  2.1    Surname                           Forenames                                        Maiden name
  2.2    Place of birth                    Date of birth                  Sex               Nationality
  2.3    Address ( 3 ) :
   3      Institution with which the worker was previously registered
  3.1    Name :
  3.2    Address ( 3 ) :
   4      Institution of the place of residence of the members of the family
  4.1    Name :
  4.2    Address ( 3 ):
 ---pagebreak---                                                                                                                      E 405
j 5       Institution with which the worker is currently registered
  5.1     Name :
  5.2     Address ( 3 ) :
  5.3     File reference number :
  5.4     Stamp
                                                                                      5.5     Date :
                                                                                      5.6     Signature
 B. To be completed by the institution competent for the granting of family benefits or family allowances with which the
 worker was previously registered.
    6
   6.1    We certify that the worker named in box 1
   6.2     completed                      days of work,                                         from                to
   6.3     in (4)
   6.4     (2) Q He is entitled                     Q He is not entitled to family benefits or family allowances.
   6.5     Family benefits or family allowances were paid to him
                                                                                                                       i
           from                                      to
    7       Institution with which the worker was previously registered
    7.1     Name :
    7.2    Address ( 3 ):
    7.3     Stamp
                                                                                       7.4     Date :
                                                                                       75      Signature
                                                                INSTRUCTIONS
                     Please complete this form in block letters, writing on the dotted lines only.
                                                                      NOTES
  (1 )  Symbol of the country to which the institution completing part A of the form belongs : B = Belgium ; Dk = Denmark ; D = Germany;
        F = France ; Irl = Ireland ; I = Italy; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
  (2)   Put a cross in the square preceding the appropriate subject.
  (3 )  Postal code, town , street, number, country.
  ( 4)  Country in which the employment under consideration was carried out.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                     See ' Instructions' page 3
Social Security Regulations
                                                                                             E 406             F    (1 )
CLAIM FOR FAMILY ALLOWANCES TO BE SUBMITTED BY A WORKER WHO IS SUBJECT TO
FRENCH LEGISLATION AND WHOSE FAMILY RESIDES IN A MEMBER STATE OTHER THAN
                                                        FRANCE
                                     Reg. 1408171 : Art. 73.2 ; Art. 75.2.b ; Art. 76
                                                 Reg. 574172: Art. 87. 1
This claim form, drawn up in duplicate (in triplicate if the members of the family reside in Italy) (2), should be sent
by the worker direct to the French family allowances institution with which he is registered by virtue of his employ­
ment.
 1       Worker
 1.1     Surname                         Forenames                                         Maiden name
 1 .2    Place of birth                  Date of birth                  Sex                Nationality
 1.3     Address in France ( 3 ):
 1.4     Occupation (4):
  1.5    Date of entry into France :
 2        Person who should receive the family allowances
  I declare that the person named below maintains the members of my family and I request that the family allowances
  be paid to him/ her.
 2.1     Surname                          Forenames                                         Maiden name
 2.2     Place of birth                   Date of birth                 Sex                 Nationality
 2.3     Relationship to the worker :
 2.4     Name if it is a legal person :
 2.5     Address ( 3 ):
                                                                        2.6    Date :
                                                                        2.7    Signature
 2.8     Name and address of the institution which has to pay the family allowances to the members of the family
         in their place of residence ( 3):
 ---pagebreak---                                                                                                        E 406         F
m      Dependent members of the family
3.1   Surname                              3.2    Forenames                                 3.3   Date of birth
       1)
      2)
      3)
      4)
       5)
       6)
       7)
       8)
       9)
3.4    Relationship                        3.5    Place of residence     3.6   Remarks
       1 ) ( 5 ) --
       2)
       3)
       4)
       5)
       6)
       7)
       8)
       9)
3.7    I declare that there is no entitlement to family allowances on account of a professional or trade activity under
       the legislation of the country of residence of the members of my family.
                                                                        3.8   Date :
                                                                        3.9   Signature
 4      ( 6 ) Income of members of the family, if any ( nature and monthly amount, including social benefits)
   Number
                      Members of the family                     Nature of income                      Amount
     (5)
 ---pagebreak---                                                                                                                           E 406           F
   5
   5.1     If you were in gainful employment in another Member State during the month in which you arrived in France
           and if a form E 405 has not yet been drawn up, indicate :
   5.2     the period of employment :
   5.3     the name and address ( 3 ) of the institution competent for family allowances with which you are registered :
   5.4     your insurance number with this institution :
                                                                                     5.5    Date :
                                                                                     5.6    Signature
   6 I      Statement of employer
   6.1     Name of employer or firm :
   6.2     Branch of activity ( 7 ):
   6.3     Address ( 3 ):
   6.4     Date when employment commenced :
   6.5     The worker              (8) Q does                   Q does not hold a contract for seasonal work.
   6.6     If he does, state duration of the contract :
                                                                                     6.7    Date :
                                                                                     6.8    Signature
                                                             INSTRUCTIONS
 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 even if it does not contain any relevant information .
Information for the insured person
The worker subject to French legislation and the unemployed person who is receiving unemployment benefits from France are entitled,
for the members of their family who reside in a Member State other than France, to family allowances under the legislation of the country
of residence of the members of the family. The allowances are paid by the institution of the place of residence of the members of the family
on presentation of a certificate E 407 issued by the French family allowances institution.
                                                                   NOTES
(1 )   Symbol of the country to whose legislation the worker is subject : (F = France.)
(2)    To mêet the requirements of Italian institutions, a copy of form E 406 must be attached to form E 407 .
(3)    Postal code, town , street, number, country.
( 4)   To meet the requirements of Italian institutions, specify whether manual or clerical worker.
(5)    Indicate at each number the information concerning the person named at the same number in the three columns at point 3 .
(6)    To be completed only if the members of the family reside in Italy.
(7)    Persons employed in trade and industry, the professions ( supervisory staff, clerical staff, manual workers ), professional journalists,
       persons employed by insurance companies or credit institutions, in the crafts or in agriculture .-
(8)    Put a cross in the square preceding the appropriate subject.
 ---pagebreak---  EUROPEAN COMMUNITIES                                                                                                                 See Instructions ' overleaf
  Social Security Regulations
                                                                                                                                             E 407            F         1
CERTIFICATE OF PERIODS OF EMPLOYMENT IN FRANCE , OR PERIODS OF UNEMPLOYMENT IN FRANCE FOR
WHICH BENEFITS WERE PAID, FOR THE PURPOSE OF GRANTING FAMILY ALLOWANCES TO MEMBERS OF THE
 FAMILY OF A WORKER OR UNEMPLOYED PERSON WHO RESIDE IN A MEMBER STATE OTHER THAN FRANCE
                                                 Reg. 1408/ 71 : Art. 73.2 ; Art. 74.2 — Reg. 574172 : Art. 87.1 to 5; Art. 89.1
 This certificate is issued to the worker, the unemployed person or, where appropriate, the institution of the place of residence by the. French institution competent for
family allowances. The worker or unemployed person should forward it to the members of his family, who should send it to the institution of their place of residence. If
the members of the family are resident in Ireland or in the United Kingdom, this certificate should be sent direct to the institution of these countries competent for the place
of residence of the members of the family. Subject to the conditions set out below and unless it is subsequently cancelled, the certificate is valid for three months in the
case of persons in permanent employment and for the duration of the contract in the case of seasonal workers.
   11         ( 2 ) Q Worker               □ Seasonal worker                □ Unemployed person                     Insurance number :
   1.1          Surname                                        Forenames                                                                Maiden name
   1.2          Place of birth                                 Date of birth                            Sex                             Nationality
   1.3          Address ( 3 ):
   2 I        Natural or legal person who is to receive the family allowances
   2.1          Surname and forenames or name of body                                                   Sex                             Maiden name
   2.2          Address ( 3 ) :
   3 I        Institution of the place of residence of the members of the family                                   Insurance number :
   3.1          Name :
   3.2          Address ( 3 ):
   4 I        Certificate of entitlement
                The person shown in box 1
   4.1          ( 2 ) □ has satisfied the conditions of employment in France entitling him / her to receive the full amount of monthly family allowances, except in case of
                         subsequent cancellation , for the following months :
   4-2          ( 2 ) □ has carried out an occupationin France entitling him /her, except in case of subsequent cancellation , to                                    (fraction )
                         of the monthly family allowances for the months of                                                               and
                         and to the full amount for the months from                                                                       to
                         inclusive, and entitling him /her to payment of family allowances on this basis
   4.3          ( 2)  □   holds a contract of seasonal work in France, valid from                                                         to
                         which entitles him/her to receive the full amount of family allowances for the months from                       to
                         inclusive, and on a pro rata basis for the months of                                                             and
   4.4          ( 2) Q received unemployment benefits under French legislation in the period from                                         to
                         for                                                                                               days
   5 j - French institution competent for family allowances
   5.1          Name :
   5.2          Address ( 3 ):
   5.3           Stamp
                                                                                                                      5.4  Date :
                                                                                                                      5.5  Signature
 ---pagebreak---                                                                           INSTRUCTIONS
Please complete this form in block letters, writing on the dotted lines only. To meet the requirements of Italian institutions a copy of form E 406
must be attached .
                                                                              NOTES
(1 ) Symbol of the country to which the institution completing the form belongs : (F = France ).
(2)  Put a cross in the square preceding the appropriate subject.
(3)  Postal code, town , street, number, country.
                                                                                                                                                ©
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                    See instructions overleaf
 Social Security Regulations
                                                                                             E 408                (1 )
                                         REQUEST FOR INFORMATION
                                               Reg. 1408/ 71 : Art. 73.2
                         Reg. 574/ 72: Art. 87.1 ; Art. 87.7, second subparagraph ; Art. 89.2
This request for information may be sent at any time by the institution of the place of residence of the members of
the family to the French institution with which the worker is registered.
A. To be completed by the institution of the place of residence of the members of the family.
   1    (2) EH Worker                             Q Seasonal worker                  Q] Unemployed person
  1.1   Surname                         Forenames                                          Maiden name
  1.2   Place of birth                  Date of birth                  Sex                 Nationality
  1 .3  Address ( 3 ) :
  2     Employer
  2.1   Name of employer or firm :
  2.2   Address ( 3 ) :
   3 j Person who is to receive the family allowances in the country of residence
  3.1   Surname                         Forenames                                          Sex
  3.2   Address ( 3 ):
  4     Request for information
  4.1   Certificate of periods of employment (Art. 87.1 of Regulation 574/72 ) completed
        between                                                         and
  4.2   Other information relating to the worker's entitlement to allowances (Art. 87.7 of Regulation 574/72):
 ---pagebreak---                                                                                                                      E 408
   5 J Institution of the place of residence of the members of the family
   5.1      Name :
   5.2      Address ( 3 ):
   5.3      Stamp
                                                                                    5.4     Date :
                                                                                    5.5     Signature
B. To be completed by the competent French institution .
   6 j Information requested
  6.1       ( 2) Q Reply to point 4.1 : see form E 407 attached .
  6.2       ( 2) Q Reply to point 4.2 :
   6.3      Stamp
                                                                                    6.4     Date :
                                                                                    6.5     Signature
   7 j Competent French institution
  7.1       Name :
  7.2       Address ( 3 ) :
  7.3       Stamp
                                                                                    7.4     Date :
                                                                                    7.5     Signature
                                                             INSTRUCTIONS
               Please complete this form in block letters, writing on the dotted lines only.
                                                                     NOTES
(1 )   Symbol of the country to which the institution completing part A of the form belongs : B = Belgium ; Dk = Denmark ; D = Germany ;
       Irl = Ireland ; I = Italy ; L = Luxembourg ; N = Netherlands ; UK = United Kingdom .
(2)    Put a cross in the square preceding the appropriate subject.
(3)    Postal code, town, street, number, country.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                       See Instructions overleaf
 Social Security Regulations
                                                                                                E 409          F     1)
       VERIFICATION OF THE DECLARATION OF ABSENCE OF ENTITLEMENT TO FAMILY
ALLOWANCES BY VIRTUE OF A PROFESSIONAL OR TRADE ACTIVITY IN THE COUNTRY OF
                                           RESIDENCE OF THE FAMILY
                                                 Reg. 1408/ 71 : Art. 73.2
                                 Reg. 574/ 72: Art. 87.1 ; Art. 87.7, third subparagraph
This request for information should be used by the French competent institution to verify, if necessary, the declara­
tion of the head of the household that there is no entitlement to family allowances by virtue of the pursuit of a profes­
sional ortrade activity inthe country ofresidenceof the members of the family. A copy of form E 406 should be attached.
A. To be completed by the French institution competent for family allowances .
   1 I (2) Q] Worker                                Q Seasonal worker                  Q Unemployed person
  1.1    Surname                         Forenames                                             Maiden name
  1 .2   Date of birth                   Place of birth                   Sex                  Nationality
  1.3    Address in France ( 3 ):
  1.4    Reference E 406 of (date):
   2      Request for information
  2.1    (2 ) Q] Please verify the declaration at point 3.7 of form E 406 concerning the person
                 named at No                                           in box 3 of that form .
  2.2    ( 2) Q Please verify form E 406 of (date):
                 concerning
   3      French institution
  3.1    Name :
  3.2    Address ( 3 ) :
  3.3    Stamp
                                                                          3.4   Date :
                                                                          3.5   Signature
 ---pagebreak---                                                                                                                 E 409         F
B. To be completed by the family allowances institution of the place of residence of the members of the
     family.
  4 !     Information requested
  4.1     (2) Q There is entitlement                  \^\ There is no entitlement
         as a result of the pursuit of a professional or trade activity in the country of residence of the members of the family.
  4.2    The following members of the family are entitled to family allowances :
   5      Institution of the place of residence of the members of the family
  5.1     Name :
  5.2    Address ( 3 ):
  5.3    Stamp
                                                                                   5.4    Date :
                                                                                   5.5   Signature
                                                          INSTRUCTIONS
               Please complete this form in block letters, writing on the dotted lines only .
                                                                 NOTES
(1)   Symbol of the country to which the institution completing part A of the form belongs : (F = France ).
(2 )  Put a cross in the square preceding the appropriate subject.
(3)   Postal code, town , street, number, country.
 ---pagebreak--- EUROPEAN COMMUNITIES                                                                      See ' Instructions' overleaf
 Social Security Regulations
                                                                                                 E 410           F     n
        NOTIFICATION OF CANCELLATION OF ENTITLEMENT TO FAMILY ALLOWANCES
                                         Reg. 1408/ 71 : Art. 73.2 ; Art. 74.2
                                       Reg. 574/ 72: Art. 87.3 and 7 ; Art. 98.2
The French institution competent for family allowances should complete this form and send it to the institution of
the place of residence of the members of the family.
  1     Family allowances institution to which form is addressed
  1.1   Name :
  1 .2  Address ( 2 ) :
  1.3   Reference : E 407 of ( date): .
  2     (3 ) Q Worker                               Q] Seasonal worker                Q] Unemployed person
  2.1   Surname                         Forenames                                             Maiden name
  2.2   Place of birth                  Date of birth                   Sex                   Nationality
  2.3   Address in France ( 2 ):
  3
  3.1   The person named above
  3.2   ( 3 ) Q has not satisfied the condition of pursuing a professional or trade activity required in order to receive
                 family allowances
                 during the month of                                     (Art. 87.7 of Regulation 574/72 )
  3.3   (3 ) Q ceased to pursue a professional or trade activity on                                             (4);
  3-4   (3 ) Q] interrupted his contract of seasonal work
                 from (date ):                                     (Art. 87.3 of Regulation 574/72 )
  3.5   (3 ) \_j transferred his residence to ( 5 )
                 from (date):                                      (Art. 87.7 of Regulation 574/72 ).
   4     French competent institution
  4.1   Name :
   4.2  Address ( 2):
   4.3  Stamp
                                                                          4.4  Date :
                                                                          4.5  Signature
 ---pagebreak---                                                                                                 [ E 41 0 | | F
                                                          INSTRUCTIONS
                  Please complete this form in block letters, writing on the dotted lines only.
                                                                NOTES
(1 ) Symbol of the country to which the institution completing the form belongs : (F = France).
( 2) Postal code, town, street, number, country .
(s)  Put a cross in the square preceding the appropriate square .
(4)  Complete only if the form is to be sent to a United Kingdom institution .
(5 ) Indicate the country.
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